A Feasible Workflow for Retinal Vein Cannulation in Ex Vivo Porcine Eyes with Robotic Assistance

A potential Retinal Vein Occlusion (RVO) treatment involves Retinal Vein Cannulation (RVC), which requires the surgeon to insert a microneedle into the affected retinal vein and administer a clot-dissolving drug. This procedure presents significant challenges due to human physiological limitations, such as hand tremors, prolonged tool-holding periods, and constraints in depth perception using a microscope. This study proposes a robot-assisted workflow for RVC to overcome these limitations. The test robot is operated through a keyboard. An intraoperative Optical Coherence Tomography (iOCT) system is used to verify successful venous puncture before infusion. The workflow is validated using 12 ex vivo porcine eyes. These early results demonstrate a successful rate of 10 out of 12 cannulations (83.33%), affirming the feasibility of the proposed workflow.

Towards Motion Compensation in Autonomous Robotic Subretinal Injections

Exudative (wet) age-related macular degeneration (AMD) is a leading cause of vision loss in older adults, typically treated with intravitreal injections. Emerging therapies, such as subretinal injections of stem cells, gene therapy, small molecules or RPE cells require precise delivery to avoid damaging delicate retinal structures. Autonomous robotic systems can potentially offer the necessary precision for these procedures. This paper presents a novel approach for motion compensation in robotic subretinal injections, utilizing real-time Optical Coherence Tomography (OCT). The proposed method leverages B$^{5}$-scans, a rapid acquisition of small-volume OCT data, for dynamic tracking of retinal motion along the Z-axis, compensating for physiological movements such as breathing and heartbeat. Validation experiments on \textit{ex vivo} porcine eyes revealed challenges in maintaining a consistent tool-to-retina distance, with deviations of up to 200 $\mu m$ for 100 $\mu m$ amplitude motions and over 80 $\mu m$ for 25 $\mu m$ amplitude motions over one minute. Subretinal injections faced additional difficulties, with horizontal shifts causing the needle to move off-target and inject into the vitreous. These results highlight the need for improved motion prediction and horizontal stability to enhance the accuracy and safety of robotic subretinal procedures.

Real-time Deformation-aware Control for Autonomous Robotic Subretinal Injection under iOCT Guidance

Robotic platforms provide repeatable and precise tool positioning that significantly enhances retinal microsurgery. Integration of such systems with intraoperative optical coherence tomography (iOCT) enables image-guided robotic interventions, allowing to autonomously perform advanced treatment possibilities, such as injecting therapeutic agents into the subretinal space. Yet, tissue deformations due to tool-tissue interactions are a major challenge in autonomous iOCT-guided robotic subretinal injection, impacting correct needle positioning and, thus, the outcome of the procedure. This paper presents a novel method for autonomous subretinal injection under iOCT guidance that considers tissue deformations during the insertion procedure. This is achieved through real-time segmentation and 3D reconstruction of the surgical scene from densely sampled iOCT B-scans, which we refer to as B5-scans, to monitor the positioning of the instrument regarding a virtual target layer defined at a relative position between the ILM and RPE. Our experiments on ex-vivo porcine eyes demonstrate dynamic adjustment of the insertion depth and overall improved accuracy in needle positioning compared to previous autonomous insertion approaches. Compared to a 35% success rate in subretinal bleb generation with previous approaches, our proposed method reliably and robustly created subretinal blebs in all our experiments.

Bimanual Manipulation of Steady Hand Eye Robots with Adaptive Sclera Force Control: Cooperative vs. Teleoperation Strategies

Performing intricate eye microsurgery, such as retinal vein cannulation (RVC), as a potential treatment for retinal vein occlusion (RVO), without the assistance of a surgical robotic system is very challenging to do safely. The main limitation has to do with the physiological hand tremor of surgeons. Robot-assisted eye surgery technology may resolve the problems of hand tremors and fatigue and improve the safety and precision of RVC. The Steady-Hand Eye Robot (SHER) is an admittance-based robotic system that can filter out hand tremors and enables ophthalmologists to manipulate a surgical instrument inside the eye cooperatively. However, the admittance-based cooperative control mode does not address crucial safety considerations, such as minimizing contact force between the surgical instrument and the sclera surface to prevent tissue damage. An adaptive sclera force control algorithm was proposed to address this limitation using an FBG-based force-sensing tool to measure and minimize the tool-sclera interaction force. Additionally, features like haptic feedback or hand motion scaling, which can improve the safety and precision of surgery, require a teleoperation control framework. We implemented a bimanual adaptive teleoperation (BMAT) control mode using SHER 2.0 and SHER 2.1 and compared its performance with a bimanual adaptive cooperative (BMAC) mode. Both BMAT and BMAC modes were tested in sitting and standing postures during a vessel-following experiment under a surgical microscope. It is shown, for the first time to the best of our knowledge in robot-assisted retinal surgery, that integrating the adaptive sclera force control algorithm with the bimanual teleoperation framework enables surgeons to safely perform bimanual telemanipulation of the eye without over-stretching it, even in the absence of registration between the two robots.

Cooperative vs. Teleoperation Control of the Steady Hand Eye Robot with Adaptive Sclera Force Control: A Comparative Study

A surgeon's physiological hand tremor can significantly impact the outcome of delicate and precise retinal surgery, such as retinal vein cannulation (RVC) and epiretinal membrane peeling. Robot-assisted eye surgery technology provides ophthalmologists with advanced capabilities such as hand tremor cancellation, hand motion scaling, and safety constraints that enable them to perform these otherwise challenging and high-risk surgeries with high precision and safety. Steady-Hand Eye Robot (SHER) with cooperative control mode can filter out surgeon's hand tremor, yet another important safety feature, that is, minimizing the contact force between the surgical instrument and sclera surface for avoiding tissue damage cannot be met in this control mode. Also, other capabilities, such as hand motion scaling and haptic feedback, require a teleoperation control framework. In this work, for the first time, we implemented a teleoperation control mode incorporated with an adaptive sclera force control algorithm using a PHANTOM Omni haptic device and a force-sensing surgical instrument equipped with Fiber Bragg Grating (FBG) sensors attached to the SHER 2.1 end-effector. This adaptive sclera force control algorithm allows the robot to dynamically minimize the tool-sclera contact force. Moreover, for the first time, we compared the performance of the proposed adaptive teleoperation mode with the cooperative mode by conducting a vessel-following experiment inside an eye phantom under a microscope.

Steady-Hand Eye Robot 3.0: Optimization and Benchtop Evaluation for Subretinal Injection

Subretinal injection methods and other procedures for treating retinal conditions and diseases (many considered incurable) have been limited in scope due to limited human motor control. This study demonstrates the next generation, cooperatively controlled Steady-Hand Eye Robot (SHER 3.0), a precise and intuitive-to-use robotic platform achieving clinical standards for targeting accuracy and resolution for subretinal injections. The system design and basic kinematics are reported and a deflection model for the incorporated delta stage and validation experiments are presented. This model optimizes the delta stage parameters, maximizing the global conditioning index and minimizing torsional compliance. Five tests measuring accuracy, repeatability, and deflection show the optimized stage design achieves a tip accuracy of <30 $\mu$m, tip repeatability of 9.3 $\mu$m and 0.02{\deg}, and deflections between 20-350 $\mu$m/N. Future work will use updated control models to refine tip positioning outcomes and will be tested on in vivo animal models.

Micromanipulation in Surgery: Autonomous Needle Insertion Inside the Eye for Targeted Drug Delivery

We consider a micromanipulation problem in eye surgery, specifically retinal vein cannulation (RVC). RVC involves inserting a microneedle into a retinal vein for the purpose of targeted drug delivery. The procedure requires accurately guiding a needle to a target vein and inserting it while avoiding damage to the surrounding tissues. RVC can be considered similar to the reach or push task studied in robotics manipulation, but with additional constraints related to precision and safety while interacting with soft tissues. Prior works have mainly focused developing robotic hardware and sensors to enhance the surgeons' accuracy, leaving the automation of RVC largely unexplored. In this paper, we present the first autonomous strategy for RVC while relying on a minimal setup: a robotic arm, a needle, and monocular images. Our system exclusively relies on monocular vision to achieve precise navigation, gentle placement on the target vein, and safe insertion without causing tissue damage. Throughout the procedure, we employ machine learning for perception and to identify key surgical events such as needle-vein contact and vein punctures. Detecting these events guides our task and motion planning framework, which generates safe trajectories using model predictive control to complete the procedure. We validate our system through 24 successful autonomous trials on 4 cadaveric pig eyes. We show that our system can navigate to target veins within 22 micrometers of XY accuracy and under 35 seconds, and consistently puncture the target vein without causing tissue damage. Preliminary comparison to a human demonstrates the superior accuracy and reliability of our system.

Deep Learning Guided Autonomous Retinal Surgery using a Robotic Arm, Microscopy, and iOCT Imaging

Recent technological advancements in retinal surgery has led to the modern operating room consisting of a surgical robot, microscope, and intraoperative optical coherence tomography (iOCT). The integration of these tools raises the fundamental question of how to effectively combine them to enable surgical autonomy. In this work, we address this question by developing a unified framework that enables real-time autonomous surgical workflows utilizing the aforementioned devices. To achieve this, we make the following contributions: (1) we develop a novel imaging system that integrates microscopy and iOCT in real-time, accomplished by dynamically tracking the surgical instrument via a small iOCT scanning region (e.g. B-scan), which was not previously possible; (2) implementing various convolutional neural networks (CNN) that automatically segment and detect task-relevant information for surgical autonomy; (3) enabling surgeons to intuitively select goal waypoints within both the microscope and iOCT views through simple mouse-click interactions; (4) integrating model predictive control (MPC) for real-time trajectory generation that respects kinematic constraints to ensure patient safety. We show the utility of our system by tackling subretinal injection (SI), a challenging procedure that involves inserting a microneedle below the retinal tissue for targeted drug delivery, a task surgeons find challenging due to requiring tens-of-micrometers of accuracy and precise depth perception. We validate our system by conducting 30 successful SI trials on pig eyes, achieving needle insertion accuracy of $26 \pm 12 \mu m$ to various subretinal goals and duration of $55 \pm 10.8$ seconds. Preliminary comparisons to a human operator performing SI in robot-assisted mode highlight the enhanced safety of our system.

Deep Learning Guided Autonomous Surgery: Guiding Small Needles into Sub-Millimeter Scale Blood Vessels

We propose a general strategy for autonomous guidance and insertion of a needle into a retinal blood vessel. The main challenges underpinning this task are the accurate placement of the needle-tip on the target vein and a careful needle insertion maneuver to avoid double-puncturing the vein, while dealing with challenging kinematic constraints and depth-estimation uncertainty. Following how surgeons perform this task purely based on visual feedback, we develop a system which relies solely on \emph{monocular} visual cues by combining data-driven kinematic and contact estimation, visual-servoing, and model-based optimal control. By relying on both known kinematic models, as well as deep-learning based perception modules, the system can localize the surgical needle tip and detect needle-tissue interactions and venipuncture events. The outputs from these perception modules are then combined with a motion planning framework that uses visual-servoing and optimal control to cannulate the target vein, while respecting kinematic constraints that consider the safety of the procedure. We demonstrate that we can reliably and consistently perform needle insertion in the domain of retinal surgery, specifically in performing retinal vein cannulation. Using cadaveric pig eyes, we demonstrate that our system can navigate to target veins within 22$\mu m$ XY accuracy and perform the entire procedure in less than 35 seconds on average, and all 24 trials performed on 4 pig eyes were successful. Preliminary comparison study against a human operator show that our system is consistently more accurate and safer, especially during safety-critical needle-tissue interactions. To the best of the authors' knowledge, this work accomplishes a first demonstration of autonomous retinal vein cannulation at a clinically-relevant setting using animal tissues.

Human-Robot Interaction in Retinal Surgery: A Comparative Study of Serial and Parallel Cooperative Robots

Cooperative robots for intraocular surgery allow surgeons to perform vitreoretinal surgery with high precision and stability. Several robot structural designs have shown capabilities to perform these surgeries. This research investigates the comparative performance of a serial and parallel cooperative-controlled robot in completing a retinal vessel-following task, with a focus on human-robot interaction performance and user experience. Our results indicate that despite differences in robot structure and interaction forces and torques, the two robots exhibited similar levels of performance in terms of general robot-to-patient interaction and average operating time. These findings have implications for the development and implementation of surgical robotics, suggesting that both serial and parallel cooperative-controlled robots can be effective for vitreoretinal surgery tasks.