Robotic precision: Elevating the state of laser cataract surgery

Current robotic cataract laser technology is paving the way for the next era of eye surgery—where robotic precision meets surgical expertise to deliver the most advanced cataract care for patients today. (Image credit: AdobeStock/ipopba)

The use of robotic systems in health care is increasing. According to market research, the global medical robots market is expected to reach $12.7 billion this year.¹ With a primary function of performing minimally invasive surgical procedures with increased precision, robotics is poised to transform ophthalmology. Successful integration in the operating room (OR), however, relies on a delicate balance of tasks between surgeon and robot—with the robot playing a supporting role.

Surgeon control

Although the number of tasks a robotic system can perform will likely increase, robotic laser cataract surgery is not intended to replace a surgeon’s experience and skill. Contrarily, it is intended to automate specific steps of the procedure with unparalleled accuracy so surgeons can concentrate on the aspects of surgery that demand human expertise. In other words, robotic laser cataract surgery complements surgeon control.

One such platform (ALLY; LENSAR, Inc) allows me to focus on what I do best—the delicacies of surgery, decision-making, and patient care—while leveraging robotic precision with advanced instrumentation, superb visualization, and real-time feedback. The symbiosis between surgeon and technology ultimately leads to a better patient experience with greater predictability, efficiency, and safety.

Synergistic optimization

One defining feature of the robotic cataract laser system is its ability to integrate imaging, diagnostics, and treatment planning into a single intelligent system. Preoperative diagnostics are seamlessly transferred from the clinic to the OR, eliminating human translation errors and enhancing surgical accuracy.

Robotic technology enhances cataract surgery by combining precise imaging, real-time feedback, and seamless integration within the operating room for improved surgical accuracy and efficiency. (Photo courtesy of Vance Thompson, MD)

Additionally, advanced image recognition software and computational power allow highly accurate image analysis, which is particularly important in cataract grading, personalized treatment planning, and astigmatism management. By bridging the gap between clinic-based diagnostics and intraoperative execution, robotic laser cataract surgery enhances precision and reduces the potential for alignment errors.

Astigmatism management is an example of how robotics can augment a surgeon’s skill. First, preoperative diagnostics are automatically incorporated into the laser system for robotic treatment planning aided by artificial intelligence (AI). Second, the robotic laser cataract system’s IntelliAxis software ensures precise toric alignment by creating 2 tabs in the capsulotomy. Traditional corneal marking techniques can introduce parallax errors, but the robot-generated tabs align directly with the marks on the toric IOL, improving accuracy and predictability. A prospective multicenter study of 72 eyes that underwent toric IOL implantation with iris registration–guided capsular marks showed a statistically significant reduction in astigmatism at postoperative week 6 compared with preoperatively (0.11 ± 0.21 vs 1.81 ± 0.74 D, respectively). Most eyes (99%) were within ±0.50 D of the intended refraction.²

IntelliAxis also accounts for surgically induced astigmatism and compensates for cyclorotation and patient positioning, which ensures optimal incision placement and alignment. The technology may be used for manual limbal relaxing incisions and arcuate incisions.

READ: Dialing in precision: Astigmatism management with arcuate incisions, by Gary Wörtz, MD

A study of 189 eyes that received laser arcuate keratotomy incisions for corneal astigmatism ranging from 0.50 to 2.00 D showed that the residual astigmatism was 0.50 D or less in 95.8% of eyes.³

Robotic intelligence optimizes several key surgical steps, including cataract grading and fragmentation, capsulotomy, incisions, and IOP monitoring. The laser’s ability to create precise fragmentation patterns eliminates the need for deep manual grooving, which can sometimes cause complications during phacoemulsification, and the laser’s ability to create a perfectly round and consistent capsulotomy simplifies one of the most technically demanding steps of cataract surgery. Additionally, the laser’s precise astigmatic incisions further improve refractive outcomes. These robotic enhancements help to refine the process, making it more efficient, reproducible, and safe.

The use of a robotic cataract laser system also helps optimize phaco energy settings. Studies have shown a statistically significant decrease in both total and effective phaco time and cumulative dissipated energy use, as well as minimized trauma to ocular structures such as the cornea and endothelial cells.^4,5 Such benefits also play a critical role in maximizing surgical outcomes.

READ: AI applications in cataract surgery: A surgeon’s perspective, by Arjan Hura, MD

Enhancing the patient experience

Beyond surgical precision, robotic laser cataract surgery improves workflow efficiency. Traditional femtosecond laser platforms for cataract surgery often require a patient to be moved between different rooms, one for laser treatment and one for phacoemulsification and IOL placement. This disrupts sterility and adds time to the surgical case. The robotic cataract laser system sits directly in my OR, which maintains sterility and reduces overall surgical time by up to 8 minutes per case.⁶ It has a retracting laser head, making it easy to swing the laser out of the way when transitioning to phacoemulsification. I also have found that pupil size is maintained more efficiently when patients remain in 1 position compared with moving between rooms during the procedure.

Moreover, the laser system enhances visualization for both the surgeon and surgical team. It provides multiple real-time displays of critical data to enhance communication between team members, ensure seamless execution of each surgical step, reduce variability, and improve predictability.

This enhanced workflow efficiency benefits not only the surgeon but also the patient, who experiences a smoother and less stressful procedure. Patients today expect LASIK-like results from their cataract surgery. Although not always achievable, laser cataract surgery with a robotic system provides the technological advancements necessary to deliver exceptional outcomes. Faster healing times, more predictable results, and reduced variability all contribute to higher patient satisfaction.

The future of cataract surgery

As AI and robotics continue to advance, it is exciting to think about what the future holds. Current robotic cataract laser technology is setting the stage for the next era of laser cataract surgery. The combination of robotic precision and surgical expertise ensures that ophthalmologists can deliver the most advanced cataract surgery available today, benefiting both surgeons and patients alike. This closed-loop system eliminates manual errors, aligns diagnostics with treatment, and allows me to focus on what I do best: performing surgery with confidence and precision.

Vance Thompson, MD

E: vance.thompson@vancethompsonvision.com

Thompson is in private practice at Vance Thompson Vision in Sioux Falls, South Dakota. He is a consultant to LENSAR, Inc.

References

1. Medical robots market worth $12.7 billion by 2025 – exclusive report by MarketsandMarkets. News release. PR Newswire. November 23, 2020. Accessed February 14, 2025. https://www.prnewswire.com/news-releases/medical-robots-market-worth-12-7-billion-by-2025--exclusive-report-by-marketsandmarkets-301178730.html

2. Visco D. Outcomes of toric IOL implantation guided by iris registration-guided femtosecond laser-assisted capsular marks and evaluation of postoperative IOL rotation in patients undergoing cataract surgery. Presented at: American Society of Cataract and Refractive Surgery 2020 Annual Meeting; May 16-17, 2020; Virtual.

3. Visco DM, Bedi R, Packer M. Femtosecond laser-assisted arcuate keratotomy at the time of cataract surgery for the management of preexisting astigmatism. J Cataract Refract Surg. 2019;45(12):1762-1769. doi:10.1016/j.jcrs.2019.08.002

4. Kolb CM, Shajari M, Mathys L, et al. Comparison of femtosecond laser-assisted cataract surgery and conventional cataract surgery: a meta-analysis and systematic review. J Cataract Refract Surg. 2020;46(8):1075-1085. doi:10.1097/j.jcrs.0000000000000228

5. Popovic M, Campos-Möller X, Schlenker MB, Ahmed II. Efficacy and safety of femtosecond laser-assisted cataract surgery compared with manual cataract surgery: a meta-analysis of 14 567 eyes. Ophthalmology. 2016;123(10):2113-2126. doi:10.1016/j.ophtha.2016.07.005

6. Visco D. Comparison of full sterile and nonsterile FLACS procedures in an OR environment. Presented at: 2022 CEDARS/ASPENS Annual Meeting; December 8-10, 2022; Scottsdale, AZ.