By: Paul M. Karpecki, OD, FAAO Clinical Director – PECAA

I was reading a study that showed patients undergoing visual field testing, after being greeted and instructed by a technician, did as well or better with robotic monitoring than by a human. It made me think that optometry robotics may make a real difference for the future, but, as I started researching it I discovered that a number of robotic applications already exist. It is clearly not so futuristic.

Recent research using the da Vinci robot, showed that with modified software, da Vinci could provide applications for ocular surgery – in particular transscleral (vitrectomy) and subretinal injections. In the year 2000, the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, Calif.) became the first robotic surgical system approved by the U.S. FDA for minimally invasive surgery. In the 18 years since, it’s use has expanded dramatically, but as of yet has not had applications for ocular surgery. A poster presented at ARVO showed that subtle changes to the software could make the robot’s ability apply to intra-ocular procedures with less tremors than surgeons. One could see a future where robots may inject anti-VEGF and steroid injections into the vitreous given the fact that the technology may be able to sense pending patient movement such as a cough more easily.

But there are two new technologies that now have robotics at their core that are much more optometry focused. This first technology was approved as a Robotic Retinal Imaging System just this summer. Nexy is a fully automated, small footprint retinal or fungus imaging machine (US distribution by Konan Medical, Irvine CA).(1)

This amazing technology simply requires the patient to put their head onto the band at the top and the operator press a green “go” button. Automatically, the robot guides 3-axis positioning for each eye capturing remarkably clear polarization clarified images, with only a minimally trained person to administer the test. The information is sent wirelessly to EHR or a reading center. In fact, Nexy is being used in Europe for diabetic eye screening and other health care initiatives to provide access to care in minimally served locales prior to its US approval. This telemedicine feature may also be used to integrate with Artificial Intelligence (AI) processing systems to extract additional key information.

Another advanced robotic technology is the VASR auto-refractor by VMax Vision Inc. (Orlando FL). VASR stands for voice activated subjective refraction. The scientific evidence showed that it was equally or more accurate to that of an eye doctor’s manual reaction in 97% of the cases. Drs. Christopher Lievens, Christina Newman, Alan Kabat, and a second year optometry student (Jacob Weber) at the Southern College of Optometry (SCO) conducted the study, It included 50 patients who were examined by a masked investigator using a standard autorefractor (Nidek TonoRef II), followed by a traditional subjective refinement using a manual phoropter including binocular balance and all the usual steps of a subjective refraction and the VASR auto-refactor,

The phoropter measurements were conducted by faculty members at SCO with decades of combined experience and the VASR subjective measurements were conducted by an optometry student with little to no experience in refracting.

The results revealed that there was no statistically significant difference between Vmax VASR and the manual phoropter refractions. The starting refractions were very similar with the traditional refraction ranged from +1.13 to -12.75 (95% confidence interval = -1.63 to -3.63), with a median of -2.50. The VASR, values ranged from +1.08 to -14.39 (95% confidence interval = -1.26 to -3.46), with a median of -2.69 as well as cylinder power and axis (Cylinder: P = 0.6377, r = 0.864) (Axis: P = 0.6991, r = 0.738).

What was most impressive was that 14% of patients had better acuity with the VASR System (> 1 line Snellen compared to the phoropter refraction), 3% of subjects had worse acuity with VASR (>1 line Snellen worse refraction), and 83% had less than 1 line Snellen line difference compared to a faculty physicians traditional refraction.

The student had only 2 hours of training compared to decades of training on a manual phoropter from the SCO faculty, indicating that the training requirement to refract with the robotics of VASR auto-refractor was substantially easier than training to refract using a traditional phoropter, which takes several months (or even years).

The VASR autorefraction system utilizes wavefront aberrometry and the subjective refraction component utilizes proprietary point spread function (PSF) technology. The VASR exam is voice-guided during the entire refraction and it combines artificial intelligence to optimize refraction outcomes. When discussing this with one of the investigators he stated the only place that the manual phoropter in the hands of a faculty members beat VASR was in being about 20-30 seconds quicker to complete the refraction compared to a fully voice activated system that took the patient from start to finish!

From what I learned from Shui Lai, its CEO, another level of advancement is in the making but would be compatible with the current VASR. He promised that it would be another high jump above the current technology. Vmax seems to have developed non-stop, one breakthrough after another and I can’t wait to see it.

Indeed robotics will affect eye care and the technologies at hand are incredible and exciting. They belong in the hands of the eye care practitioner but may prove to make ours and the lives of our patients easier.


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