In vitreoretinal surgery, membrane peeling is a prototypical task where a layer of fibrous tissue is delaminated off the retina with a micro-forceps by applying very fine forces that are mostly imperceptible to the surgeon. Previously, we developed sensitized ophthalmic surgery tools based on fiber Bragg grating strain sensors, which were shown to precisely detect forces at the instrument's tip in two degrees of freedom perpendicular to the tool axis. This paper presents a new design that employs an additional sensor to capture also the tensile force along the tool axis. The grasping functionality is provided via a compact motorized unit. To compute forces, we investigate two distinct fitting methods: a linear regression and a nonlinear fitting based on second-order Bernstein polynomials. We carry out experiments to test the repeatability of sensor outputs, calibrate the sensor, and validate its performance. Results demonstrate sensor wavelength repeatability within 2 pm. Although the linear method provides sufficient accuracy in measuring transverse forces, in the axial direction, it produces a root mean square (rms) error over 3 mN even for a confined magnitude and direction of forces. On the other hand, the nonlinear method provides a more consistent and accurate measurement of both the transverse and axial forces for the entire force range (0-25 mN). Validation, including random samples, shows that our tool with the nonlinear force computation method can predict 3-D forces with an rms error under 0.15 mN in the transverse plane and within 2 mN accuracy in the axial direction.

Membrane peeling is a standard vitreoretinal procedure, where the surgeon delaminates a very thin membrane from retina surface using surgical picks and forceps. This requires extremely delicate manipulation of the retinal tissue. Applying excessive forces during the surgery can cause serious complications leading to vision loss. For successful membrane peeling, most of the applied forces need to be very small, well below the human tactile sensation threshold. In this paper, we present a robotic system that combines a force sensing forceps tool and a cooperatively-controlled surgical robot. This combination allows us to measure the forces directly at the tool tip and use this information for limiting the applied forces on the retina. This may prevent many iatrogenic injuries and allow safer maneuvers during vitreoretinal procedures. We show that our system can successfully eliminate hand-tremor and excessive forces in membrane peeling experiments on the inner shell membrane of a chicken embryo.

Highly accurate positioning is fundamental to the performance of vitreoretinal microsurgery. Of vitreoretinal procedures, membrane peeling is among the most prone to complications since extremely delicate manipulation of retinal tissue is required. Associated tool-to-tissue interaction forces are usually below the threshold of human perception, and the surgical tools are moved very slowly, within the 0.1-0.5 mm/s range. During the procedure, unintentional tool motion and excessive forces can easily give rise to vision loss or irreversible damage to the retina. A successful surgery includes two key features: controlled tremor-free tool motion and control of applied force. In this study, we present the potential benefits of a micro-force sensing robot in vitreoretinal surgery. Our main contribution is implementing fiber Bragg grating based force sensing in an active tremor canceling handheld micromanipulator, known as Micron, to measure tool-to-tissue interaction forces in real time. Implemented auditory sensory substitution assists in reducing and limiting forces. In order to test the functionality and performance, the force sensing Micron was evaluated in peeling experiments with adhesive bandages and with the inner shell membrane from chicken eggs. Our findings show that the combination of active tremor canceling together with auditory sensory substitution is the most promising aid that keeps peeling forces below 7 mN with a significant reduction in 2-20 Hz oscillations.

Retinal vein cannulation is a technically demanding surgical procedure where therapeutic agents are injected into the retinal veins to treat occlusions. The clinical feasibility of this approach has been largely limited by the technical challenges associated with performing the procedure. Among the challenges to successful vein cannulation are identifying the moment of venous puncture, achieving cannulation of the micro-vessel, and maintaining cannulation throughout drug delivery. Recent advances in medical robotics and sensing of tool-tissue interaction forces have the potential to address each of these challenges as well as to prevent tissue trauma, minimize complications, diminish surgeon effort, and ultimately promote successful retinal vein cannulation. In this paper, we develop an assistive system combining a handheld micromanipulator, called “Micron”, with a force-sensing microneedle. Using this system, we examine two distinct methods of precisely detecting the instant of venous puncture. This is based on measured tool-tissue interaction forces and also the tracked position of the needle tip. In addition to the existing tremor canceling function of Micron, a new control method is implemented to actively compensate unintended movements of the operator, and to keep the cannulation device securely inside the vein following cannulation. To demonstrate the capabilities and performance of our uniquely upgraded system, we present a multi-user artificial phantom study with subjects from three different surgical skill levels. Results show that our puncture detection algorithm, when combined with the active positive holding feature enables sustained cannulation which is most evident in smaller veins. Notable is that the active holding function significantly attenuates tool motion in the vein, thereby reduces the trauma during cannulation.

Retinal vein cannulation (RVC) is a challenging procedure proposed for drug delivery into the very small retinal veins. The available glass cannulas for this procedure are both hard to visualize and fragile thereby limiting the feasibility of both robot-assisted and manual RVC approaches. In this study, we develop and test a new force-sensing RVC instrument that can be easily integrated with the existing manual and robotic devices. The tool enables (1) the measurement of the forces required for puncturing retinal veins in vivo and (2) an assistive method to inform the operator of the needle piercing the vessel wall. The fiber Bragg grating based sensor can be inserted into the eye through a small (Ø 0.9 mm) opening and provides a quantitative assessment at the tool tip with a resolution smaller than 0.25 mN. Assessment of forces during vessel penetration in the chorioallantoic membranes of chicken embryos have revealed a consistent sharp drop in tool tip force upon vessel puncture that has been used as a signature to provide auditory feedback to the user to stop needle advancement and begin drug delivery.

In vitreoretinal surgery, application of excessive forces and unintentional motion due to hand-tremor can easily result in serious complications. Robotic assistance when combined with tool-to-tissue force sensing capabilities has significant potential to improve such practice. In this paper, we evaluate the membrane peeling performance of a single user for two distinct robotic systems with integrated force sensing capabilities: Micron and the Steady-Hand Robot. We show that these systems provide promising performance improvement with similar impact on peeling forces and comparable tremor cancellation trends.