Robotics and the Future of Cataract Surgery

A Natural Evolution Toward Surgical Excellence

By Uday Devgan, MD, FACS, and Rajesh K. Rajpal, MD

Robotic cataract surgery is a natural evolution in the quest for greater surgical precision and safety. Reshaping the cornea for refractive purposes, which once required eight or 16 incisions created manually with a diamond blade, can now be accomplished largely by lasers and their software algorithms under the surgeon's control with a footpedal. In cataract surgery, femtosecond lasers can create highly consistent capsular openings. Planning systems calculate IOL power and the expected residual refractive error. These automated elements of ocular surgery can be considered guidance systems - the first stage of robotic surgery.

The next stages of robotic ocular surgery include telesurgery, in which the surgeon operating these tools could just as easily be 200 km away as 2 m away. Beyond that is robot-assisted surgery, in which a robotic system controlled by a surgeon enhances precision, accuracy, and safety, and true automation, in which a robotic system performs surgery autonomously. Ophthalmology is advancing along this trajectory carefully, and we are optimistic about its potential implications for surgeons and patients.

We anticipate three potential benefits from robotic surgery.

Potential Benefit No. 1: Increased Precision and Accuracy

Robotic systems are being designed with a tolerance of 5 um compared with approximately 40 um for manual surgery by a good surgeon. Robotic assistance may also help reduce variability in surgical performance. Surgeons like to think they are all above average. The reality resembles a bell curve, with some performing significantly better than others. Robotic assistance may help smooth out subtle inconsistencies and reduce variability among surgeons.

Potential Benefit No. 2: Greater Safety

Many surgical complications, such as posterior capsular rupture, are iatrogenic. The posterior capsule is a thin (4 um), transparent tissue that is difficult for the human eye to see, especially when nuclear material obstructs the view. What if a robotic system could be programmed to monitor the position of the posterior capsule using real-time OCT and provide a haptic feedback warning when the phaco probe comes within a certain distance of the capsule? The prospect of automating safety features to reduce the risk of complications is exciting.

Potential Benefit No. 3: Improved Access

In just over a decade, the number of ophthalmologists is projected to fall 28% short of patient needs.¹ Older ophthalmologists are retiring faster than they can be replaced at the same time that a growing number of aging baby boomers are demanding eye care and surgery for age-related diseases such as cataract, glaucoma, and macular degeneration. Compounding the problem are shortages of trained ophthalmic nurses and technicians. Robotic cataract surgery could help address these mismatches - not by replacing ophthalmologists but by potentially increasing throughput. In the future, robotic systems might allow a surgeon to supervise multiple procedures, monitoring routine cases and intervening when necessary.

I (U.D.) performed the first robotic cataract surgeries in the world in El Salvador in October 2025 with the Polaris platform (Horizon Surgical Systems), an investigational device that is not approved by the US FDA or any other global regulatory body. The points raised in this article will be validated as part of ongoing studies with regulatory bodies. Of these first 10 cases, I controlled half by using a joystick to operate the robotic arm. I supervised the other half; the robotic system sculpted the nucleus autonomously, and I performed the other steps (Figure 1). The robot uses the same instruments and machines ophthalmologists are accustomed to in cataract surgery, with a heads-up display monitor, making the procedure comfortable and familiar.

Figure 1. Dr. Devgan (pictured at far left in black scrubs and wearing 3D glasses) performs the world's first robotic cataract surgery. He controls the robotic arm of the Polaris robot, which holds the phaco probe and is positioned over the patient in the center of the frame. The phaco machine is located to the left of the robotic device, and the heads-up 3D display is at the far left.

Barriers to the adoption of robotics in cataract surgery, including cost and surgeon and patient acceptance, are not insignificant. Increased case volume might help recoup the initial costs of technology acquisition. Evidence demonstrating a clinical benefit will be important to surgeon adoption as robotic technology matures. Patient acceptance will also be an important consideration as robotic systems enter broader clinical use.

The Path Forward

Horizon plans to continue clinical studies outside the United States, and the company is working with the US FDA to initiate US clinical trials. The availability of robotic systems in the OR will require approval and validation of these concepts. In the first few cases performed with the Polaris system, however, the clinical benefit seemed clear.

The system combines real-time swept-source OCT with multiple 3D, high-definition video streams and integrates all that information faster than the human brain can. The result is a realistic representation of where the instrument is in the eye relative to delicate ocular structures (Figure 2). Click here to watch the procedure.

Figure 2. The Polaris system integrates 3D video with real-time OCT to show the probe's position relative to ocular structures.

What if surgeons could see residual cortex clearly or visualize exactly how the lens was positioned in the capsular bag during the cataract procedure? This level of intraoperative visualization could have applications beyond cataract surgery, including MIGS without a gonio lens and retinal procedures that require precise manipulation near delicate tissue. Visualization will also be critical for what is known as physical AI - AI that autonomously takes physical action. In the nearer term, however, visualization is incredibly helpful to a surgeon controlling surgical devices directly.

Robotic surgical technology should be designed to perform more than cataract procedures, to perform surgery autonomously, and to adapt to new ways of operating. Right now, the robot mimics the way humans operate, but there is the potential for a robot to do things humans cannot. For example, surgical incisions need not be limited to places a surgeon using two instruments can reach comfortably. There may be better ways to operate that have not yet been envisioned.

As progress along this trajectory of physical AI and robotic surgery is made, we encourage our colleagues to be open to and curious about what advanced robotics could mean for the future of ophthalmic surgery.

Robotics as a Force Multiplier

By Cathleen M. McCabe, MD

Cataract surgery is the most commonly performed operation in the world and one of the most efficient and successful. In 2021, however, the 74th World Health Assembly endorsed a global target of a 30-percentage point increase in effective cataract surgical coverage by 2030.¹ By effective, the assembly meant that the patient sees better than 20/40 Snellen postoperatively, not merely that a surgery occurred. The most recent modeling projects that this target will be missed by more than 20 percentage points, with global effective cataract surgical coverage rising just 8.4 percentage points over the decade.²

The gap between what cataract surgery can do and what health systems actually deliver is, at its core, a workforce problem. Robotics might help to close this gap.

The Workforce Is the Root Cause

By some estimates, 600 million people worldwide need cataract surgery, but only about 30 million procedures are performed each year.³ Cataracts remain the leading cause of blindness, accounting for roughly 40% of cases.³ The unmet need has several causes, but the largest and among the most difficult to resolve is that there are too few surgeons and they are distributed too unevenly.

The global ophthalmology workforce numbers roughly 275,500 physicians, an average density of 34 doctors per 1 million people.⁴ That average is inadequate but also hides a steep gradient. High-income countries have 76 ophthalmologists per million, upper-middle-income countries have 46, lower-middle-income countries have 17, and low-income countries have just four.^4,5

The geography is as skewed as the economics. Sub-Saharan Africa averages three ophthalmologists per million, and seven countries have a ratio below one per million. Two-thirds of the world's ophthalmologists are concentrated in 13 countries, and a recent survey found that six nations hold half the global total.⁵ That distribution shows up directly in outcomes: effective cataract surgical coverage reaches 77.7% in Qatar and just 2.1% in Burundi, where roughly four of every five patients who underwent cataract surgery did not recover good vision.² Where cataract surgeons are scarcest, both procedural quality and volume suffer. Even among patients who undergo cataract surgery, a median of 26% of outcomes worldwide fail to meet functional vision thresholds, and at least half of those failures were attributable to uncorrected refractive error.²

This Is Not a Problem Only in Developing Nations

Aging populations are straining even well-resourced systems, as evidenced in the United States. Projections from the Health Resources and Services Administration's workforce simulation model predicted that the supply of US ophthalmologists will decline by 12% between 2020 and 2035 while the demand for ophthalmic care will rise 24% over the same period - a 30% adequacy gap that ranks ophthalmology second-worst of 38 medical and surgical specialties studied. It trails only thoracic surgery.⁶

Providing skilled surgical care in rural areas and developing countries has always been a challenge, one that is worsening in many places, but a future workforce shortage is projected even in the urban centers of developed countries. The bottleneck is fundamentally a problem of supply versus demand.

Where Robotics Could Fit

Robotic systems have the potential to standardize technique and reduce the field's dependence on years of manual dexterity training. The technology could extend the reach of a limited pool of surgeons, improve outcomes by adding precision and safety guardrails, and - critically - scale those outcomes in the regions of greatest need.

For a high-volume surgeon in a developed market - someone who efficiently turns over a case in minutes and for whom complications are rare - robotic cataract surgery may look like a solution in search of a problem. Most cataract procedures are uncomplicated, and outcomes are excellent. Adding capital costs, disposables, and workflow disruptions to a system that works may be hard to justify for increased precision alone.

That framing, however, assumes that the only problem worth solving is marginal precision on a routine case. The problems are actually the global capacity gap, the variability between a trainee's 10th case and an experienced surgeon's 10,000th case, the difficulty of transferring surgical expertise into places where experienced ophthalmologists are scarce, and the physical longevity of surgeons who face a musculoskeletal toll. Frame the question that way, and the value proposition changes. A robot that can standardize the operation, extend the careers and reach of skilled surgeons, and consistently handle a larger volume of surgery would solve a fundamentally different problem than marginal precision on a routine case.

Four Ways Robotics Could Close the Gap

Outcomes

The clearest evidence so far comes from adjacent ophthalmic robotics rather than cataract surgery itself. Trained human hands can trace a spiral to roughly 100-um precision; a robotic platform (Luca, Acusurgical) has demonstrated roughly 10-um precision in the same task.⁷ In retinal surgery, a 12-patient randomized trial of the Preceyes robotic system (Preceyes) found efficacy equal to manual surgery for subretinal drug delivery, indicating that robotic assistance does not have to trade safety for steadiness.⁸ On the planning side, AI-assisted IOL calculation formulas such as the Hill-RBF, Kane, and PEARL-DGS can deliver greater refractive accuracy compared with classical formulas in complex eyes.

None of this proves that robotic cataract surgery can currently outperform a skilled human hand, but it indicates that greater precision and stronger safety guardrails may be possible.

Throughput

Developers argue that their platforms will save intraoperative time and increase surgical throughput at scale - the rationale for using robotics to close a gap measured in hundreds of millions of untreated cases.⁹ Throughput gains, if they materialize, will come only after workflow is optimized. They will not become evident with the first-generation systems in trials now. In the longer term, automation combined with one surgeon who oversees several parallel cases could increase volume per surgeon and per center, but that is not achievable with the first commercialized systems.

Ergonomics and Surgeon Longevity

In surveys, 66% to 82% of US ophthalmologists have reported work-related musculoskeletal pain concentrated in the neck, shoulders, and lower back, and roughly 14% have considered retiring early because of the pain.¹⁰ A workforce already projected to shrink cannot afford to lose experienced surgeons to a preventable occupational injury. A robot that reduces the physical toll of thousands of microsurgeries a year would directly address the supply side of the shortage by extending the careers of trained surgeons.

Training Speed and Precision

Recorded, repeatable motion and simulation can compress the learning curve for new surgeons, an explicit design goal of the platforms in development.⁹ A shortened path from inexperience to competent independence could matter more in workforce-scarce regions than in well-staffed ones. A trainee who never struggles, however, might never learn to rescue a case a robotic system cannot handle. Any curriculum built around these platforms must teach judgment and focus on complex tasks that robotic systems cannot yet reliably manage.

Precision Versus Burden

Today's platforms are designed to extend, not replace, surgeons. Horizon Surgical Systems, a spinout from the University of California, Los Angeles, reported the first robot-assisted human cataract surgery in October 2025. The 10-patient first-in-human series was performed by Dr. Devgan, with no adverse events.¹¹ Uniquely among robotic platforms in development, a portion of the phacoemulsification in five of the 10 eyes was fully automated. ForSight Robotics followed in April 2026 with what the company described as the first fully surgeon-guided complete robotic cataract surgery, which was performed start to finish without general anesthesia at the Asian Eye Institute in Manila, Philippines.¹²

Neither platform has been cleared by the US FDA. Both are investigational and will be judged on the question every precision technology eventually faces: Does the benefit justify the burden? Important considerations include capital equipment, per-case disposables, OR footprint, docking and setup time that eats into throughput, a reimbursement pathway that does not yet exist for the robotic component, and a training curriculum built from scratch. The precision that a skilled surgeon already delivers by hand is not worth that burden. Precision delivered reproducibly, at scale, in the hands of surgeons who do not yet have 10,000 cases - or who might have retired earlier without it - might be.

So Which Is It?

Whether robotic cataract surgery represents an evolution or a solution in search of a problem remains to be seen. If the goal is to make a routine case marginally better in a well-staffed practice, justifying the technology today will be a challenge - though that calculus may shift as platforms mature, costs fall, and precision and safety data accumulate. A robot that reliably prevents even a small fraction of iatrogenic complications could earn its place on that basis alone.

The case is clearer, however, when the goal is to address a capacity gap of 600 million people waiting for care, an ophthalmologist workforce concentrated in a handful of countries, lagging coverage gains worldwide, and the longevity of the surgeons on whom closing that gap depends. Here, too, robotic cataract surgery could address a real need for which there are currently few clear alternatives.