Ultra–Long-Distance Robotic-Assisted Subretinal Injection for Submacular Hemorrhage

Abstract

Importance Submacular hemorrhage (SMH) is a vision-threatening condition sometimes requiring timely intervention to try to reduce retinal damage. However, access to experienced vitreoretinal surgeons remains limited in many geographically remote regions, and further studies with controlled comparisons are needed to evaluate potential solutions. Objective To evaluate the feasibility and safety issues of ultra–long-distance robotic-assisted subretinal injection for the treatment of SMH. Design, Setting, and Participants This single-case report conducted between October 2025 and January 2026 at the following 2 centers separated by approximately 4000 km: Zhongshan Ophthalmic Center in Guangzhou, China (remote control center), and Xinjiang Production and Construction Corps Hospital in Urumqi, China (patient site). One patient with SMH was enrolled. Intervention Following pars plana vitrectomy performed manually, while the participant still was under general anesthesia, a retinal surgeon remotely teleoperated an ophthalmic robotic system to perform subretinal injection of recombinant tissue plasminogen activator. Main Outcomes and Measures Primary outcomes were procedural feasibility and safety, defined as successful completion of robotic subretinal injection without conversion to manual surgery and absence of intraoperative complications or serious postoperative adverse events. Secondary outcomes included hemorrhage resolution and best-corrected visual acuity during follow-up. Results The robotic-assisted procedure was successfully completed without intraoperative complications, with 7 minutes of robotic teleoperation during a total surgical time of 46 minutes. Mean (range) network latency was 77.9 milliseconds (71-90 milliseconds). A total of 0.056 mL of recombinant tissue plasminogen activator was delivered. No serious adverse events occurred during 3 months of follow-up. Optical coherence tomography demonstrated progressive hemorrhage reduction, with complete absorption by postoperative day 26. Preoperative best-corrected visual acuity measured 1 day before surgery was 0.6 logMAR (Snellen equivalent, 20/80) and remained stable at 0.6 logMAR (20/80) at 3 months postoperatively. Conclusions and Relevance In this single-case report, robotic-assisted intraocular microsurgery was feasible and safe across 4000 km. These findings provide proof-of-concept evidence that telesurgical robotic systems like this subretinal injection may expand access to specialized retinal procedures in geographically remote regions.