Recent advances: Augmented reality, robotics, and navigation in oculoplasty and orbit

Abstract

Oculoplasty and orbital surgeries demand high precision due to confined anatomy and nearby critical structures. Recent innovations in orbital surgeries include augmented reality, robotic assistance, and computer-assisted navigation. These technologies are increasingly being explored to enhance surgical accuracy, improve outcomes, and reduce complications. Augmented reality provides real-time visualization of patient-specific anatomy, supporting preoperative planning and intraoperative guidance. Robotic systems offer tremor-free manipulation, enhanced dexterity in restrictive spaces, and minimally invasive reconstructions. Navigation enables accurate localization of deep orbital structures, thereby aiding orbital surgery. This review aims to provide current evidence on clinical practices, advantages, and limitations of newer technologies.

Surgical intervention in the periorbital and orbital region requires meticulous precision owing to the compact arrangement of muscle, vessels, nerves, and adjacent intracranial structures. Surgical challenges are further heightened in conditions such as trauma, thyroid eye disease, and revision surgery, where altered anatomy can obscure landmarks and increase operative risk.

Recent advances in digital technology have introduced augmented reality, robotic systems, and computer-assisted navigation into oculoplasty practice. These tools aim to enhance spatial orientation, reduce human error, and improve surgical accuracy through real-time visualization, motion stabilization, and instrument tracking. Augmented reality (AR) enables the integration of imaging data into operative fields.[1] Robotics facilitates precise manipulation within confined spaces, and the navigation system provides continuous anatomical localization during complex orbital procedures. This review examines the current applications and future potential of these technologies in oculoplasty and orbital surgery, highlighting their clinical utility, limitations, and role in advancing technology-assisted precision surgery.

Augmented Reality

Oculoplasty focuses on the surgical management of the eyelids, lacrimal system, and orbit. These regions contain vital anatomical components closely packed within a limited operative area, increasing the risk of complications even during a routine procedure. Although radiological imaging has improved diagnostic accuracy, surgeons must still mentally reconstruct three-dimensional (3D) anatomy from two-dimensional images during surgery.

AR systems function by registering preoperative imaging datasets, such as computed tomography (CT) or magnetic resonance imaging (MRI), with the patient’s anatomical landmarks. These datasets are converted into 3D models that are projected or overlaid onto the surgeon’s field of view through head-mounted displays or monitor-based interfaces. Real-time tracking systems continuously align the virtual anatomical structures with the patient’s position, allowing surgeons to visualize hidden anatomical landmarks and surgical targets during the procedure [Fig. 1]. In this way, AR allows integration of imaging data directly into the surgical field, offering a bridge between preoperative planning and real-time execution. Early feasibility of AR in oculoplasty was demonstrated using mobile applications, showing that this technology could be adapted even with minimal hardware requirements.[1] Since that time, AR has seen broader application throughout ophthalmology, including surgical navigation, training, and diagnostic assistance.[2,3] The growing availability of consumer-grade AR devices has led to increased adoption in plastic and reconstructive surgery.[4]

Figure 1.

Schematic representation of an augmented reality-assisted workflow

Clinical Applications in Oculoplasty

Orbital surgery and tumor localization

Recent studies have described the incorporation of AR into navigation-assisted orbital procedures. Toncev and colleagues described integration of AR with optical navigation during orbital surgery in a technical feasibility study (level V evidence).[5] In their study, preoperative CT/MRI models were registered intraoperatively. This enabled real-time AR overlay of critical anatomy within the surgical field. This integration allows precise anatomical alignment and helps in reducing surgical uncertainty. However, this report presents an early technical demonstration rather than a clinical cohort study, which limits conclusion regarding clinical effectiveness.

Orbital fracture reconstruction

Preoperative AR modeling helps in understanding fracture geometry and planning implant placement. A 2023 systematic review found that AR-assisted reconstruction improves recognition of orbital anatomy and restoration of symmetry, though final accuracy depends on correct image registration. However, the included literature consisted largely of heterogeneous studies with variable sample sizes and predominantly lower-level evidence (level III-IV) including simulation studies and feasibility report.[6] Similarly, Arias-Amezquita et al.[7] demonstrated the feasibility of an immersive VR platform for accurate simulation during orbital prosthetic rehabilitation, enabling surgeons to optimize reconstruction prior to surgery. The authors created interactive 3D models of orbital defects that could be manipulated in a virtual environment. This allowed surgeons to assess defect volume, symmetry, and prosthetic positioning with greater accuracy than conventional 2D imaging.[7]

Lacrimal and eyelid surgery

Although direct literature is limited, AR-based image guidance has theoretical benefits in external DCR and complex eyelid procedures. Evidence from other microsurgical disciplines suggests AR enhances depth perception and confidence. Dubron et al.[6] performed a comprehensive systematic review assessing AR in preoperative trauma planning. This review included experimental studies, clinical feasibility reports, and early outcome studies, evaluating an immersive 3D visualization system. The authors emphasized that while AR technologies probably offer specific advantages in surgical planning, their clinical effectiveness is linked to registration, accurate segmentation, and hardware calibration. This highlights current technical limitations and need for standardized protocols before routine clinical implementation.

Esthetic oculoplasty

Augmented visualization supports facial symmetry assessment and surgical simulation, offering patients a better understanding of the achievable outcome. This may enhance preoperative counseling and surgical planning. Sullivan et al.[8] reviewed the evolving role of augmented and virtual reality in plastic surgery and likely highlighted the increasing use of patient-specific three-dimensional planning and procedural rehearsal. Mixed reality applications have been widely utilized in craniofacial reconstruction and other complex procedures, where immersive simulation based on individual imaging data may improve surgical precision, optimize operative efficiency, and enhance clinical outcomes. Similarly, Chou et al.[4] highlighted AR value in esthetic and reconstructive facial procedures where patient-specific simulation improves communication and expectation management. In this review, 58 articles were taken, which were published between 1997 and 2023, and which met inclusion criteria of AR technologies across clinical settings. It included data from different studies involving diverse sample sizes and surgeries, including craniomaxillofacial trauma, facial analysis, reconstructed flaps, rhinoplasty, and oculoplasty procedures. The authors concluded that AR appears promising for enhancing 3D visualization and surgical planning.

Training and education

AR simulation allows trainees to develop microsurgical skills in controlled environments. AR-based ophthalmic simulation has been shown to enhance fine motor coordination and visualization in high-precision tasks such as retinal surgery. These principles are translatable to oculoplasty training.[5] Lungu et al.[9] reviewed simulation technology and concluded that it improves anatomical learning, technical precision, and procedural sequencing across surgical disciplines. In this review, data were taken from a broad range of studies, experimental models, simulator-based training platforms, and early clinical implementations. It was seen that there was better hand–eye coordination, anatomical understanding, and error recognition in microsurgical procedures.

Spinal surgery literature further supports AR’s efficacy in improving surgical accuracy and confidence. Sakai et al. and Bui et al. reported better understanding of hardware positioning and anatomy among trainees using mixed reality devices, suggesting potential benefits for orbital surgeons in training.[10,11] Their study included multiple clinical cases and trainee participants using head-mounted mixed reality devices to visualize patient-specific anatomy and hardware trajectories during surgery. Although the study was focused on spine surgery, it provides a strong analogy for orbital surgery where the surgical space is confined.

Robotics

Robotic technology is increasingly expanding into surgical subspecialities that demand high precision and functional preservation. Oculoplasty and orbital surgery, characterized by restricted operative spaces and proximity to vital neurovascular and ocular structures, represent a domain where robotic assistance may offer distinct advantages. The application of robotic platforms in this field remains in the developmental phase, but recent feasibility studies and case series demonstrate their potential role in orbital tumor excision, decompression surgery, and minimally invasive access routes. The application of robotics in general surgery and urology is well established; however, ophthalmology presents unique challenges due to microscale anatomy and the delicacy of periorbital tissue.[12] Despite these limitations, growing interest in robotic assistance for orbital and oculoplasty surgery has emerged over the last decade. Enhanced visualization, tremor reduction, motion scaling, and ergonomic benefits are among the advantages offered by robotic systems.

Evolution of robotic surgery in ophthalmic surgery

The earliest robotic contribution to ophthalmology focused primarily on microsurgical assistance in vitreoretinal procedures. These developments demonstrated tremor cancellation and precision, paving the way for exploration into other surgical subspecialities.[13]

Orbital robotic surgery largely evolved through the adaptation of existing general surgical robotic platforms, such as the Da Vinci Xi and SP (single-port) systems. These systems offer articulated instruments capable of a high degree of freedom, allowing navigation through confined anatomical corridors. Initial cadaveric feasibility studies established the possibility of robotic access to orbit through trans conjunctival approaches using general surgical robotic platforms.[13] Subsequent human clinical application, although limited, has been reported in small case series evaluating tumor excision and orbital decompression procedures.[14,15,16] The application of a general-purpose robotic platform from other surgical disciplines to orbital surgery demonstrated feasibility but not optimal functionality due to inadequate instrument size and lack of customizable ophthalmic tools.[17] Over time, specialized robotic research efforts emerged to develop ophthalmic compatible platforms that address tremor compensation, force limitation, and enhanced image magnification.[18,19]

Clinical Applications in Oculoplasty

Orbital tumor surgery

The most promising and well-documented application of robotics in oculoplasty is in orbital tumor excision. Several early human clinical reports, primarily small case series, have described robotic-assisted removal of benign and malignant orbital tumors.[16,19] These studies represent level IV clinical evidence and demonstrate technical feasibility, although the limited sample sizes and absence of comparative studies restrict broader conclusions regarding clinical superiority. Jeannon et al.[19] described a novel application of robotic-assisted orbital surgery (RAOS) in a single patient with advanced orbital malignancy, illustrating that a robot-assisted approach can achieve tumor resection while preserving visual acuity and ocular motility.

Robotic systems offer superior visualization and wrist-like motion, facilitating controlled dissection around critical structures such as the optic nerve and extraocular muscles. Malik et al.[16] subsequently published a case series of four patients with advanced periocular and orbital tumors managed using the da Vinci XI robotic system. The cohort included locally advanced malignancies involving the orbit in which conventional management would have been disfiguring. In all four cases, robotic-assisted resection achieved tumor clearance with globe preservation, and no perioperative vision loss was reported. Short-term outcomes demonstrated acceptable functional and cosmetic results, supporting the feasibility and early safety profile of the technique. This series included patients with both malignant and benign tumors where robotic access enabled tumor excision, avoiding orbital exenteration. This study demonstrated complete tumor removal with preservation of ocular function and acceptable cosmetic outcomes in selected patients.

Orbital fat decompression

Robotic-assisted orbital fat decompression has also been explored in thyroid eye disease. It was first reported in a human model by Wang et al.[14] using the da Vinci XI surgical system in 10 patients with stable Graves’ ophthalmopathy (level IV evidence). The procedures were completed in all patients, with a mean operative time of 124.3 ± 33.2 minutes and minimal intraoperative blood loss (17.8 ± 6.2 mL). Postoperative assessment demonstrated a significant reduction in exophthalmos and improvement in quality of life for both appearance and visual function domains, with no major vision-threatening complications. Patients were selected based on stable disease, significant proptosis, and absence of acute inflammatory activity. The authors highlighted improved control during fat excision and reduced risk to surrounding structures. Although favorable short-term outcomes were reported, the small sample size and lack of a control group limit definitive conclusions.

Lacrimal and endoscopy-guided surgery

Robotic platforms have been explored in lacrimal surgery primarily through endoscope guiding systems. These robotic arms help stabilize visualization, enabling efficient bimanual surgical performance. This has been shown to reduce surgeon fatigue and improve procedural ergonomics.[20] Boehm et al.[21] evaluated the use of robotic-guided systems in nasolacrimal surgeries. These studies included a small clinical and experimental cohort. In this study, a robotic arm was used to hold in a dynamic position while the surgeon performed bimanual dissection. The robotic system provided stable tremor-free visualization of the surgical field. This reduced the need for assistance and allows primary surgeons to maintain consistent orientation throughout the procedure.

Reconstructive and scar minimization approaches

The use of transconjunctival and single-port robotic access allows for scarless orbital surgery in selected cases. This has a cosmetic advantage and may reduce wound complications.[22,23] In these studies, transconjunctival and single port routes were discussed. These routes enabled scarless and cosmetically concealed surgery while maintaining exposure to deep orbital structures. These studies included feasibility reports and early clinical experiences. This demonstrated that robotic platforms allow precise dissection and reconstruction in confined orbital spaces.

Navigation in Oculoplasty and Orbital Surgery

Computer-assisted surgical navigation has gained importance in oculoplasty and orbital surgery by allowing real-time localisation of anatomical structures, enhanced surgical precision, and improved intraoperative safety. Given the surgical complexity of the orbit, navigation has demonstrated benefits in orbital decompression, tumor excision, trauma management, and reconstruction. Several studies have shown improved outcomes, particularly in thyroid-associated orbitopathy, where navigation allows controlled bony decompression and minimizes complications. With progressive advancements in image-guided technology, navigation is poised to become a standard adjunct in advanced orbital surgery.[20,24]

Principles of navigation systems

Navigation systems rely on matching patient anatomy with preoperative CT or MRI data through image-to-patient registration. A tracked probe communicates spatial location to the tracking camera, allowing simultaneous visualization on axial, coronal, and sagittal images. Registration can be performed using surface landmarks or fiducial masks, enabling accurate localization of deep orbital structures such as the orbital apex and intraconal space.[20,24]

Clinical Applications in Oculoplasty

Orbital decompression for thyroid-associated orbitopathy

Navigation-assisted orbital decompression improves accuracy during bone removal and helps avoid complications such as cerebrospinal fluid leak, hemorrhage, and optic nerve damage. Millar et al.[23] first demonstrated the utility of stereotactic navigation-guided decompression in Graves’ orbitopathy, establishing better anatomical control and surgical reproducibility.

Subsequently, Murchison et al.[25] reported practical advantages of using facial mask-based registration systems, particularly in revision surgeries. Similarly, Heisel et al.[26] reported improved functional outcomes in patients undergoing decompression for thyroid-associated orbitopathy.

Orbital tumor surgery

Surgical excision of deep or posterior orbital tumors often demands intraoperative localization beyond visible landmarks. Navigation allows accurate targeting of intraconal and apical lesions and minimizes collateral tissue damage. Lee et al.[24] emphasized improved spatial orientation using stereotactic guidance in difficult orbital tumor cases. In this study, a patient with large sphenoid wing meningioma involving orbit underwent image-guided resection. Navigation ensured safe tumor removal along with safeguarding adjacent critical structures. In the same study, a second patient with disfiguring proptosis from thyroid eye disease underwent orbital decompression using stereotactic navigation. Navigation-assisted surgery enabled targeted decompression with good functional and cosmetic outcomes. Udhay et al.[20] also reported improved safety when navigation was incorporated for tumor excision in distorted orbital anatomy.

Orbital trauma and reconstruction

Accurate realignment of bony orbital structures is essential in fracture repair. Navigation provides real-time verification of implant position and symmetry. While ophthalmic literature is limited, oral and maxillofacial surgery studies demonstrate strong evidence for navigation in craniofacial reconstruction. Collyer et al.[27] reported improved outcomes with navigation in complex skeletal reconstruction. This study focused how preoperative imaging is related to the patients’ actual anatomy in the operating room. Image-to-patient registration is essential in all computer-assisted navigation systems. In this study, authors described two main categories of image to patient registration. Fiducial marker-based registration: Invasive markers (bone anchored screw) provide stable reference point with minimal motion and surface-based registration: uses anatomical features (facial contour) instead of implanted markers. Bobek further highlighted the benefit of navigation in orthognathic and reconstructive surgeries, which translates effectively to orbital reconstructions.[28]

Conclusion

The incorporation of advanced digital platforms into oculoplasty and orbital surgery marks a paradigm shift in how complex procedures are planned and executed. Augmented reality, robotic technology, and image-guided systems offer novel ways to improve intraoperative decision-making and procedural control in challenging surgical environments. Together, these innovations are redefining traditional workflow and expanding the technical capabilities of the oculoplasty surgeon. As hardware becomes more refined and software intelligence advances, these technologies are expected to become more streamlined and clinically accessible. Continued research, interdisciplinary collaboration, and structured training will be essential to ensure their safe and effective integration into future oculoplasty practice. However, the widespread application of these technologies remains constrained by several practical challenges, including high acquisition cost, the need for specialized infrastructure, and the requirement for dedicated training. These factors may limit their routine implementation, particularly in resource-limited and developing healthcare settings. Future research should therefore focus on larger clinical studies and cost-effectiveness analyses.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.