A Review of Robot-Assisted Needle-Insertion Approaches in Corneal Surgeries

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This paper reviews the current advances, challenges, and translational potential of robotic-assisted approaches in corneal surgery, focusing on needle insertion techniques identified through a selected database. The topic is interesting and relevant, and it would attract attention in this field due to the emerging development of artificial intelligence–powered surgical robotics. However, this paper has multiple issues that need to be addressed:

1. Abstract: The abstract requires significant polishing. The sentence between lines 19 and 22 contains grammatical errors. Sentences between lines 23 and 33 lack logical connections, making the content loosely organized. Additionally, some of the selected keywords are not appropriate—specifically, “soft autonomous robotic systems,” “adaptive control,” and “soft robots for minimally invasive surgery”—as these topics are not covered in the main text of the review.

2. Figure 2: The content of Figure 2 appears outdated and does not reflect the current state of development. It is recommended to update or redesign the figure to present the contemporary progress and, if possible, predict future trends. The revised figure should also highlight the years in which ophthalmic robotic systems achieved key milestones, as this area is central to the paper’s focus.

3. Quantitative Data: More detailed data should be provided regarding the critical parameters of robotic corneal procedures. For example, in subsections 3.1, 3.2, and 3.3, the improvements in precision should be supported with specific quantitative values. This applies to statements such as:
“... thus enhancing the precision of needle placements in ...” (line 233)
“... capable of steering flexible needles can achieve higher precision in targeting ...” (lines 247–248)
“... have demonstrated superior precision ...” (line 265)
“... further enhancing the accuracy ...” (line 274).

4. Figures and Tables:
The sentence “The configuration of the robotic arms and the stereoscopic camera used for these early procedures” should refer to Figure 5, not Figure 4.
Figures 6 and 7 are presented but not mentioned in the main text.
The numbering of Table 2 appears to be a typo—it is labeled as Table 1 in line 525.

5. Evidence Level: The meaning of the term “Evidence Level” in the last column of Table 2 is unclear. Please define or explain this classification criterion.

6. Unreferenced Figures: Figures 9 and 10 are not mentioned or discussed in the main text. Please revise accordingly.

7. Conclusion: While Sections 5 and 6 address the limitations and future directions, a distinct and well-structured conclusion section is still missing from the paper. A Conclusion should be added to summarize the main findings, highlight the paper’s contributions, and outline potential future directions in a conclusive and concise approach.

8. References: The reference section requires substantial revision. The URL links are inconsistent, and some are missing. DOI links are recommended instead. Furthermore, several references are incomplete or incorrectly formatted—such as missing journal names, page numbers, or other bibliographic details. This applies to references [10], [13], [15], [16], [17], [18], [19], [23], [25], [32], and [35].

Author Response

Thank you for the review. Please see the attached PDF for our response.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The paper reviews robot-assisted corneal needle insertion systems while investigating OCT-guided, cooperative, and autonomous approaches. It highlights promising precision gains but acknowledges that most of the present evidence stems from ex-vivo.

Strengths:

• Clear statement of the coverage gap between robotic systems for anterior-segment vitreoretinal surgery in the review literature.
• Synthesis of robotic corneal surgery systems and performance metrics.
• Emphasis on currently low clinical maturity.

Weaknesses:

• Literature search is not entirely reproducible and comprehensive (limited databases, e.g., no IEEE Xplore/Scopus, unclear rationale behing inclusion/exclusion criteria).
• Focus rather lies on clinical outcomes, while the review of the technical details remains shallow. The emphasis should shift towards a more descriptive review of the underlying robotic systems to align with the scope of the journal.
• Simulation/conceptual papers are excluded yet foundational; consider a secondary tier for them.

Promising work, that may benefit from some revisions for transparency, rigor, and clarity.

Author Response

Thank you for the review. Please see the attached PDF for our response.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The paper presents a rather narrative review on robotic systems for needle insertion in corneal surgery. It covers several procedures, such as corneal laceration repair, pterygium repair, penetrating keratoplasty or DALK. The narrative approach seems to be justified due to heterogeneity and early-stage evidence, describing a PubMed + Open Evidence (LLM) search from June 2005–June 2025, with English-only inclusion.

The paper seems well written, but there are a few issues to consider before publication.

The database coverage is too narrow for this topic. Why didn’t the authors include other databases as well, besides PubMed? This is not very well explained.

The search keywords ‘robotic’ AND ‘ophthalmology’ can be too few. Perhaps others should have been included in the research too, i.e. cornea, keratoplasty, DALK/DMEK, pterygium, trephin, cannula, injection, telemanipulation, haptic, Preceyes, OCT, just to name a few.

The study selection, although quite standard, lacks a flow diagram and listing, no inclusions/exclusions, no PRISMA like figures, etc.

Can the authors explain how the LLM was validated? Like manual verification, de-duplication against database results, etc to avoid bias.

A quality assessment of the considered papers should be generally performed. Some criteria might include: type of experiment (ex-vivo, human, etc) and setup, sampling details, measurement quality, TRL, etc.

Minor:

Who is X.X.?

Check Tables numbering

“The 329 configuration of the robotic arms and the stereoscopic camera used for these early 330 procedures is shown in Figure 4.” Are you sure?

Author Response

Thank you for the review. Please see the attached PDF for our response.

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

The authors present a review manuscript on robotics in corneal and surface ophthalmic surgery.

 

Table 1 on page 3 is too confusing – is not clear how they chose those references whereas more significant robotic corneal papers are listed in a subsequent table also called Table 1 on page 14.

 Methodology – would have been better if authors would include papers not written in English and translated their importance since many readers can easily search pubmed and read the English.  However, robotics is prominent in Asian countries and would have been much better to translate and include the papers written in Chinese, Japanese and Korean, etc.  Or included if an English abstract was presented.

 

Page 6. Disagree that increasing the annual papers from 3 to 4 per year in Figure 4 is a significant increase.  Include the references of the individual papers in the figure as well as an overall P value of all papers.

 

Page 6 – Why did you not include 2019 at 3 papers in the 2020-2024 reported increase of 3 -4 papers from prior years of 2 papers?

 

Too many vague sentences without reference to the past abstract/presentation/ paper/

Such as page 11 “they were found to be safe for ocular surface  tissues and offered acceptable millimetre-level precision.”

 

And page 11 “eliminate surgeon fatigue” is written without a reference .  Injections are just one part of the procedure. Was it actually measured experimentally to reduce fatigue?

 

Other vague sentences are present in the document ---recommend improving.

 

 

0n page 16 - Gray literature, including conference abstracts, theses, and preprints, were also not considered, which may have resulted in publication bias and limited the comprehensiveness of the review.  Why were these other sources not considered?  Could include and label as nonpeer-reviewed documents for readers without easy access to these documents.

Author Response

Thank you for the review. Please see the attached PDF for our response.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The reviewer is now satisfied with the current version.

Author Response

Thank you.

Reviewer 4 Report

Comments and Suggestions for Authors

Review of revised manuscript:

Prior Original Reviewer Comment 3: Page 6. Disagree that increasing the annual papers from 3 to 4 per year in  Figure 4 is a significant increase. Include the references of the individual papers in the figure as well as an overall P value of all papers.

 

Reviewer Response 3: We agree that increasing the annual papers from 3 to 4 per year in Figure 5 is not a significant increase; therefore, we have removed this claim and modified the statement to reflect the revised version of Figure 5. Figure 5 was revised and references of the individual papers have been added (see below). Please note that an additional figure was added at the beginning of the paper and so the numbering for the figures have changed.

“There is an increase in annual papers published in 2019 to 2024 from prior years of three papers,bwhich account for more than 60% of all included references.”

Figure 5: Distribution of References Included By Year [1-34] [36-40].

Upon re-evaluation, we found that only a minority of the studies we included reported

conducting a power analysis or specific p-values. Among those that did, the results were

consistently reported as p < 0.05. Therefore, the authors believe that adding a p-value based off a minority of studies may confuse the readership and would appreciate it if the reviewer accepts our explanation.

 

Review of Revised manuscript Response 3

The authors have changed their original manuscript labeled Figure 4 to the revised manuscript labeled Figure 5.  Since the authors did not report adding additional papers to their review, it is unclear how the dates of publication have so drastically changed including zero publications in 2021, yet 4 publications in 2020 and peak of 7 publications in 2022.

In addition, in the original Figure 4 there are a total of 39 publications graphed, whereas in the revised Figure 5 there are a total of 38 publications graphed.  Why is there a discrepancy in numbers between the two figures?

Author Response

Thank you for the comment. Please see attached PDF. Thanks

Author Response File: Author Response.pdf