A humble servant

In his shortlisted essay for the 2020 John Henahan Prize, Dr Peng Sim explains how he sees humans and technology working together like a rider on a horse

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Dr Peng Sim
“That’s excellent…”, whispered my consultant. My heart sank as I stared at a large posterior capsule hole. Hands trembling, I hastily injected visco with the old adage “visco is cheaper than vitreous” playing on my mind. The case proceeded uneventfully as I held my breath and watched an experienced pair of hands go to work, steady and unperturbed by the aftermath I have created. Yet another complication added to the logbook. I was disheartened. But I realised I needed more practice. Focused and determined, I spent every free moment I had for the rest of the week on the department’s Eyesi simulator. Consumed by the drive to improve, I practiced each step over and over with deliberation and purpose on this unwavering and forgiving machine. Slowly but surely, I became more adept and competency gradually came within grasp. But as hard as I worked and as much as I would like to claim sole credit for this achievement, I did not get here by myself. Unbeknownst to me, robotassisted learning, albeit a rudimentary version, helped pave the ascent up the steep learning curve of cataract surgery. Through virtual simulation, I was able to refine my techniques in an unparalleled manner. However, like many others, I realised how I have taken this important privilege for granted in the pursuit of surgical excellence. In an accelerating world, it is easy to lose sight of how technology has become intertwined with almost every aspect of contemporary life. Cataract surgery is no exception. We heavily rely on modern day phacoemulsification machines with advanced technology that most of us are benignly oblivious to. Over the 50 years of its existence, phacoemulsification has undergone countless incremental upgrades culminating in an intelligent, automated system that now self-adapts to changing conditions within the eye. As much as this is a display of human ingenuity, it is important to recognise the reciprocal relationship between us and our machines. Like a rider on a horse, both elements engage in a continuous cycle of flexibility and reconfigurability, learning from and supporting each other. The dawn of automation, robotics and artificial intelligence is upon us. Although the adoption of surgical robotic systems into ophthalmology has trailed behind other surgical specialties, this landscape is rapidly changing. The concept of robot-assisted cataract surgery has been gaining unprecedented momentum since it was first explored using the da Vinci Xi surgical system in 2017. As more and more manufacturers join the expanding robotic bandwagon, we can look forward to a rapid development and proliferation of novel robotic systems that will continue to expand the realm of possibility in cataract surgery. WORKING IN SYNERGY Despite its promising potential, there are challenges ahead for robotic cataract surgery: How do we ensure that we bestow the best of qualities of a master cataract surgeon on our robots? And how do we nurture our robots to understand our instincts? In our ongoing endeavour to increase automation of surgical robots, we must not overlook the importance of symbiosis – not either surgeons or robots, but surgeons and robots working in synergy for the ultimate benefit of our patients. With a new normal racing in after COVID-19, there will be a new impetus for robots to power change in the pandemic’s wake. This adversity has revealed the vulnerabilities of our healthcare systems but at the same time inspired us to innovate and accelerate the pace of robotic revolution in surgery. PERSONAL AI ASSISTANT It is the year 2050. I wake up and get ready for my cataract list in the comfort on my living room. While I brush my teeth, my personal AI assistant consents the first patient and sets up my personal settings on the latest “photo”emulsification robot. I don my virtual headset and haptic gloves as the coffee brews in the background. I get down to business in no time. With just a few taps, I seamlessly optimise the photoemulsification parameters on my index finger which now houses the entire surgical machinery… Given the limitless possibilities of robotics, it is perhaps not too farfetched to envisage such a future where robotic telesurgery coupled with an armamentarium of novel cataract removal techniques becomes our next reality. As we leap forward, we would do well to take a look back and remember the struggles of the likes of Sir Harold Ridley and Charles Kelman who believed and persevered with what seemed impossible in their times. Regardless of what the future holds, one thing is certain: the robotic approach will continue to grow and it will be up to us embrace it for all it has to teach us. Dr Peng Sim is a second-year ophthalmology trainee at the Royal Free Hospital in London, UK