How Innovations from AAO and the West Can Help the Developing World
After a big show like the 128th Annual Meeting of the American Academy of Ophthalmology (AAO 2024), it would typically be time to note all the movers and shakers and what they’re doing for eye care. But this time around, I decided to take some more time to explore a topic that is near and dear to my heart’s eye, so to speak.
Living in the developing nation of Vietnam for 10 years, and having lived all over emerging Asia for 18, I’m keenly aware of the eye care challenges faced by many. And yet, year after year, at conferences like AAO, the buzzword is “innovation.”
Well, how do those innovations actually apply to where eye care often is needed most, in the developing world?
We’ve heard a lot from the International Agency for the Prevention of Blindness (IAPB) about how eye care doesn’t just impact the affected persons. It impacts communities and economies because the seeing can be more active members of families and societies.
And again, we hear a lot about innovation and the help it supplies doctors and their patients. But how many of those patients are wealthy, versus in true need? There seem to be, for example, endless supplies of premium IOLs. But how much refractive tweaking is needed for the blind and impoverished patient?
No judgment here.
Perhaps it will be helpful to – for this moment in time – reframe the dialogue to get us all thinking. One more time: what innovations from the West are truly helping the developing world? How can we get more innovations out to those in need? And what is the need that should be addressed?
We asked 12 key delegates at AAO this question. Here’s what they pointed to….
Oh, and in the meantime, if you feel inspired to support the developing world, you can donate to Hakuna Matata Foundation here, which supports children’s eyes and mental health in Kenya. I’ve supported this charity over the year by participating in Charity Runs alongside the DOC and ESCRS meetings, along with Ophtec, and it’s a cause we all can get behind. Again, here is the donation link: https://www.hakunamatata.foundation/en/donations.html
1. OphthoScope can help, notes Dr. Cynthia Matossian.
Eyecelerator is one of the best places to review innovations alongside AAO.
While Dr. Cynthia Matossian, MD may no longer practice ophthalmology full-time, she has become a very wise one to listen to in high-level ophthalmic conversations.
And so we sat down with her to ask, which innovation from Eyecelerator was most striking in potentially supporting eye care in the developing world?
One word said it all. “OphthoScope.”
OphthoScope, involving smartphone fundus photography, and spearheaded by Brandon Kingrey, MD, and Jibran Sharieff, MD, in fact, took second place in The Winning Pitch Challenge.
EyeWorld Onsite summarized this well, noting:
“The problem is that non-ophthalmologists cannot examine the optic nerve easily, they said. The direct ophthalmoscope is difficult to use, and life-threatening and vision-threatening diseases can go undiagnosed. OphthoScope is a smartphone attachment that allows anyone to perform fundus photography. The images can be sent for telemedicine or AI review, and it can help diagnose life-threatening and vision-threatening conditions. The product is affordable, and it can be manufactured for less than $5. It’s also easier to use than the direct ophthalmoscope, they said, and there are no dilating drops (pupillary dilation is not necessary). It stands out from the competition because it’s inexpensive and easy to use, allowing for wide adoption, Dr. Kingrey said.”
In summary, the points here that are valid for the developing world are:
- Anyone can perform fundus photography, so in areas that lack specialists, this is critical
- Images not only can be sent via telemedicine but also now can be analyzed by AI – an incredible step from even some years back when telemedicine required another human to analyze
- It can be made cheaply
- It’s easy to use
Nice pick, Dr. Matossian!
2. “Where goodwill and capitalism collide,” says Erik Bror Bonn, MST.
It was a thoughtful exercise to speak with MicroSurgical Technology Chief Business Development Officer Erik Bror Bonn in the halls of Eyecelerator about accelerating the pace of innovation to where it is needed most.
“Once you have a finished product that’s designed for, say, the U.S. market, there’s only so much cost at times that you can take out of it,” he said. “Now, you can kind of restart the process and say, hey, you know what, there are patients in every environment who have a need for certain elements of care.”
MST is a niche instrumentation business, he mentioned.
“We don’t necessarily focus on the biggest markets, but rather the biggest areas of need, like the really complex and more niche situations where there’s a heck of a lot of need for that in developing nations,” he said.
Safe reuse must be a big consideration in this regard. And sustainability is a theme that also crosses into all aspects of use worldwide.
“We have a couple of early-stage product projects that we’re looking at in developing countries, but I think that the mentality is the first step, right?” Erik said. “Having those conversations with a group that starts the process [is critical].”
He added: “I think if if all companies can have those same conversations and say, hey, we got to solve this because there’s a heck of a lot of patients in these nations and that population is growing. And as the need for care is growing, we have to solve that too. Then eventually, you know, collectively it’s kind of like where goodwill and capitalism collide in a sense.”
3. “Angle-closure glaucoma is a critical need,” notes Kate Hunt, CCO of Nova Eye Medical.
“My response is going to be around angle closure glaucoma and the fact that it is largely contraindicated for MIGS devices,” said Kate Hunt, Chief Commercial Officer of Nova Eye Medical, after speaking on the panel of Eyecelerator symposium, Unexpected Bottlenecks in Glaucoma Innovation, “It’s just not something that industry is focused on. I don’t know if that’s because it’s just in the too-hard bucket…. But I think we are distracted by other things.”
Many surgeons do try to persist in treating angle-closure glaucoma with a MIGS procedure, although these contraindications exist, she noted. “So we’re not supposed to touch that patient population,” Kate said. “So we definitely can’t advocate for it.”
However, there may be a possibility for companies to try to expand their indication to angle-closure glaucoma. Or it could involve looking at aspects of angle-closure glaucoma that standard treatments do not address, she mentioned.
Further, note this about the impact of primary angle-closure glaucoma (PACG): “Primary open-angle glaucoma (POAG; 44.7 million cases worldwide) is considered more common than primary angle closure glaucoma (PACG; 15.7 million) but the latter is more likely to cause blindness among affected persons, and thus accounts for almost half of total glaucomatous vision loss,” according to the late Prof. Ravi Thomas, writing for the Indian Journal of Ophthalmology.
Thus PACG is a problem to address indeed.
4. “Geographic atrophy drugs,” notes Prof. Dr. S. Natarajan, India.
Pharmaceuticals for geographic atrophy (GA) are coming online, but more work needs to be done in this area, especially for the developing world, said Prof. Natarajan S. “[GA drugs] are still very expensive, even in the U.S., and they are not that good, but I’m happy the science is progressing,” he said.
Prof. Natarajan recalled the time when the use of Avastin spread like wildfire throughout India because it was a much cheaper alternative to the closely related Lucentis, both manufactured by Novartis. Avastin was only indicated for the treatment of colon and other cancers at the time but was used effectively off-label for macular degeneration, and at a fraction of the cost of Lucentis.
Asked if a similar situation may need to arise again for the developing pockets of India to take advantage of GA drugs, Prof. Natarajan indicated that biosimilars instead may provide a much-needed solution.
5. “Vyzulta around the world,” notes Andrew Stewart, of Bausch + Lomb.
“In particular, when I consider Vyzulta—a glaucoma treatment with a unique mechanism of action compared to typical PGAs—bringing it to other markets worldwide adds another valuable option for physicians and healthcare professionals in treating patients with glaucoma and elevated IOP,” said Andrew Stewart, who is the President of Global Pharmaceuticals and International Consumer at Bausch + Lomb.
The drug, which Bausch + Lomb calls “the first eye drop approved in 20 years with a novel approach to reduce eye pressure,” is approved in markets like Colombia, Brazil, Jordan, Thailand and Turkey.
“As a global company with Bausch + Lomb, we operate in over 100 markets,” Andrew said. “And so when we think about our portfolio, not just in the United States, but in many markets around the world, we’re always looking for what is the best product that we can bring to help patients.”
He continued: “We just launched in several countries in the Middle East. We continue to look in Africa in some of the markets that we are either direct or semi-direct in those markets. And so anywhere where we can leverage a U.S. dossier is always a great starting point where you have the foundational data that can be used and are given regulatory authority to start that initial discussion that will help you ultimately commercialize an asset.”
6. “Low-cost IOLs, and posterior segment products,” says Jose Carlos Coutinho Manhaes, Jr.
Jose Carlos Coutinho Manhaes Junior, Bausch + Lomb LATAM Surgical Director, mentioned that 75% of the IOL market in Brazil is for low-cost varietals.
“So we’ve launched an IOL called Loop, and this is focused either for government- or for lower-cost health insurance,” he said. This allows Bausch + Lomb to offer a good quality IOL to people who cannot afford to pay for a premium lens.
It has been a huge success.
“In Brazil, we had to reorganize our forecasts two times in the first year [after launch],” because of that success, Carlos said. “The demand was trending greater than what we expected.”
Further, on the posterior segment side of the industry, Bausch + Lomb is bringing gasses, dyes, etc. “For example, regarding a dye for the vitreous, there is no other company in the market that offers a dye for the vitreous,” Carlos said. Instead, triamcinolone is used often, which is not a dye but is still used for that purpose.
Bausch + Lomb also relaunched the brand Synergetics in Latin America, which is 100% focused on the posterior segment, he said. “So there are a lot of new products becoming available not only in the U.S. and Europe but also in developing countries as well,” he said.
7. “Affordable swept source OCT,” says Dr. Oliver Findl, Austria.
Dr. Oliver Findl and colleagues are about to publish a paper in January in the American Journal of Ophthalmology that may make all the OCT difference in the world.
“The problem with OCT is that the swept source in there – the laser diode – is pretty expensive,” Dr. Findl said. “And so we’re using the pixels – the kind of stuff you have in your phone… or laser printers — they’re much cheaper. They cost like $10 each.”
With this more affordable technology, Dr. Findl said successful and beautiful OCT and axial length measurements have been created.
“We have done a study – comparing the IOLMaster to that prototype – a very cheap diode… so what I hope we will see in a few years is an inexpensive biometry device and OCT device,” he said. “That could be a real game changer. Theoretically, just from a production point of view, you could produce a biometry machine for $2,000.”
Dr. Findl presented on this at AAO Subspecialty Day. He only needed 30 seconds of his 5-minute talk to explain it, and potentially change the world of eye care.
8. “The middle class is out there,” says Sergio Duplan, of Alcon.
“Demand in eye care is overflowing the system,” said Sergio Duplan, Region President, Alcon Americas. “By 2050, 50% of the world will be myopic. That’s huge. And that’s not of course only older populations but younger populations. When you add the burden of cataract disease, of glaucoma and then myopia, and then retinal diseases in older adults…it’s just crazy.”
Fortunately, Sergio said, demand isn’t only increasing globally. Wealth also is. “The middle class is growing across the world — not only in the U.S.,” he said. “But in the globe, 1.7 billion people will actually be in the middle-class status, which is great. But as we know, as people come into the middle class they demand better services.”
Also, remote training is now possible.
“We are developing for teaching institutions a product called Fidelis – which is a virtual reality way of training surgeons,” he noted. “We have it at the booth at AAO. You have seen it before but it continues to evolve every year. Now they can actually feel the resistance when entering to make the incisions. This is an amazing way for surgeons in the U.S. to train the surgeons in some of these countries without even having to travel.”
Sean Clark, President of the Global Surgical Franchise at Alcon, added: “We do have mid-tier equipment we bring to market on the cataract and vitreoretinal side. Next on our agenda will be thinking about upgrading that mid-tier line of equipment as well.”
Given that regulatory clearance globally also slows the uptake of new technology, Sean also had some thoughts there.
“Another thing we spend a lot of discussion time on is actually from a regulatory pathway standpoint to make sure we are compressing the timelines everywhere around the world,” he said. “Turn back the clock several years and we probably had a U.S.-first mindset or a Europe-first mindset. Now we are thinking about all the markets at the same time, trying to go from a timeline that is this long to compress it to as short as possible – to bring some of those features and benefits to those markets as quick as we can.”
9. “It’s the Pentacam,” says Lars Michael, OCULUS.
For Southeast Asia, India, and China, the Pentacam worked wonders. “It added a level of safety… in corneal refractive surgery — pre-screening and really becoming confident in doing refractive surgery in more patients,” said Lars Michael, Director of Global Sales at Oculus. “Before touching the cornea, you would need to have a Pentacam.”
Another big breakthrough was also the Corvis. “The Corvis landed big time in Asia,” he said. “And until now, this is what no other company has managed to do — to combine corneal biomechanics with the structural analysis of the Pentacam. So structure and function, that’s the unique combination. And it’s something that some Western markets struggle to get to absorb, because simply in many Western countries like Germany, that’s not a refractive market. It is a very conservative spectacle country.”
So in a way, supporting Sergio’s point above about the developing middle class worldwide, Lars noted that LASIK in many markets is not really a luxury. It is an elective procedure but it is accessible to the middle class in developing markets. OCULUS’s diagnostics support those procedures every step of the way. “And it will improve their lives. It will improve their lives,” he reiterated.
10. “Medication for pediatric cataract surgery,” says Dr. Robert Melendez.
When a child has cataract surgery, sometimes in a developing nation, there is no YAG laser for posterior capsulotomy.
“So oftentimes, surgeons would do surgery on the children,” he said. “They’ll go ahead and just do what’s called the primary posterior capsulotomy and open up the capsule since they’re already in there.”
Dr. Robert F. I Melendez, MD, MBA is working on a new project to tackle this problem.
“It’s a medicine that you inject in the eye when you do the cataract surgery that will eradicate or kill those residual lens cells,” he said. “By doing that, that will prevent PCO.”
The medication would be mixed in the bag with the BSS, and subsequently would then be in contact with the lens epithelial cells to eradicate or kill them. It would be a big step for every cataract surgery, in fact… not just for children.
11. “Lasers have a role,” says Ulla Haapanen, Modulight Corporation.
“Lasers are used in ophthalmology more than any other medical subspecialty,” according to Modulight. “The transparent nature of the human eye makes it possible to target intraocular structures without the need for endoscopy or separate surgery.”
That leaves a massive opening for the use of lasers worldwide, and it is for conditions like ocular melanoma, AMD and other retinal indications that can also be treated with laser and PDT, said Ulla Haapanen, Marketing Director, Modulight Corporation.
“So the traditional treatment is something that requires a stay in the hospital, whereas the PDT treatment is as easy as a roughly ten-minute stop in the ophthalmologist’s office,” she said. “So it’s very easy to do, but it doesn’t require a state hospital.”
The treatment burden via laser also is less than with, say, anti-VEGF injections, which are much more frequent, she said. These procedures also are all possible to afford in the developing world, she said.
12. “Europe is innovating more strongly, but there is a dark side,” says Tarun Jaggi, of OptiTech.
“The U.S. has always taken a lead on innovation as compared to the European market,” said Tarun Jaggi, CEO, Optitech Eye Care, which is based in India. “Also, people are becoming more open-minded there in Europe and they are showing off much more. But the U.S. is still on the higher end, though Europe is opening up.”
Tarun, meanwhile, sees myopia care — also showing strongly at AAO — as something that is taking off in his region and beyond.
“People are talking about dry eye. OCTs of course, with AI involved,” he said. “But, the products are expensive. A normal ophthalmologist will have to think at least two times to buy the product. Once it goes to the higher end of society, younger [doctors] feel they can’t afford it. If they take a loan, they are in a hurry to fulfill their bank installments. The actual working [for the good of the patient] is missed. That I see, every day. He has to buy an OCT because his friend has an OCT. He will do OCT on 60%, 70%, 80% of his patients, just for the heck of doing it.”
Clearly, ethical considerations of doing business in the developing world are critical, and yet the region must be engaged to improve eye sight globally.
Editor’s note: To support the developing world of eye care today, take action and donate to the Hakuna Matata Foundation here to support children’s vision and mental health in Kenya. This year, I have supported Charity Runs at DOC and ESCRS to advance the cause of Hakuna Matata, along with Ophtec and other groups. But it’s never too late to donate. Again, please consider taking a moment, and donate here (and thanks m’eye friends!): https://www.hakunamatata.foundation/en/donations.html
