Sharpening the Focus: Experts share cutting-edge anterior segment innovations at the 35th APACRS Annual Meeting

At the 35th Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS) annual meeting, held recently in Singapore, experts shared breakthrough innovations in anterior segment that are revolutionizing the field, promising a brighter future for ophthalmology.

Artificial intelligence is already here. In ophthalmology, AI’s potential is reaching optimum level. The growing role of AI in diagnosing and treating anterior segment diseases was one of the highlights during the meeting, with predictions of its increasing importance in healthcare. A smart shape memory polymer was introduced for safe and efficient pupil expansion in cataract surgery. Anterior segment optical coherence tomography (OCT) was also highlighted for its benefits in pre- and postoperative evaluations. And last but not least, biomarkers were explored as tools to predict and improve refractive surgery outcomes.

An increasingly AI-driven world

The rise of AI is permeating every aspect of human lives, including how the eyes are treated.

In his talk, Prof. Ecosse Lamoureux from Singapore shared how AIassisted, patient-centered evaluation could make eye care more holistic. He noted that collecting patientreported outcome measurements (PROMs) data is important and aligns with global value-based care initiatives in which incorporating the patient’s voice and experience of clinical care is central. However current “fixed-length” PROMs are problematic as they are paper-pencil scales, burdensome, resourceintensive, and require manual data entry and scoring.

To overcome this problem, his team developed a suite of eyespecific computerized adaptive tests (CATs) for nuanced and sensitive measurement of patientreported outcomes. “These are fast, precise, and fully integrated into the electronic medical record (EMR), allowing real-time feedback,” he said.

Following a successful pilot implementation at Singapore National Eye Centre (SNEC) in 2021, he and his team are currently scaling up their CAT implementation across selected retinal, glaucoma and refractive clinics at SNEC using a detailed implementation science approach. This AI-assisted approach is important to eye clinics as it repositions their mission to incorporate holistic as well as clinical care. “We treat the patient, not just the organ,” he quipped.

Meanwhile, Dr. Daniel Ting, also from Singapore, said that the global trend for AI application in anterior segment diseases includes keratoconus detection, infectious keratitis detection, refractive screening (for suitability and entasis risks), pterygium detection, corneal transplant (detection of DSAEK/ DMEK graft detachment), cataract (severity grading) and IOL calculation.

He foresaw that in the future, areas that will become increasingly important are AI implementation science (e.g., health economics, perception studies, AI health guidelines), AI education and social determinants of health, privacy-preserving technology (e.g., federated machine learning, blockchain), metaverse and nonfungible tokens, explainable AI, synthetic AI (with human in the loop) and generative AI (e.g., ChatGPT and large language models).

“I think, in the next five, 10, 15 or 20 years, the use of robots together with deep learning and generative AI could actually be one of the mainstreams in healthcare,” he said, pointing out that governing framework and safety regulations need to be in place to govern these technologies.

Smart tool for efficient pupil expansion

With 32 million cases per year, cataract surgery is the mostperformed surgery worldwide, emphasized Dr. Shamira Perera from Singapore. To facilitate successful cataract surgery, it is necessary to achieve pupil expansion. While pharmacologic drops are usually used to dilate the pupil, they can be ineffective in about 5% to 10% of cases, prompting the need for pupil expanders, added Dr. Perera.

Nevertheless, there are problems associated with the use of current pupil expanders, which include insufficient expanded dilation, high iris stress, and lack of protection to the pupil margin.

To address these problems, Dr. Perera and his research group developed a smart shape memory polymer named Spiralis, which expands the pupil safely and easily for cataract surgery. Made from biocompatible polyurethane, this product has a compact shape at low temperatures and deforms to an expanded shape at body temperature.

In 2020, the technology was licensed to Geuder, a Germanybased multinational ophthalmic product company. After taking over the product, the company has taken steps to refine it, including the finalization of the product design, analysis of usability with other instrumentation required for surgery, as well as the development of assistive instruments to improve usability and function. Samples for human use are set to be available this year.

“Ultimately, we would have this potentially best-in-class expander for rapid commercialization,” said Dr. Perera.

Advantages of the anterior segment OCT

Since the development of the world’s first swept-source anterior segment optical coherence tomography (ASOCT) device by Tomey (Nagoya, Japan) in 2008, this technology has witnessed a surge in clinical applications. Its ability to penetrate deeper and provide enhanced tissue visualization has contributed to its growing utilization.

During his talk, Dr. Yoshihiko Ninomiya from Japan shared the preand postoperative benefits of ASOCT in cataract surgery.

According to him, preoperative identification of corneal irregular astigmatism and zonular dehiscence is critical for the success of cataract surgery. Tomey’s CASIA2 ASOCT platform has effectively addressed such preoperative evaluation needs. “Having access to the lens analysis provided by CASIA2 enables surgeons to anticipate potential complications and develop alternative strategies or techniques to address dehiscence,” he said.

CASIA2 is also useful in both pre- and postoperative clinical settings of intraocular lens (IOL) dislocation in terms of measuring and describing the position of IOL.

In addition, CASIA and CASIA2 come in handy with IOL power calculations, providing accurate predictions of the postoperative IOL depth. “CASIA2 can transform previous approaches of toric IOL calculations and IOL power calculations,” he noted.

Biomarkers-enabled refractive surgery

According to Dr. Rohit Shetty from India, despite the use of current diagnostics modalities which help to decide the appropriate refractive surgery and predict postoperative outcomes, 20% of all outcomes are still unpredictable and undesirable, including postoperative haze, dry eye, neuropathic pain, and epithelial remodeling. All these are due to an altered immune profile.

When looking under the microscope, he and his teammates saw that a healthy epithelium actually gulps up dead cells, while unhealthy epithelium is unable to digest dead cells. This becomes the primary source of inflammation. With tear collection using Schemer’s strips and the fluorescence reader (Bio-M Pathfinder), they were able to build a point-of-care diagnostic kit to evaluate inflammatory factors in tear fluid. The entire process takes about 90 minutes.

Dr. Shetty shared the reasons they chose certain biomarkers to be included in the test. “Interleukin-17A is a common cause of neuropathic pain, tumor necrosis factor-α is a very strong predictor of postoperative corneal haze and ICAM-1 (the itch factor) plays a role in dry eyes,” he said.

In essence, he noted that biomarkerenabled refractive surgery helps to determine which eye drop to use for diabetic eye disease (DED) subjects, monitor subjects with irritation and for treatment responses, discover and stratify clinically healthy eyes with abnormally high levels of inflammation and treat them before the disease worsens or before surgery.

As for the future, Dr. Shetty foresaw that there will be an expansion of the present biomarker panel by the incorporation of more molecules, testing the validity of the panel in the diagnosis and prognostication of systemic diseases.

Editor’s Note

• The 35th Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS) annual meeting was held on June 8 to 10, 2023. Reporting for this story took place during the event.
• A version of this article was first published in CAKE Magazine Issue 19.