How the COVID-19 pandemic has transformed the way eye surgeons treat patients; the importance of protecting intellectual property; and whether MIGS can play a role in achieving greater IOP control minus the complications, were just some of the topics discussed at the recently held virtual Ophthalmology Futures Forum.
With the coronavirus onslaught forcing healthcare to go digital, artificial intelligence (AI) technology looks set to revolutionize ophthalmology — and contribute to better clinical outcomes.
“We see AI today playing a huge role in diagnosing dry eye disease,” said Malcolm Ngiam, deputy managing director of Hong Kong-based biopharmaceutical company EssexBio. “We should be able to differentiate between evaporative and non-evaporative dry eye, and then further categorize the mild, moderate and severe symptoms. So, using the right kind of chemical entity or approach modality to treat the underlying cause of dry eye disease will help very much for a better clinical outcome.”
Further, Mr. Ngiam added that AI will form a very important role in triaging and diagnosing. “I believe it’s a gap that we see today,” he said. “In ophthalmology we’re very lucky because it is image processing, whereas other diseases and treatment areas are not based on that. In ophthalmology, we have the luxury of doing that, and AI in today’s space is very advanced in image processing. So we can tap on that.”
AI could also potentially alter the way in which glaucoma is monitored.
While eye drops are used to manage intraocular pressure (IOP), one of the problems is managing doses in real-time by monitoring IOP. AI could play a part in vital signs monitoring, said Mr. Ngiam.
“Some companies have the ability to do real-time management of intraocular pressure through a contact lens and it becomes a transmitter of sorts. That allows the physician or the nurse to manage that in real-time, and then give their comments or instructions or change the dose,” shared Mr. Ngiam. “I do think that AI technology will pay a huge role in delivering a better clinical outcome at the end of the day,” he concluded.
Protect Your Patents Before it’s Too Late
Protecting patents should be a top priority for inventors, said industry players during a session on Navigating IP management challenges in Asia.
Before launching its operations in China as part of its international expansion, France-based medical device company EyeTechCare made sure to have its basic patents granted in China.
“That is really a very important point because otherwise, if you present your product elsewhere, it might happen that a Chinese who’s walking around at a trade show in Europe or the United States tries to get some protection upfront,” said Dietrich Wolf, CEO of EyeTechCare.
Knowledge of intellectual property (IP) and patents remains at a generally low level in Asia.
“The awareness in Asia is still not as strong as it is compared to, say, in Europe and the U.S.,” said Tony Yeo, director at leading Singapore law firm Drew & Napier LLC.
“Countries like China, Japan and Korea are already out there, but when you consider the companies and inventors in the Southeast Asian region, I think the awareness is still not there,” Mr. Yeo added.
“They may have a very good invention but they’re not aware that they should follow-up as soon as possible. Then what happens is that they commercialize it and before you know it, the patent rights are lost. So that’s the first point I think. We need to provide information to the inventors that they have very valuable rights they need to consider to file as patents, and what steps they need to take beforehand,” Mr. Yeo advised.
Handling the Pandemic-induced Cataract Backlog
The pandemic has caused a serious backlog for Prof. Dr. Sunil Shah, consultant ophthalmic surgeon at Midland Eye in Birmingham (United Kingdom), after a lockdown in which many public hospitals halted operations almost completely, with ophthalmic nurses being transferred to intensive care units.
“We’ve been doing urgent operations only. So, I think here it’s going to be a huge problem. I estimate we’ve got about 2,000 patients waiting for surgery. And there’s no obvious way to solve this at the moment. It’s going to be a very slow process,” said Dr. Shah.
Nationwide restrictions have been in place in England since early January as part of efforts to curb a surge in coronavirus infections that swept the country late last year. Britain has had Europe’s worst coronavirus outbreak, with more than 127,000 confirmed deaths.
For Prof. Dr. Sanduk Ruit, executive director of Tilganga Institute of Ophthalmology (Kathmandu, Nepal), after some nine months of pressing the pause button, everything has almost returned to normal in the last two months.
“The surgical volume has gone back to about 80 percent of the normal figures. And we are seeing patients now, about a little more than 1,000 a day.” He confessed he is feeling a bit worried about what’s going to happen if there’s a surge” in COVID-19 cases.
“We really put on our best attempt on social distancing, putting on masks and everything. Many patients are coming back but we are not very comfortable,” shared Dr. Ruit.
In the Philippines, during the partial lockdown, fear of contracting the potentially deadly virus has led to the public sector — comprising mostly charity hospitals, government hospitals and training institutions of residents — seeing “a very dramatic decrease in surgeries, across the board, whether cataract, or subspecialty surgeries,” said Dr. Robert Ang, senior consultant ophthalmologist at the Asian Eye Institute, Makati City, the Philippines.
“We also noticed a trend that the patients are now going more toward the private surgery center because the patients feel safer to go to us than to go to a hospital where the emergency room is filled with COVID-19 patients,” he added.
The lack of face-to face consultation is a real concern for Dr. Shah: “We’ve been told to have to continue with virtual consultations for ophthalmology, which you know you’ve tried to explain to them, ‘I can’t really see my cornea transplant on the telephone.’ But they don’t seem to be too concerned about that as long as you’ve spoken to the patient and the patient says they think they’re alright, that’s fine.
“I think the problem is going to come within the next year, when they see the backlog properly when everything else is fine for them. And also, we now have to assess all of our patients who we think have come to harm because they haven’t been operated on,” he added.
Besides affecting the way doctors diagnose their patients, the pandemic has also hit some of them financially. “We had to cut our salary by about 30 percent during the lockdown, in the middle of the lockdown. That was one of our issues,” said Dr. Ruit.
But some remain optimistic about what lies ahead after the COVID-19 dust settles.
“Everybody was afraid to go out last year, but then by October, many people came out so there’s a little bit of a surge, and then in January, more people came out, went to restaurants and met people. So, I think that by the end of the year, whether they’re vaccinated or not, people will want to live their normal lives, and they will see us for their eye problems. Now they’re kind of afraid, but when that fear dissipates and more people get vaccinated, I think all of us will be busier,” said Dr. Ang.
MIGS for Angle Closure: The Next Horizon?
While standard glaucoma surgeries — trabeculectomy and ExPRESS shunts, external tube-shunts like the Ahmed and Baerveldt styles — are effective at lowering eye pressure and preventing progression of glaucoma, they often come with a long list of potential complications.
Minimally invasive glaucoma surgery (MIGS), which uses microscopic-sized equipment and tiny incisions, was developed to overcome this problem and reduce some of the complications most standard glaucoma surgeries entail.
However, some degree of effectiveness is traded in place of safety. Subconjunctival MIGS devices are more effective in lowering the IOP compared with trabecular bypass procedures, and are able to achieve lower postoperative IOP. On the flip side, they are associated with a higher risk profile with potential bleb-related complications, and the surgeon would need to be skilled in postoperative bleb management.
Professor Ningli Wang, director and vice president of the Eye Center of Beijing Tongren Hospital in China, prefers to conduct phacoemulsification and MIGS combined surgery on his patients with mild to moderate angle closure glaucoma (ACG).
“With MIGS, that really has changed the scene, at least for my practice and the scenario in private practice in Hong Kong,” he said, adding that he performs the phaco MIGS combined surgery on about half of his ACG patients.
Adding MIGS to phacoemulsification improves the moderate IOP lowering effect of the cataract procedure and reduces the need for postoperative medication in the medium term in glaucoma patients. “There will be a better target IOP achievement for these patients,” said Prof. Wang.
Bleb-related complications, however, limit the use of subconjunctival MIGS, and therefore could limit their use for more advanced cases of ACG.
“While it’s generally accepted that procedures using subconjunctival MIGS do potentially achieve lower pressures, that does come with increased risk, and so, as a result, I would say most clinicians would still reserve subconjunctival MIGS for more advanced glaucoma patients,” said Victor Chan, head of marketing and sales at Surgical Device, Santen Inc.
“Now what is less clear though, is whether or not some ACG patients would benefit from more aggressive, earlier surgical intervention compared with just phaco alone. For that, there really isn’t a whole lot of clinical evidence to help guide ACG management and that whole, you know, prognosticate which patients would respond best to which procedures or combination of procedures,” added Mr. Chan.
“Ultimately, the use of MIGS in angle closure glaucoma is still currently off-label use, and we hope that with more data emerging, the role of MIGS in angle closure glaucoma will become more established,” said the session’s chair, Dr. Chelvin Sng, glaucoma specialist from National University Hospital, Singapore.
Dr. Sng is a pioneer of MIGS surgery in Asia, and was the first Asian surgeon accredited to use some of the MIGS devices available. She uses a variety of MIGS devices in her practice, including the iStent from Glaukos (both iStent trabecular micro-bypass stent and the iStent Inject), the XEN Gel Implant from Allergan and the InnFocus Microshunt from Santen.
Prospective randomized controlled studies with longer follow-up periods are needed to verify the durability and long term safety of MIGS procedures and devices, especially when compared with traditional glaucoma filtering surgeries, to determine the long-term efficacy of these procedures.
Editor’s Note: The 2021 Asian Retina and Asian virtual forums, organized by the Ophthalmology Futures Forum, were held on March 25 and 26, respectively. Reporting for this story took place during the event.