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Artificial intelligence in Ophthalmology

Artificial intelligence (AI) in Ophthalmology

Introduction


In April 2018, the first-ever autonomous Artificial Intelligence system  was approved by the FDA.

The health care system had been totally constructed around doctors diagnosing, treating, as well as recording outcomes, and it was definitely not ready for autonomous AI, where a computer makes a diagnosis or therapy choice. Guideline, ethics, obligation, medical records, payments, and also quality procedures: none of those aspects were ready to take care of autonomous AI, so we need to conquer these difficulties one at a time. So we welcome honest guidelines for autonomous AI, a path for valuing repayment for autonomous AI based on the novel idea of “AI work,” just how to certify autonomous AI analysis results for clinical quality measures, the legal structure, obligation problems, as well as inputting AI right into clinical records.

What is the experience with artificial intelligence (AI) and also deep learning in ophthalmology?


Deep learning is simply a rebranding of man-made neural networks – a principle that has actually been around since the 1950s. They are computational versions that superficially appear like the brain in the manner in which they process details. They are not pre-designed or pre-specified. You feed them information, such as an electronic picture, containing a matrix of numbers, which are fed right into the layers of a neural network, as well as you educate the neural network to acknowledge certain instances by repeating the process millions of times.
This method is verified to be far more powerful than classical computer system programming methods, where you would basically try to describe the functions of a particular phenomenon by utilizing thousands of lines of code.

AI/Deep Learning in a nutshell is a way to gain from one’s mistakes. The core instrument at the centre of almost all AI formulas is a neural network. Neural networks transform data successively via a network framework into an outcome that can be compared to the proper label of, say, the disease shown in an ocular picture. If the neural network’s outcome is different from the appropriate diagnosis, the neural network is penalized. In the following round of training, it responds to that charge by trying to improve its guessing capacity. This process proceeds iteratively till the neural network has the ability to gradually get the right responses a lot of the times. The desirable, however not ensured, outcome of educating a neural network is called convergence.
One can think of AI as consisting of data science and data engineering. Within this framework, knowledge – such as of disease features – is saved in skilled neural network models, housed in a computing architecture that permits release of the AI solution for use by people such as physicians as well as, ultimately, patients. The training of the neural network models is “data science,” while the construction of architecture to home and serve the skilled model is “data engineering.”
To construct a durable Deep Learning (DL) system, it is important to have two primary components– the “brain” (technical networks – Convolutional Neural Network; CNN) and the “dictionary” or datasets. A CNN is a deep neural network including a cascade of processing layers that look like the organic processes of the animal visual cortex. It transforms the input volume into an outcome volume by means of a differentiable function. Each nerve cell in the visual cortex will certainly react to the stimulation that is specific to a region within a photo, similar to just how the mind neuron would certainly respond to the visual stimuli, which will trigger a particular area of the visual space, called the receptive field. These receptive fields are tied together to cover the whole visual field. 2 courses of cells are discovered in this region – simple and complex cells.
Extensively, the CNN can be split into the input, hidden (additionally called feature-extraction layers) as well as result layers. The hidden layers generally contain convolutional, pooling, fully connected and normalization layers, and the variety of hidden layers will certainly differ for different CNNs. The training as well as development stage is usually split right into training, recognition, and also testing datasets (see below for descriptions). These datasets have to not converge; a picture that remains in one of the datasets (like training) have to not be utilized in any one of the other datasets (like validation). Ideally, this non-intersection needs to encompass patients. The general class distribution for the targeted disease needs to be maintained in all these datasets.
Training dataset: Training of deep neural network is generally carried out in batches (parts) randomly sampled from the training dataset. The training dataset is what is used for optimizing the network weights through backpropagation.
Validating dataset: Validation is utilized for parameter selection and tuning, and also is customarily additionally used to carry out stopping conditions for training.
Testing dataset: Lastly, the reported performance of the AI formula should be calculated specifically utilizing the chosen optimized design weights on the screening datasets. It is important to examine the AI system making use of independent datasets, captured using different devices, population and also clinical settings. This process ensures the generalizability of the system in the medical setups.
The issue with building autonomous AI using CNN in the fashion defined by others is that no one recognizes how such an AI makes its clinical decision. Since the CNN’s efficiency depends entirely on the training information, and also not on any kind of understanding of the disease markers, it is at risk to devastating failing, as we and also others have discovered, in addition to racial and also ethnic bias.
Therefore CNNs as well as other AI algorithms can be made use of in different ways, building AI making use of numerous detectors, each of which detect the markers of disease themselves, which are invariant to race, ethnicity, and also age, as well as combine their outputs to a patient-level clinical result. It is this focus on developing autonomous AI – so it is maximally reducible to characteristics straightened with scientific expertise of human clinician cognition– that seems to have actually made regulatory authorities as well as physicians more comfy with autonomous AI.

Which unmet requirements in ophthalmology can be met by AI – and just how?
Worldwide, there is an aging populace with increased prevalence of illnesses like diabetes mellitus: 25 percent of people over the age of 60 in the European Union have very early or intermediate Age-related Macular Degeneration (AMD). As the earth’s populace gets older, it ends up being more than simply an issue about retinal conditions – it’s a concern that is integral in the aging procedure itself. If you might visualize tools like AI being made use of in every person over 60 in every nation in the world on a regular basis, as part of an evaluation of aging populations and general health and wellness, the extent is huge. If we do not create new and cutting-edge strategies, we’re most likely to be in trouble. It’s not a question of luxury, there’s a necessity to come up with ingenious solutions.
AI has appropriately been compared to electricity in the feeling that it will certainly penetrate and locate applications in basically all locations of human endeavour, including ophthalmology. The even more obvious applications include image classification, like making use of AI to tell whether a fundus photograph illustrates modest Diabetic Retinopathy (DR) or mild DR. The majority of such photo classifications have actually not yet been done, yet they can exist in the future for conditions such as corneal dystrophies or retinal dystrophies. Non-image based ophthalmic disease classification is an area that is essentially untouched thus far; there, the input is not an image, however hereditary, demographic, metabolomic, symptomatologic data, as well as some combination of those. One more broad area of application, as well as one in which RETINA-AI has started work, is in the construction of generative models for latent feature exploration and artificial data generation. There is a myriad of chances there for personalised pharmaceutical development and also synthetic data generation.
By 2050, the globe’s populace aged 60 years and older is estimated to be 2 billion – up from 900 million in 2015 – with 80 percent living in low- and middle-income nations. People are living longer, as well as the speed of aging is quicker than ever. Because of this, there is a need for long-term surveillance of many ocular as well as systemic problems like DR, glaucoma, AMD, as well as cardio problems. Population explosion additionally produces pressure to screen for vital causes of childhood blindness, such as retinopathy of prematurity (ROP), refractive error, as well as amblyopia. For example, diabetic patients need lifelong screening for DR. With nations in Africa having simply one doctor per 300,000 individuals, this is simply not feasible. Hence, AI can significantly enhance the testing rate – although the implementation of such AI technology calls for mindful preparation, facilities and also specialists’ assistance for those with vision-threatening DR.
The abilities of deep learning ought to not be taken as skills. What networks can supply is superb performance in a well-defined job. Networks are able to classify DR as well as identify risk aspects for AMD– but they are not a substitute for a retina specialist.
What are the main barriers to clinical adoption of AI?
Developing an AI formula is currently relatively easy, and analytical AIs are an asset. What is testing is developing AI into a system, aligned with clinical standards, as well as medical decision making, durable as well as simple to use by existing personnel in the centre, in order to relocate specialty care to medical care, or into the community. Instead of having to take a trip to a retina expert, you can currently most likely go to a facility at a grocery store to obtain a diabetic retinal testing. Minimal training in taking good-quality photos and operating a robot camera, and assimilation into the medical care system – this is what really counts if we want to make AI adoption widespread. Most notably, utilizing strenuous validation versus scientific results (instead of comparison to unvalidated medical professionals) for safety, efficiency as well as equity, in a scientifically legitimate, transparent and also accountable means for the whole populace, while guaranteeing patient derived information is utilized fairly and transparently. Currently there is little training on autonomous AI recognition, medical trials, how to compare to clinical results, exactly how to validate human factors. However, it is important that as clinicians, all of us become a lot more familiar with understanding whether a certain independent AI is the appropriate method, suitable for our patients.

 

It is essential to keep in mind that AI and also deep learning are not magic. There are specific applications where deep learning will function extremely well, however there are numerous others, where it won’t. There is no question of AI replacing ophthalmologists.

 

Specific AI systems may get a much better reception in specific health care setups. In a public health care setting, struggling with large varieties of individuals, it’s most likely to be a lot more appealing to have something that focuses on clients with a sight-threatening illness, so the quantity of time invested in people with less severe illness is minimized. In a private healthcare setting, you cannot reduce the general number of referrals that are entering into the system. Likewise, any type of brand-new technology needs a pathway to be presented right into the system.

At many clinics, it is found out how curated data is a significant traffic jam for AI jobs. So, clinicians learned exactly how to aggregate and also curate sensory information for the functions of training AI designs, as well as present the technical facilities, so that they can harness the power of the substantial quantities of information that the clinic creates. 

Clinics have learned about issues around using patient information – this is possibly a delicate topic, which calls for care. Many clinics have learnt the use of anonymized professional information from public medical registries and are transparent, keeping patients as well as the general public educated regarding what they’re doing.

They’ve attempted to produce an environment of world-leading AI professionals, to ensure that they can do great deals of novel, early-stage growth of AI systems in an academic setup. They may begin a hundred early-stage projects, however just a minority of those will be translated right into medical procedure, with an industry collaborator.

The largest difficulty to fostering is the interdisciplinarity of the problem at hand. Communication among clinicians, medical managers, regulators, data scientists, and information engineers is vital, but these people commonly speak various languages. The uniqueness of AI technologies also requires time for everybody to come on board as well as comprehend each other’s languages. Regulative barriers are properly in position and rate the deployment of AI into professional usage. There are likewise some engineering challenges to overcome to have full range continuity in understanding and also improvement of systems.

Expense will also play a role; cloud-based systems as well as AI capability are both expensive. All in all, suitable cross-talk and continued improvement will inevitably result in progression because the general forecasted cost-savings and also professional effectiveness is considerably engaging.

The prospective obstacles of AI study and medical fostering in ophthalmology are countless. First, AI strategies in ocular disease need a great deal of photos. Information sharing from different facilities is an evident method to increase the variety of input data for network training, nonetheless, raising the number of data components does not always boost the efficiency of a network. For example, including big quantities of information from healthy subjects will probably not improve the category of disease. Furthermore, very large datasets for training might raise the likelihood of making spurious links. When it comes to using retinal images to forecast and also identify ocular and also systemic illness, a clear guideline for the ideal number of cases for training is needed.

Second, when information is to be shared in between various facilities, policies and state privacy policies require to be taken into consideration. These might vary between countries, as well as while they are made to make certain patients’ personal privacy important, they often form obstacles for efficient research efforts and also patient care. Normally, there is an arrangement that photos and also all various other patient-related information require to be anonymized as well as individual’s authorization has to be gotten before sharing, when possible. The application of the essential options – consisting of information storage space, monitoring, and also evaluation – is time – and cost-intensive. Purchasing data-sharing is a challenging choice, since the economic demands are high, and also the advantage is not immediate. However, all AI research study groups around the world ought to continue to collaborate to correct this obstacle, aiming to harness the power of large information and DL to advance the discovery of clinical understanding.

Third, the decision for data sharing can in some cases may be affected by the concern that competitors might check out novel outcomes initially. This competition can also take place within an institution. Indeed, key efficiency signs (as defined by funding bodies or colleges, consisting of number of publications, outcome variables and citation metrics) may stand for significant obstacles for efficient information sharing. On an institutional level, the filing of collaboration contracts with various other members is a long and labour-intensive method that decreases analysis of shared data. Such periods may also get extended when intellectual property issues are to be negotiated. Given that these are typically multiple-institution agreements, time periods of one year or more are common and may thus extend timelines.

Fourth, a great number of images are required in the training set as well as they require to be well phenotype for various conditions. The efficiency of the network will depend upon the number of photos, the high quality of those pictures, and how representative the information is for the entire range of the disease. Additionally, the applicability in clinical method will depend upon the top quality of the phenotyping system and also the ability of the human graders to follow that system.

 

Fifth, though the variety of images that are available for conditions such as glaucoma, DR and AMD is sufficient to educate networks, orphan diseases are an issue because of the lack of cases. One method is to create artificial fundus pictures that simulate the disease. This is an uphill struggle and also existing techniques have actually shown to be not successful. Furthermore, it is doubtful that proficient authorities would approve a strategy where information does not stem from genuine patients. Nevertheless, generation of artificial images is a fascinating approach that may have potential for future applications.

Sixth, the abilities of DL should not be understood as proficiency. What networks can offer is exceptional performance in a well-defined task. Networks have the ability to categorize DR and spot threat factors for AMD, yet they are not an alternative to a retina professional. Thus, the inclusion of unique technology into DL systems is tough, since it will need a lot of information with this novel technology. Addition of novel technology into network-based category systems is a lengthy as well as expensive effort. Given that there are several unique imaging strategies imminent, consisting of OCT-angiography or Doppler OCT, this might have considerable capacity for medical diagnosis, category and progression evaluation. And that is a crucial challenge for the future.

Seventh, giving health care is logistically intricate, as well as services vary considerably between different nations. Implementing AI-based options right into such workflows is tough and requires enough connection. A collective initiative from all stakeholders is required, consisting of regulatory authorities, insurance coverages, health centre supervisors, IT groups, doctors, and also patients. Execution needs to be very easy as well as uncomplicated, and also without management difficulties. Quick circulation of outcomes is a crucial element in this regard. An additional step for AI being implemented into a clinical setting is a practical business design that needs to take into consideration the specific rate of interest of the patient, the payer, as well as the insurance supplier. Main factors to be taken into consideration in this regard are repayment, effectiveness, and also unmet medical requirements. Commercial versions also require to take into consideration the long-lasting ramifications, because constant connectivity and also the capability to find out is related to the capacity to improve scientific efficiency over time.

Eighth, there is a lack of moral as well as lawful guidelines for DL algorithms. These problems can take place throughout the information sourcing, product advancement, and also clinical release phase. The intent behind the design of DL algorithms likewise needs to be taken into consideration. One requires to be mindful regarding developing racial biases into the health care algorithms, specifically when the medical care delivery currently differs by race. Moreover, offered the growing relevance of quality indicators for public analyses and also reimbursement rates, there might be a propensity to make the DL formulas that would result in much better performance metrics, however not always much better clinical care for the individuals. Typically, a physician might keep the patient information from the medical record to keep it private. In the era of digital health and wellness records incorporated into the deep-learning-based choice support, it would be difficult to hold back patient’s medical information from the electronic system. Hence, the clinical values in these problems might require to advance with time.

 

Lastly, the AI system is meant to be an affordable tool for evaluating eye disease. Therefore, this might not be the bottleneck when compared with those other challenges.

For how long before we see actual adjustments in patient results as a result of applying AI/deep understanding?

Autonomous AI solves access, cost as well as quality problems in places where the diabetic person eye examination was previously not easily accessible for people with diabetic issues. We have actually executed the systems at areas where the access time to ophthalmology was half a year or even more. After installing autonomous AI, these health systems can currently give patients eye care with same-day visits. AI has currently identified countless people who have actually been checked for diabetic retinopathy, and a significant percent were found to have diabetic retinopathy, as well as were for that reason referred for additional therapy – which we understand saves sight. As a matter of fact, since the ease of access and also cost aspect of the diabetic eye test has been addressed, we have been focusing on the complete treatment path to ensure enhanced end results.
Things are happening at an exceptionally rapid pace. Besides ophthalmology, autonomous AI is not offered to the public anywhere: you cannot buy a self-driving car and truck yet, you cannot get a financing from a autonomous, unsupervised AI, but you can now obtain a medical diagnosis from an AI system. And also, patients are getting diagnosed by AI today. We find it impressive that health care was the initial area to release autonomous AI when we listen to a lot concerning self-driving cars and trucks.
What’s amazing in AI/deep learning right now?
For AI to transform medical care, specialists need to be central to the procedure. It cannot be changed by people beyond the profession, and it is far more powerful to have a healthcare specialist who has some knowledge of both worlds, than it is to have a world-leading ophthalmologist with no expertise of AI or a world-leading AI professional without knowledge of ophthalmology.
On the data science side, one very exciting area is generative models, such as generative adversarial networks as well as variational auto-encoders, which are approaches that permit one to produce artificial data, in addition to discover the latent features of a representation. On the engineering side, developments in AI DevOps platforms and also methods bring us closer to viable truly-continuous systems.
The most amazing advancement in AI/deep learning is the evolution of quantum physics published by Arute and associates from Google AI. The processor that has been called one that can dramatically boost the processing rate for data analysis. It takes about 200 seconds (3.5 minutes) to sample one instance of a quantum circuit a million times– to put this in context, the very same job done by a supercomputer currently takes approximately 10,000 years. This technology may well take us to industry 5.0 within the next couple of decades as it may, once more, interrupt several technical and also medical industries.

Does the execution of AI/deep learning into ophthalmic practice have a competitive element to it?
There definitely is an affordability aspect! Country-wise, several of the top challengers in the field of AI as a whole are the US, China as well as Russia, while the fastest-growing in regards to ability is in Africa and also Nigeria, specifically. In terms of funding as well as state-level enthusiasm, China is far in advance of every other country. The United States is a distant 2nd in financing of AI. Anecdotally, it appears that 8 of every 10 venture firms wanting to invest in AI are based in China. It will be interesting to see how it all plays out.
US/Canada and Europe have always been performing at the forefront of lots of countries worldwide due to the closeness to all the world class computer technology institutions (like Cambridge, Imperial, University of Toronto, New York City College and the California Institute of Modern Technology). Singapore is additionally fortunate to have a world-class technological team to create many durable algorithms in ophthalmology. Singapore just has a populace of 5 million. It is much smaller sized than other countries, but likewise, thanks to this, it is simpler to develop a robust ecosystem to support the scientific release of an AI formula – as an example, the abovementioned assimilation of the AI system right into the Singapore nationwide DR testing program. However, China will still get on first for numerous factors. Initially, China is the country with the largest population worldwide, and also in terms of data, they will certainly always defeat other countries. Second, individuals will after that doubt the cleanliness of their data.
The leading 5 eye organizations in China are already competing at the world-class level, including AI, and many of the Chinese medical professionals are, under-rated. It is surprising to find what they had actually currently accomplished in AI and data science in ophthalmology. Third, the Chinese government, led by President Xi, is incredibly supportive of making China an AI-integrated culture. There are lots of funding opportunities available for R & D associated tasks. At present, there are already many ongoing real time AI-integrated algorithms released in the clinical domain. That being stated, while China might still be a little ahead of the game, the language obstacle may impede some excellent clinical findings from being accepted in the high-impact medical journals worldwide.
What’s next for AI and deep learning in eye care?
The largest trouble for bringing new self-governing AI to market now is agreeing on what the disease really is. For DR or AMD, we have had outcome-based standards for decades: surrogates for outcome. It is easier to rigorously verify a self-governing AI to market when we have such an end result or surrogate outcome that is commonly accepted and also evidence based. In glaucoma, we are slowly evolving an appropriate surrogate result, as well as when that is done, we can rigorously validate independent AI for glaucoma, and also likewise for various other conditions.
10 years from now, a patient will certainly be available in, as well as we will have 10 various kinds of high-resolution imaging of the eye, like adaptive optics or OCT, a lot of different useful examinations, such as visual field screening, electrophysiological examinations, Electroretinography (ERGs), as well as complete genomic screening. Possibly we have the patient’s metabolomics as well as their proteomics from an urine sample, as well as they have actually published the contents of their phone or smartwatch, so it informs us concerning their daily tasks and also real-world visual functions. We will certainly after that need AI systems to aid us incorporate all this complicated multi-modal information, so we can make the best decisions for our patients.
Incremental steps are how we will certainly progress. The value of implementation and design will significantly be valued. Furthermore, healthcare financing models will establish as well as mature on a case-by-case basis to slowly inch us forward towards increased medical care access.

 


Panoptix  trifocal lens
 
FDA gave approval in the last week of August 2019 to Alcon’s Panoptix trifocal technology. We are excited to welcome another option to the family of PIE (presbyopia Implant in eye). We will explore the nuances of this lens, the lens material, the unique optical design and finally patient satisfaction in clinical and international trials.
 
Trifocal IOL

 
 
Multifocal lenses are defined as having more than one focus. They can have two in the traditional multifocal like tecnis and restor. Trifocals have three foci. Finally quadrifocal have four foci. Panoptix is actually a quadrifocal lens which has been modified to behave like a trifocal to improve distance vision.
If you are interested in physics and optics you can read on otherwise skip this paragraph. In a trifocal there are three points of foci. The distance is set at infinity. The intermediate add should be twice the focal length of the near. If near is at 40 cm than intermediate focus will be at 80 cm. In a quadrifocal we have distance still set up at infinity. The second add is at 1.5 times the near add and the third add is at 3 times the near. So if 1st add is 40 cm 2nd will be 60 and third at 120 cm.
 
Quadrifocal IOL

 
 
In Panoptix a special enlighten proprietary technology shifts this extended intermediary focus towards infinity or distance. This improves the distance vision.
 
ENLIGHTEN ™ Optical Technology
 

Panoptix lens is built on the acrysof platform of Alcon. More than a million acrysof lens have been implanted. This timetested platform produces glistening’s. These glistening’s can affect vision in some patients.
 
 

ReSTOR+2.5 D VS ReSTOR+3.0 D

Comparing and contrasting Presbyopia implants ReSTOR+2.5 D VS ReSTOR+3.0 D

ReSTOR®+2.5 D IOL

ReSTOR ® +2.5 D IOL with ACTIVEFOCUSTM optical layout for the patients with energetic lifestyles, such as those who

  • Participate in activities requiring more intermediate (53 cm/21 in) and distance (4 m/13 ft.) vision
  • Are not willing to compromise distance vision for a full range of vision
  • Desire more opportunity for a range of vision versus mono-focal
  • Might prefer an alternative to mono-vision
  • Desire increased spectacle independence

The ACTIVEFOCUS optical layout is crafted to take those patients’ distance vision a step further while offering the well balanced near as well as intermediate efficiency with the objective of reducing spectacle dependency for tasks like:

  • Driving and dashboard viewing while driving
  • Playing or watching live sports
  • Attending theater or performance events live

* Active-lifestyle individuals join activities that need intermediate as well as distance vision such as golf, tennis, home cleaning and also driving.

ACTIVEFOCUSTM Optical Design

Using sharp distance vision plus well balanced efficiency at near as well as intermediate focal points, the AcrySof® IQ ReSTOR®+2.5 D IOL features:

  • 7 diffractive steps
  • 3.4 mm diameter diffractive region (8.4 mm2 total diffractive area)
  • Large peripheral zone that allocates more light to distance as pupil size increases
  • 0.94 mm-diameter central refractive zone dedicated fully (100%) to distance vision
  • -0.2 μm negative asphericity

The result?

  • ReSTOR ® +2.5 D IOL designates a lot more light to the distance focal point at every pupil size, however particularly in mesopic problems.

Light distribution at a 3.0 mm pupil aperture:

  • Distance: 69.4%
  • Near: 18.0%
  • Total: 87.4%

ReSTOR®+3.0 D Multifocal IOL

Ophthalmologists should recommend IQ ReSTOR ® +3.0 D IOL with a pupil-adaptive layout for their appropriate patients who desire:

  • A broad range of vision from 16 inches (40 cm) to distance
    • The greatest opportunity for spectacle independence
    • To engage in a variety of activities requiring near, intermediate and distant focal points

Developed to minimize spectacle dependency in all distances for the broadest array of vision, this sophisticated IOL can aid your patients refocus on the activities they love:

  • Reading
    • Cooking
    • Playing cards
    • Watching TV

Pupil-Adaptive Optic Design

Providing exceptional performance at whatsoever distances, the AcrySof ® IQ ReSTOR ® +3.0 D IOL includes a pupil-adaptive optical layout crafted to maximize efficiency in all lighting conditions with the following features:

  • 9 diffractive steps spaced closer together
  • A larger diffractive region (3.6 mm diameter, 10.2 mm2 area)
  • A 0.86 mm-diameter central diffractive zone dedicated 60% to the near focal point (40% to distance)
  • Negative asphericity of -0.1 μm

The result?

ReSTOR ® +3.0 D IOL disperses light much more uniformly in between the near and distance focal points in photopic problems, preferring distance much more as the pupil broadens in mesopic problems.

Light distribution at a 3.0 mm pupil aperture:

  • Distance: 59.0%
  • Near: 25.5%
  • Total: 84.5%

We would like to summarize that both ReSTOR+2.5 D VS ReSTOR+3.0 D are PIE manufactured by Alcon. Dr. Khanna has experience with both the styles.

MIGS- minimally invasive glaucoma surgery

INTRODUCTION

MIGS is a solution for Open Angle Glaucoma, a disease of increased pressure in eye.

Open angle glaucoma (OAG) is an illness impacting an estimated 2.8 million people in the USA. It represents an approximate cost of $1.5 billion annually.  Preliminary therapy for OAG usually consists of drops that can assist in lowering aqueous humor production or boosting aqueous humor discharge uveoscleral pathway. Furthermore, laser trabeculoplasty is an additional alternative for the therapy of very early, mild, open angle glaucoma. Long-term efficiency has actually been discovered to be comparable to clinical management with drops. Commonly, pharmacologic and also laser therapy have actually been the mainstays of treatment up until the condition advances to a phase that calls for the need for trabeculectomy. This treatment is commonly reserved for those with moderate to advanced cases of glaucoma as a result of the invasiveness of the treatment and also possible complications.  While surgical alternatives had been reserved for individuals with moderate to severe glaucoma, creating micro invasive glaucoma surgical treatments (MIGS treatments) are creating brand-new alternatives for those that do not fulfill the requirements for trabeculectomy. These treatments have a greater safety profile with fewer complications and also a much more quick recovery time than various other intrusive methods. They have actually been revealed to be reliable in lowering IOP along with a patient’s need for medications, which is necessary provided a commonly reduced conformity rate for medication adherence.

Indications

Patients that are prospects for micro-invasive glaucoma surgery are:

Patients with mild-moderate glaucoma.

Primary open-angle glaucoma, pseudo-exfoliation glaucoma, or pigmentary dispersion glaucoma.

Glaucoma is uncontrolled with optimum pharmacologic treatment or there are obstacles preventing sufficient medication dosing.

Age more than 18.

Those Patients who have clinically significant cataract, their surgery may be performed simultaneously.

All patients should have a pre-operative extensive eye examination including gonioscopy and a thorough case history.

Contraindications

Contraindications for this treatment may include angle-closure glaucoma, secondary glaucoma moderate-advanced glaucoma, previous glaucoma surgical treatment, or significantly unrestrained IOP. Various other factors to consider include patients with previous refractive procedures along with monocular patients.

Minimally invasive glaucoma surgical treatment work by increasing trabecular outflow.

  • Trabectome.
  • iStent.
  • Hydrus stent.
  • Gonioscopy aided transluminal trabeculotomy.
  • Excimer laser trabeculotomy.
  • Suprachoroidal shunts.
  • Cypass micro-stent.
  • Reducing aqueous production.
  • Endo-cyclophotocoagulation.
  • Sub-conjunctival filtration.
  • XEN gel stent.

Trabectome

Trabectome is a surgical treatment established by NeoMedix (Tustin, CA). It was introduced in 2004 that allows a trabeculotomy to be executed through an interior technique. The system works by eliminating a strip of trabecular meshwork and also the internal wall surface of Schlemm’s canal in order to produce a course for the drainage of aqueous humor. The device itself consists of a one-use, disposable hand piece that is utilized for electro-cautery, irrigation, and aspiration. It is connected to a generator with a frequency of 550 kHz that enables adjustments in 0.1 watt increments as well as is managed through a 3-stage Foot Pedal Control that initiates irrigation, aspiration, as well as electro-cautery in sequence. Constant irrigation as well as aspiration allows for removal of debris as well as regulation of temperature. Furthermore, the suggestion of the Trabectome is curved at a 90 ° angle to develop a protective triangular footplate and also enable less complicated insertion right into Schlemm’s canal as well as coated to allow smoother movement within the canal. Ablation of 60 ° -120 ° enables re-establishment of the water drainage pathway. Maeda et al reviewed the end result of surgical procedures making use of Trabectome in 80 eyes of 69 patients. A mean preoperative IOP of 26.6 ± 8.1 mmHg was found to reduce to a mean postoperative IOP of 17.4 ± 3.4 mmHg within 6 months after the surgical treatment. Average number of medicines likewise lowered from 4.0 ± 1.4 to 2.3 ± 1.2 at 6 months. The research study reported no major complications, including chorodial effusion, chorodial hemorrhage, or infection.

iStent

The device is a heparin-coated, non-ferromagnetic titanium stent with a snorkel shape to assist in implantation. The device is placed using a single-use, sterilized inserter through a 1.5 mm corneal incision. The applicator is inserted right into the anterior chamber and across the nasal angle. The pointed tip allows penetration of the trabecular meshwork and insertion into Schlemm’s canal as well as 3 retention arches ensure that the device will certainly be held in place. The iStent itself is the smallest FDA approved device, measuring at 0.3 mm in height and 1mm in length. In a prospective randomized clinical trial, the effectiveness of phacoemulsification as well as stent placement compared to cataract surgery alone was assessed in 239 patients, with 116 patients receiving the stent. Patients associated with the research were those with mild-moderate glaucoma who had an un-medicated IOP in between 22 and 36 mmHg.

CyPass Micro-Stent

The device itself is a polymide, supraciliary device for ab-interno implantation. The objective of the device is to create a regulated cyclodialysis with stented outflow to the supraciliary space. The stent is 6.35 mm long with an outer diameter of 0.51 mm. throughout surgery, the implant is loaded onto a retracting overview wire, inserted through the preliminary phacoemulsification incision, and also advanced towards the sclera spur. The overview wire is utilized to execute blunt dissection of the ciliary body in order to permit passage into the supraciliary space where the stent can be placed. In the CyCLE study, 238 patients received the CyPass Micro-Stent in addition to cataract surgery treatment. In general, the device has actually shown in initial trials that there can be a considerable decrease in number of medicines used in addition to a considerable reduction in uncontrolled IOP or maintenance of a controlled IOP. This device has been recalled due to corneal problems.

XEN Glaucoma Implant

The XEN Glaucoma Implant (AqueSys Implant) was created by AqueSys Inc and is an investigational device that is presently going through medical trials. The implant itself is constructed out of a soft, collagen-derived, gelatin that is known to be non-inflammatory. The goal of implantation is to create an aqueous humor outflow path from the anterior chamber to the sub-conjunctival space. The implant is infused through a small corneal incision with using an inserter similar to those used for IOLs. Similar to various other implants, it can be done along with cataract surgical treatment. While minimal, there is company offered data readily available from worldwide trials. In general there have actually been 118 topics that have actually received the implants. The mean preoperative IOP was 23 mmHg with approximately 3 medicines. At the 12 and 18 month postoperative follow ups, the mean IOP had actually decreased to 15.4 ± 4.5 mmHg and after that 14.5 ± 3.1 mmHg, respectively. At 24 months, it was 14.3 ± 5.1 mmHg. At all-time points, the typical variety of medicines was one and 33% of patients were using no medications at 24 months.

Hydrus Microstent

It is a device which is implantable, flexible, a metal nitinol (Nickel Titanium) tube with windows (open-back stent) pre-loaded onto a hand-held delivery system which is used to implant the stent. The Hydrus ® Microstent is meant to decrease eye pressure (intraocular pressure, or IOP) in grown-up individuals with moderate to modest primary open angle glaucoma (POAG) by functioning as a support structure in one part of the natural drainage path of the eye (Schlemm’s canal). POAG is a kind of glaucoma where there is associated eye disease causing increased eye pressure and also where the eye pressure normally increases gradually. This progressive increase in eye pressure can be related to damages to the optic nerve which will impair vision significantly.

Gonioscopy Assisted Transluminal Trabeculotomy (GATT)

GATT is a kind of ab interno trabeculotomy which was defined by Grover et al in 2014. Under the guidance of a gonioscopy lens, a goniotomy is made in the nasal trabecular meshwork which functions as the entry point for the iTrack micro-catheter (iScience Interventional Corp, Menlo Park, CA), which has a 250 micron diameter. A customized method has actually likewise been explained using 4-0 nylon suture rather than the micro-catheter. Microsurgical forceps are used to advance the micro-catheter into Schlemm canal circumferentially 360 degrees, tracking its development with its illuminated distal suggestion. Once it has actually been gone through the entire canal, the catheter is externalized to create a 360-degree trabeculotomy. In their original evaluation, Grover et al reported on the 6 as well as yearend results of 85 patients; 57 patients with primary open angle glaucoma showed an average IOP decrease of 11.1 ± 6.1 mm Hg as well as fewer medications. For the 28 patients with secondary glaucoma, IOP reduced approximately 19.9 ± 10.2 mm Hg and 1.9 fewer medications. One of the most usual problem was a short-term hyphema reported in 30% of patients which resolved by one month. Considering that the original publication, Grover and colleagues have actually reported the effective use of the GATT technique in primary congenital glaucoma, juvenile open angle glaucoma, and also even eyes with prior incisional glaucoma surgical treatment. These very early results an appealing, conjunctival sparing method that can be utilized in conjunction with, or independent of cataract surgical procedure.

Conclusion

In patients with mild-moderate glaucoma with an IOP that has actually been unable to be controlled by medicines or who have poor medication compliance, micro invasive glaucoma surgery appears to be a feasible option. Clinical trials have actually revealed there to be a substantial decrease in IOP over periods of up to 24 months along with a significant reduction medication usage. The procedure has maintained a high safety and security profile with minimal adverse impacts. While the Trabectome as well as iStent are presently the only FDA authorized devices, there are several brand-new devices pending. Micro invasive glaucoma surgery can provide a technique of treatment for glaucoma patients that reduces dependence on medicines without the risks of more invasive procedures.

RESTOR 2.5 VS SYMFONY.

AN APPROACH TO CHOOSING PRESBYOPIA CORRECTING IMPLANTS IN THE CONTEXT OF               RESTOR 2.5 VS SYMFONY.

With reference to Presbyopia Correcting Implants, it is an accepted fact amongst ophthalmologists that  extended depth of focus lenses have actually increased interest in presbyopia-correcting lenses for surgeons as well as patients. As this topic relates, these implants provide an extended focal range rather than 2 unique focal points as in a multifocal lens. Although optically the Tecnis Symfony uses a unique system, functionally the Tecnis Symfony works likewise to a low add multifocal in offering patients distance as well as intermediate vision.

However like any type of lens that prolongs beyond a single focal point, the EDOF Symfony does have its constraints. Despite an ideal emmetropic result, a couple of patients complained about “spiderweb” glare, specifically while driving at night. These complaints become much more common when there is residual refractive error. These implants are certainly much more flexible of residual refractive error than conventional high add multi-focals, however, Doctors have actually learned to avoid doing mini-monovision with them due to these undesirable visual phenomena.

Around 60% of cataract patients choose presbyopia-correcting lenses, and here’s an approach the eye surgeons actually found to be extremely rational based on data from several research studies they have actually performed on patient satisfaction.

Initially, we’ll just talk about patients who are good prospects for a multifocal or EDOF lens. They have healthy and balanced maculas, controllable completely dry eye as well as fairly aberration-free corneas.

If a patient has astigmatism more than 0.5 D and also desires distance and intermediate vision, the Symfony toric is a an option.

For patients who prefer distance, intermediate as well as near, I do not recommend targeting a mini-mono-vision with an EDOF Symfony lens. A lot of these patients do not tolerate the spider-webs in the non-dominant, near eye. With low astigmatism, it likewise makes sense to do this with a Tecnis multifocal 2.5/3.25 also.

Now lets look at Restor active focus. It is yellow in color. It also provides ability to correct astigmatism.Again we do not recommend monovision with these. We have tried mini monovision in patients who were aleready employing that strategy with contact lenses. Those pateints did well. A better option, these patients will certainly do well with a ReSTOR ActiveFocus 2.5 in the leading as well as a +3.0 ReSTOR in the non-dominant eye. Therefore, we can achieve goal of reducing spectacle dependence for activities like Driving and Dashboard viewing, Playing or watching live sports & attending theatre or performance events. While Tecnis SYMFONY IOL lessens the effects of presbyopia and enable the patients to see clearly.

COMPARISON :-

  SYMFONY   Tecnis Symfony is an extended depth of field lens. It works  a low add multifocal in offering patients distance as well as intermediate vision.   Patient’s complaints about “spiderweb” around lights, specifically while driving at night.         Tecnis Symfony is certainly much more flexible of residual refractive error than conventional high add multifocals for patients who prefer distance and also intermediate (but not near) vision and if they have low astigmatism.   Appropriate for patients who prefer distance, intermediate as well as some near vision.   It has high refractive accuracy but can rotate.   ReSTOR ActiveFocus 2.5   While ReStOR works on those patients who have astigmatism more than 0.5 D     With ReSTOR, patients have complaints of glare and also halos. They do not face “spiderweb” glare problems. They do well with a ReSTOR ActiveFocus 2.5 in the leading as well as a +3.0 ReSTOR in the non-dominant eye.   ReSTOR one may have desire more opportunity for a range of vision versus monofocal.         For patients who are not willing to compromise distance vision for a full range, ReSTOR is an appropriate answer. ResTOR is having more rotational stability for both eyes, again targeting emmetropia. This is important with toric lenses        

CONCLUSION:-

In the present scenario, multifocal intraocular lenses (MF IOLs) are the most stable,reliable and dependable method for the surgical correction of presbyopia.  While looking at the facts, residual astigmatism is one of the leading causes of dissatisfaction after the implantation of a MF IOL.  

These IOLs require emmetropia for the attainment of the best visual results, and small amounts of astigmatism that may limit visual performance significantly.  Thus, astigmatism has to be completely corrected in order to obtain the maximum efficiency of a MF IOL. Hence, we like to correct astigmatism by various methods. If it is astigmatism with spherical equivalent of zero, we perform limbal relaxing incisions at the time of cataract surgery or during follow-up period. When there is associated myopia or hyperopia we deploy advanced wavefront idesign laser vision correction achieve emmetropia.

symphony toric presbyopic implant

Symfony or Tecnis Multifocal lens for Presbyopia Treatment

Today our topic of discussion will be Symfony or Tecnis Multifocal lens for Presbyopia Treatment.

Hi. I am Doctor Khanna, here with some models of intraocular lens implants when we do cataract surgery or we want to get rid of glasses and you are not a candidate for Lasik surgery. For example, if you are 56 years old and you want to be able to see far, middle and near, then you are up for presbyopic implants. There are different types of presbyopic implants. Today, we are going to talk about the differences between ‘Tecnis’ and ‘symfony’, which are both from Johnson and Johnson.

This is how the lenses look like. This is a clear lens and this is ‘Tecnis’ and ‘symfony’. ‘Symfony’ has less rings than ‘Tecnis’ and it is considered an EDOF (extended depth of field) lens. Whereas, ‘Tecnis’ has certain ridges, which splits the incoming light into distant and near. You can see distant and near and the bimodal curve, lets you see middle. ‘Symfony’ acts like a pin hole camera where you can see middle, distance and somewhat near.

How are you going to choose between the two? If you have long hands, then choose ‘Symfony’ but if you want to real closely then choose ‘Tecnis’. If you have had previous surgery like radial keratotomy then ‘symfony’ might be a better choice. In terms of side effects, ‘Tecnis’ has glare initially which faded away and ‘Symfony’ you can see a spider web. The best option is to discuss these various choices with your surgeon and to make sure that the surgeon is comfortable with the choices.

If you have more questions about Symfony or Tecnis Multifocal lens for Presbyopia Treatment call (310) 482 1240.  You can always read my book on amazon ‘The Miracle of PI in Eye’.

Have a wonderful day.

Hydrus Microstent for Early Glaucoma

Hydrus ® Microstent is a new type of MIGS

What is it? The Hydrus ® Microstent

It is a device which is implantable, flexible, a metal nitinol (Nickel Titanium) tube with windows (open-back stent) pre-loaded onto a hand-held delivery system which is used to implant the stent. The Hydrus ® Microstent is meant to decrease eye pressure (intraocular pressure, or IOP) in grown-up individuals with moderate to modest primary open angle glaucoma (POAG) by functioning as a support structure in one part of the natural drainage path of the eye (Schlemm’s canal). POAG is a kind of glaucoma where there is associated eye disease causing increased eye pressure and also where the eye pressure normally increases gradually. This progressive increase in eye pressure can be related to damages to the optic nerve which will impair vision significantly.

How does it work?

The Hydrus ® Microstent is implanted right into the eye of glaucoma patients to help fluid in the front part of the eye anterior chamber, or AC flow much more easily through Schlemm’s canal.

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When is it used?

The Hydrus ® Microstent is intended to be used during cataract surgery. This is important for the reduction of intraocular pressure (IOP) in adult patients with mild to moderate POAG.

What will it accomplish?

In a medical research of 369 individuals, 77.2% who obtained the Hydrus ® Microstent attained a 20% or higher reduction in their IOP (intraocular pressure) compared to 57.8% (108/187) of the individuals having cataract surgery alone.

When should it not be used?

The Hydrus ® Microstent should not be used in patients who have any of the following problems:

  • When the colored part of the eye (iris) is pushed up against the drainage pathway (Schlemm’s canal) or when various other material obstructs the drainage pathway (Angle closure glaucoma);
  • Traumatic glaucoma, malignant glaucoma, or inflammation of the eye tissues (uvea);
  • Glaucoma related to the growth of abnormal blood vessels in the eye (neo-vascular); or
  • Visible birth abnormalities of the anterior chamber (AC) angle.

Treatment for Kearatoconus eye disease

Kertatoconus Expert Answers Your Questions

​Q1. Is Keratoconus eye disease hereditary?                                                                          A1. Genetics are supposed to play a part in transmission of this disease.

Q2. Neither my parents nor my grand parents had the disease. Why did I get it?           A2. Your grandparents may have had subtle disease. In those times diagnostic equipment to detect this sight threatening disease did not exist. There is also a possibility that your disease may be a new mutation. Finally there is a chance it may be not be hereditary.

Q3. Besides genes is there any cause for getting Keratoconus?                                         A3. Rubbing the eye is a major culprit. In fact there is a school of thought that this is the major common pathway for progression. So please do not tub your eyes.


Insurance and keratoconus treatment reimbursement.

​Q. Does vision insurance like VSP or Spectra cover surgical treatment of keratoocnus?                                                                                                                               A. VSP covers for contact lens like scleral contact lens​ for improving vision in keratoconus eyes. They do not reimburse for cornea cross linking or intacs.

Q. Which medical insurance covers cxl for keratoconus?                                                   A. Many medical insurances have started reimbursing for prevention of progression of keratoconus. An important caveat is that the surgeon has to be certified  to use FDA approved riboflavin. Currently Avedro Photrexa is the only FDA approved.

Q.If I have a high deductible, can I still have cxl?                                                                A. Yes you may even use affordable monthly payment plans.

Q. Can i use my flex or HSA plan towards my keratoconus eye procedure.                   A. Since this is a medically necessary procedure you can pay for it by HSA or FLEX funds.

Treatment options of Astigmatism

Astigmatism – Everything you wanted to know about it

Diagnosis of subtle refractive errors

Nearsightedness also called myopia is a condition where objects up close appear clearly, while objects far away appear blurred. In nearsightedness, light comes to concentrate before the retina after passing through the eye lens instead of on the retina. Clinically evaluated this common eyesight problem makes distant objects appear blurry, while close objects still appear sharp. Nearsightedness affects about 25 percent of all individuals in the United States, according to the National Eye Institute.

Farsightedness, likewise called hyperopia is also a common type of refractive error where distant objects might be seen much more clearly than objects that are near. However, people experience Farsightedness differently. Some people may not notice any type of problems with their near vision, especially when they are young. For people with significant farsightedness, vision can be blurry for objects at any type of distance, near or far.

Causes of Nearsightedness

The majority of nearsightedness cases result from an eyeball that's too long which prevents light from focusing directly on the retina (the "screen" at the back of the eye). Nearsightedness can be caused by a cornea (clear layer at the front of the eye) that's not shaped correctly. In fact, these two problems intercept light from focusing directly on the retina. Rather, light focuses in front of the retina, which makes distant objects appear blurry. Although researchers still don't know exactly why some people develop nearsightedness while others don't, it's possible that the problem may be genetic. If one or both of our parents is/are myopic, our chances of having the problem is higher those of a person whose parents aren't nearsighted.

Nearsightedness: Signs and symptoms

Nearsightedness might develop gradually or quickly. It usually initially occurs during childhood, and also can intensify as time goes on. Signs and symptoms of nearsightedness might consist of:

• Distant objects appearing blurry.

• The need to squint to see objects clearly.

• Headaches.

• Difficulty driving because of poor eyesight, especially at night during the night.

Identifying Nearsightedness

A complete eye examination by an optometrist can quickly detect nearsightedness. Commonly, eye-clinic vision tests will certainly be the first time a parent learns about a child’s nearsightedness. Sometimes parents or teachers will find nearsightedness after seeing a child squint in order to see distant objects. Grownups may start to realize that they have the problem when they have trouble watching movies, can't see distant objects clearly while driving, or participate in other activities that involve looking at far-away objects. If someone is having trouble seeing things that are far away, it's an excellent idea to get an eye examination. Even if he/she has no symptoms of nearsightedness, it's a good idea to get an eye examination around the time you turn 40.

Then, after that experts recommend getting an eye examination:

• Every 2 to 4 years between ages 40 and 54.

• Every 1 to 3 years between ages 55 and 64.

• Every 1 to 2 years beginning at age 65.

CASE STUDY

John who is a 10-year-old shy kid came to our clinic for a consultation reporting ‘blurry vision in one eye’. His mother searched online and learned about myopia, also known as nearsightedness. She had been told by a previous ophthalmologist that her son did not need to wear glasses since the kid had said he was ‘seeing well’ last year. However, in early February, John had started complaining his right eye was getting tired very easily and he could not concentrate well when he was reading or doing near work. John enjoys playing robotic games on the computer in his leisure time, and he said that he could no longer play as much as he used to without complaining of eye strain. His mom got concerned about the rapid change in his vision and the discomfort he experiences. As she did more in-depth research about myopia or nearsightedness, she found out about the unique ‘myopia control service’ offered by Khanna institute on Google.

Interestingly, neither parent has vision issues or need for glasses. Upon further evaluation, Dr. Khanna found that John had myopia in the right eye while his left eye displayed mild hyperopia and astigmatism. This condition is generally known as ‘anisometropia’ in which the shape and prescription is distinctively different in each eye. Given the fact that he was not prescribed with glasses last year, when they were checked, it was assumed that the level of myopia at that time might have been miniscule or considered ‘asymptomatic’. The onset of myopia often begins with a low amount of nearsightedness which can often go undetected. If left untreated for long, however, myopia can suddenly spike up and result in noticeable blurry vision for long distance vision. The case of John also raised the suspicion of ‘lazy eye’ or amblyopia due to the distinct anatomical and optical differences between the two eyes. Fortunately, he can be corrected to 20/20 perfect vision with no indication of lazy eye.

 Upon extensive educational talk and discussions with John and his mother, Dr. Khanna recommended an individualized myopia control treatment for him using K.I.D.S. (Keratometric Induced Dioptric Steepening) or overnight contact lens for the right eye to slow or halt myopia progression at that time. The untreated left eye would be monitored closely to ensure that it would not develop myopia in the long run.

 After the first day of overnight lens wear, John’s unaided vision in the right eye was 20/20 or perfect vision. He noticed that not only had his distance vision improved significantly after just one night of wearing the corrective contact lens in one eye, he also reported that he could read more comfortably with little stress or strain. His mother was amazed about the great result in such a short period of time, and the mother and kid were grateful to witness the shy kid who initially hid behind his mother’s back finally showing a grin and becoming more relaxed after knowing that he could see much better than before.

If you are concerned about your child’s myopia, please visit our website www.khannainstitute.com and schedule a complimentary evaluation with Dr. James Giraldi at our Westlake Village office..

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