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All posts by Rajesh Khanna, MD

Curing Lazy Eye – New Technology Cures Amblyopia

Curing Lazy eyes is possible in expert surgical hands. Education about lazy eyes is important as it can cause learning disabilities in children. Lazy eye is also technically referred as Amblyopia.

Recently a mother and her daughter came to our office. They both said they had lazy eyes and previous doctors had said nothing could be done for them. In fact, the mom said her optometrist cautioned her that nobody should ever touch her eye. Well we changed that unnecessary caution into sight!

            Lazy eye is an eye which is not working to its full potential. This is caused when an eye has a higher degree of prescription compared to the other eye. This may be because the eye is smaller causing farsightedness or longer leading to nearsightedness or asymmetric resulting in astigmatism. The image from this eye is not sharp and therefore the brain suppresses it. You may ask “what if the patient wore glasses or contact lenses?” and that’s a great question. The refractive defect is usually so much that with correction the image shape and/or size is markedly different leading to dissimilar images which cannot be superimposed by the brain.

This is different than a sleeping eye. In such circumstances the vision nerve called optic nerve or other components of the neuro visual pathway are not developed. Current technology cannot fix these problems, but we hope that future generations will be able to cure these issues.

We will restrict our discussion to lazy eyes caused by refractory errors. Let’s turn our attention to what has been the treatment modality for the last hundred years followed by looking at application of modern technology to fix this ailment. Traditionally the most common intervention has been to prescribe glasses and patching the “good eye” so the weak eye is forced to see. Kids hate it and get scared when they cannot see well out of the lazy eye. It is illogical to resort to patching without fixing the underlying problem. It’s like forcing a person to walk on a broken leg to make it stronger. We don’t do this do we? Instead we set the fracture and then start the rehabilitation.

We first perform a very detailed eye exam to determine the refractive state of the eye. We do scans of the cornea, nerve and macula to confirm they are normal. The treatment varies based on age but kids as young as eleven can have laser vision correction in a normal laser suite. Younger kids may need an anesthetist. If the prescription is way higher for laser vision correction than an implantable collamer lens may be employed. In patients older than forty five, PIE or presbyopia implant in eye is used.

The sooner the eye is corrected the better the chances of equalizing the both eyes. Interestingly what older textbooks taught there is no cut off age to restore lazy eyes, however patients in their seventies have had lazy eye improved by our interventions. Once in a while we are even amazed to see the lazy eye overtake the good eye and become the stronger one.

If we do not intervene, the lazy eye can deviate out or in leading to squinting or strabismus. Before any squinting surgery is undertaken, the lazy eye should be fixed. Otherwise the eye may again move away.

PIE; Cosmetic or Visual?

​PIE or as we know it as Presbyopia Implant in Eye is a groundbreaking procedure. It has been popularized and refined by Rajesh Khanna, MD. Insurance industry does not cover the procedure as they have labelled it as Cosmetic. Nothing is further from the truth. 

PIE is vision enhancing liberating surgery which increases patient mobility and safety. There is improvement in vision at all distances. There is an increase in peripheral vision as the glasses frames are eliminated. Studies have shown that the incidence of hip fractures and falls decrease by 50 % when vision is improved. So it is easy to conclude it is sight enhancing procedure. Some people may look better without glasses so it could be considered cosmetic too.

Medical or Vision Insurance

​So you might ask why is it not covered by the insurance industry. Therein lies the beauty of our health care system which every one claims to be broken.

1. ​PIE evolved from lasik eye surgery. Lasik eye surgery was never covered by insurance. It follow that the derivative is not covered.

2. Eyes are considered separate from the body. So we have medical insurance for the body. For eyes we have vision insurance. But wait, it gets more fun. Vision insurance only covers glasses and contact lens. If there is pathology in eye like cataracts, glaucoma than medical insurance is deployed. PIE does not fit any of the rigid division of medical vs vision insurance industry. It does away with glasses and future cataracts. So in a utopian world both insurances should be jumping to cover it.

How can I afford PIE procedure?

​You certainly seem interested but taken aback that all the premiums you have been paying will of no use when considering PIE eye procedure. There is hope. You can pay by credit card or avail of the no interest low monthly payment options available through care credit or wells fargo health services. A simple 1-2 minute application gives instant answers.

Lasik or PIE – That is the question

PIE or Lasik – that is the burning question question for people above 45 years of age.

This article will define the two procedures, discuss benefits of each, look at advantages and disadvantages of PIE and Lasik and finally will help you discover which is the best procedure for people who have spens more than 4-5 decades on earth.

Most people are familiar with Lasik eye surgery. Lasik is a method of vision correction surgery using laser technology to reshape the eye. Lasik on the hand is a corneal procedure and there is no entry into the eye. So it can be done in a Lasik suite. The recommended age is above 18 years. The corneal shape and thickness distribution has to be normal as well as sufficient for the treatment. IF there is shortage of tissue superlasik  or superficial Lasik may be considered. ICL or Implantable collamer lens may be the only option in severe nearsightedness. All these three procedures are static or monofocal procedures. That is they set the power of the eye to a set distance usually infinity. If the eye can change the shape and power of the natural lens than the eye can see middle and near. That means it works well for people under forty-five years of age. Therefore, these are the procedures of choice in the age group 18 to 45 years of age.

The story changes above 45. Only a handful of people would qualify for Lasik eye surgery. These would be the low hyperopes or people wanting blend vision. Of course, they should not be susceptible for dry eyes.

PIE is a newer technology. PIE is short for presbyopia implant in eye. This is a short painless procedure where the contents of the natural lens are exchanged for a manmade plastic lens. The procedure is performed under sterile conditions in an ambulatory surgery center. The implant is made of acrylic or silicone which are very well tolerated by the eye. So naturally this question gets posed very often “Doc which is the better option for me – Lasik or PIE?” For the rest PIE is the best. It allows a person to see at different distances with each eye. Once the procedure is done in both eyes it yields natural binocular vision. And wait there is more. This is a permanent procedure. The patient undergoing PIE will never develop cataracts. PIE does not induce dry eyes. It is also superior to monovision.

Few surgeons are adept with the nuances of this method of permanent vision procedure called PIE. Hence you may not have come across much info till now. Rest assured if you were born before 1975 this is the procedure of choice for you.

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Panoptix trifocal lens

Welcome to Panoptix  trifocal lens the latest strategy to reverse presbyopia.
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.

Construction of Panoptix trifocal lens

This is a single piece biconvex lens with a central optic made of a high refractive index hydrophobic acrylic material capable of being folded without damage prior to insertion through a smaller wound. The central 6.0 mm optic has two haptics on either end giving an overall lens diameter of 13 mm. In the central 4.5 mm of the optic there is a diffractive portion which divides the light to create +2.17D Intermediate (+1.65D at cornea) and +3.25 D Near (+2.35D at Cornea) add power. Front surface of the lens has negative spherical aberrations to counteract the positive ones generated from the cornea.

Panoptix Toric trifocal lens to correct astigmatism and presbyopia

Panoptix toric has a posterior toric surface marked by 3 dots on each side of the flat axis. If it rotates from intended axis it loses effect. If rotation is more than 30 degrees, it may make astigmatism worse.

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 time tested platform produces glistening’s. These glistening’s can affect vision in some patients.

We will be soon be comparing advantages and disadvantages of panoptix with restor, tecnis multifocal, symfony toric and crystalens.

PIE more favorable than Multifocal Contacts or Progressives

I can remember the day a young single woman in her forties told me why she hated her readers so much. She said her dates considered her to be in her thirties till her readers came up to check out the menu. Since then and after speaking with many youthful looking individuals, I realized that wearing readers is a true nuisance. As we stress on physical activity and good diets, we are able to keep our bodies younger for a longer amount of time but the eyes seem to be from a different world. People also hate to carry around the readers or hang them from their necks. If they forget them on a trip or the glasses break, it can affect the working day especially for a pilot.

What have the other options been for these people till now?

Let’s consider multifocal glasses termed bifocal, trifocal and progressives. Bifocals have two foci distance and near, trifocal has an additional for near while progressives have multiple foci. The first deficiency like of any eye wear is the limitation of peripheral visual field. This can vary from a nuisance of turning your head to see in periphery to difficulty performing critical tasks like driving. During rainfall or in foggy conditions these can create a real problem and you may as well forget about water activities.

Are progressives really safe? This might seem like a joke but there are people with progressives who get so tired adjusting their head and shoulders to see better that they develop neck and shoulder problems that can require physical rehabilitation. A few might even become susceptible to depression.

Contact lenses can be used to create monovision. We have discussed that elsewhere, so now we can restrict our discussion to multifocal contact lenses. These are soft contact lenses which have alternating rings for distance and near zones. In the center is a primary viewing zone. This is usually for distance (called a center-distance design), but in some model’s center-near designs also are available. These latter are more often used in non-dominant eyes and with large pupils.

The near add power, this can be low, mid or high power. They differ than PIE as they are refractive lenses and not diffractive lenses. Refractive PIE implants have been abandoned.

Why do multifocal contact lenses do not work? With each blink the lenses move. We know even a few microns movement of pie can affect vision. Now imagine constant movements with every blink, and a different amount of movement each time. That means a different version of the world every few seconds. Neuroadaptaion in such circumstances is very difficult.  Less than 30% of people can adapt. That may seem like a big number but remember very few people can tolerate contact lenses in that age group. Brain reacts to this by “Killing me slowly with your winks”.

Like any contact lenses, they are difficult to wear especially with dry eyes, hand tremors, small eyes and the like. There is always the chance of scratching or an eye infection.

PIE eliminates the movement aspect and is designed as a diffractive lens which continues to improve with time. Once implanted in sterile conditions, it is immune from infections. It does not cause dry eyes and works in even in amnesiacs who forget where they have placed their glasses or contact lenses.

Superiority of PIE Procedure over Cataract Eye Surgery

There are many advantages of PIE surgery when compared to Cataract Eye Surgery. We will enumerate the superiority of PIE Procedure over Cataract Eye Surgery.

Cataract eye surgery, believe it or not, was invented in India over 2000 years ago by a surgeon named Susruta. His concept was to let the cataract mature till the patient could not see at all. He than performed a procedure called needling which pushed the cataract back. Whatever the patient could see was considered a blessing. Over the centuries the techniques and skills of cataract surgery have evolved but the basic concept remains the same, that is remove the cataract and accept whatever the result.

PIE or presbyopia implant in eye is a paradigm shift in this thinking. Almost like how theory of relativity jolted our concepts. PIE is goal directed surgery. We define the goals or outcomes before we begin the journey. The patient and surgeon decide which zones of vision would be of utmost importance. The patient shares history of previous surgeries, current diseases and medications with the surgical team. The surgeon than does a state of the art eye exam including three dimensional scans of macula, cornea and optic nerve. The PIE surgeon than needs to reflect on the combination of all this information obtained to set up a realistic goal, which has to be achieved.

Dr Khanna explains why PIE procedure is superior to Cataract Surgery

We can turn to football to understand the difference better. Cataract is like the quarterback throwing a ball. The direction and distance is not guaranteed. His job was to throw the ball and that was it. In PIE the quarterback has to throw to score a touchdown. Most of the times it will be on the first attempt. Sometimes it will be a little short of the touchdown line and the wide receiver has to catch and take it across. In every throw a touch down is essential.

Cataract surgery is only performed when the cataract is advanced that it interferes in daily work. The doctor has to determine if the cataract is ready for surgery. Further the insurance guidelines have to met and in the case of HMO someone has to approve it. A person above forty five is free to choose PIE whenever he so desires. The doctor and patient make the decision. There are no middleman. So a person does not have to suffer with deteriorating vision

Cataract Surgery is a term encompassing various techniques. The entire lens could be removed or some parts could be left behind. Injections, sutures and patches might be employed. Of, course after the procedure the patient needs some type of glasses. PIE involves a very specific technique. There are no injections, no pain, no patches and no sutures. A presbyopia implant has to be placed well centered in a pristine position. After the successful procedure person should meet the predetermined goals of seeing at various distances without glasses.

PIE has evolved from combination of cataract and lasik eye surgery. It utilizes principles of astigmatism and power correction of lasik eye surgery and applies them to an evolved from cataract surgery.

Types of PIE or Presbyopia implant in eye

Presbyopia implant in eye has been the new revolution in vision restoration. It has eclipsed Lasik as the number one choice to improve vision in people over age fifty years.

A good tailor as well as a good surgeon knows that one size does not fit all. This holds true even with PIE. There are four classes of FDA approved PIE. These are Accommodative, extended depth of field (EDOF), Trifocal and Multifocal.

Accommodative PIE: This class of PIE were the first to be approved by FDA in 2005. They heralded the advent of PIE. Crystalens was the first out of the stable. It had various modifications till it evolved int Crystalens HD. Today we have Crystalens AO and Trulign. They are made of silicone. Crystalens AO has aspheric optics whereas Trulign has aspheric optics and built in astigmatism correction. They work by assuming a curved shape in the eye, increasing the range of focus. This shape and the unique design of the lens may also allow it to move forward and backward mimicking the natural lens. This lens has proved very useful in patients who have had previous eye surgery like lasik vision correction, radial keratotomy and other corneal procedures.

Extended Depth Of Field (EDOF)PIE: They are in a class of their own. They resemble multifocal PIE in appearance but function on a different optic principle. They increase the natural depth of field. It provides a continuous field of vision, though the range is not as extreme as in multifocal. Symfony and Symfony toric are the two contenders here. As you may have guessed from the names, sympfony toric can also correct astigmatism. Hence, they find great use in eyes with astigmatism. Both also are used in eyes where crystalens may not be an option.

Trifocal PIE: These PIE have apodaizations or rings in their center. The unique heights of the rings of this lens allow the incoming light to be split into three foci. One for distance, second for intermediate and third for near. Optical engineers can modulate the height of rings and distance between rings to design varying focal length for each zone. Currently we have Panoptix and astigmatism correcting Panoptix toric.

Multifocal: These are the lenses which arrived earlier than trifocal. They are truly bifocal but were labelled multifocal to distinguish them from bifocal glasses and contact lenses. Their mechanism of action is totally different than bifocal glasses. In bifocal glasses the top segment is for distance and lower for near. These are refractive lenses. This method was tried in the previous century but was not successful. Multifocal PIE are diffractive in construction and have a focal length for distance and one for near with an overlap for middle. They allow more light for far and therefore better distance vision. Restor and Tecnis are the two lenses in this class.

A surgeon who is an PIE expert needs to be proficient in all these types of presbyopia implants. Matching the best PIE to the patients’ after understanding the goals of the patients is paramount to success. This can sometimes involve implanting a different class of PIE in each eye.

Superiority of PIE over Monovision.

Superiority of PIE over Monovision can be demonstrated theoretically as well as recounted by various people.

We have two eyes. Each eye sees the world differently. The generated images are fused in the brain giving rise to binocular vision. This allows us to judge distances accurately. Binocular vision allows us to change lanes on either side, put thread in a needle and more tasks in our daily life. Top baseball and basketball players have been shown to have superior binocular vision. In youth this binocularity is available to us at all distances. As we hit the forties the near vision begins to deteriorate. This is due to the gradual linear failure of the autozoom mechanism of the natural lens. To restore the near binocular vision reading glasses or cheaters were invented.

PIE is hugely better than monovision

Many people do not like to carry around readers. Some even hate wearing them. Around fifty years ago or someone came up with the idea to use contact lens to give reading ability to one eye while keeping the other eye for distance. This eliminated not only reading glasses but also binocularity. As no other option was available this method of monovision was replicated with lasik and even with cataract surgery. Sone surgeons have used newer implantable lenses like acrysof and softec HD to do monovision in people seeking refractive surgery.

Now we have newer technology where we don’t have to compromise on reading or binocular vision. Presbyopia implant in eye or PIE allow us to see at all distances with depth perception.

These new generation of presbyopia implants are a technological marvel compared to monofocal softec HD. Hence their cost price is over ten times of softec HD and other monofocal lenses.

There are many people who have had monovsion in the past and now selected PIE as an option to improve their life. They recount the benefits they had missed. They say it feels more natural and makes them more youthful. They don’t have to turn their head all the time while driving. Reading is less strainful. The biggest problem the monovison people have is if some foreign body enter their eye. This takes away the distance vision completely. It could be very dangerous if it were to happen while driving.

There are four varieties of PIE. They are accommodative, extended depth of field, trifocal and multifocal. They can be utilized to restore binocular near vision even if one is wearing monofocal contacts, multifocal contacts, or had undergone RK, lasik, PRK or other refractive surgery in the past.

Artificial intelligence in Ophthalmology

Artificial intelligence (AI) in Ophthalmology


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.


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 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.


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.

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