The Digital Age and Ophthalmology

Everywhere people are talking about the digital age - autonomous cars, smart lens, wearables AI, ML and other acronyms. But where does it all fit within the ophthalmic field? Well, I will try to map it out here. 

For the sake of this article, I will define digital solutions as artificial intelligence, machine learning, home devices and automation of processes, which can also be relevant for the operation room or clinics. It is important to note that this is obviously not a full list, and I most probably missed a few promising companies and forgot a few. I am only human and I make mistakes too.

Firstly, let's ask why isn’t it trivial for the digital age to enter the ophthalmic field? Well, one reason in my opinion is the fact that unlike other medical fields, the eye is a small and “independent” organ and therefore very specific. Sophisticated devices are required to diagnose and treat certain conditions. This is (maybe) why, up till now, we only have one real home device, the iCare HOME (iCare) for self-measurement of intraocular pressure (IOP) and 2 FDA-approved AI systems, and those 2 are also for specific indications and cameras (IDx-DR and EyeArt). It’s a technological gap. Which is also why we are now seeing more and more attempts, from a variety of fields. 

Apps:

The applications for mobile apps are mainly focused on sight-related tests. For example 6over6, which was acquired by 1-800 Contacts, developed a smartphone app that, through the manipulation of light, measure optical parameters for farsighted or nearsighted vision, including pupillary distance, and astigmatism. Another app comes from Plano, which developed a suite of apps, among them the planoEyecheck for detection and management of potential vision and eye problems such as myopia.

Tilak Healthcare, which partnered with Novertis, among others, developed the OdySight® for visual acuity remote monitoring. OdySight® is a mobile Game with medical modules used to remotely monitor vision parameters of patients suffering from chronic maculopathies.

There is also Be My Eyes which is a free app that connects blind and low-vision people with sighted volunteers and company representatives for visual assistance through a live video call.

There are additional apps, either in development (such as by S-Alpha Therapeutics which raised a seed round at the end of 2020, Verily or Eyoto for tele-optometry which also raised money at the beginning of this year) or they are available in selected counties, however I believe the above is a good example of the existing mobile-apps patient-centric options.

Now let's switch to devices. Though before doing so, I'll mention Samsung's work with their EYELIKE™ fundus camera, with which it "Repurposes Galaxy Smartphones" to allow for access to eye care diagnosis in developing countries. This is for doctors to use, though a nice initiatives combining how the reuse of phones can allow access for diagnosis and treatment.

Now let's discuss home devices:

Firstly, what I believe is the first home device and still to-date the only approved home device for “on demand” tonometry - the iCare HOME (iCare). The device is based on the rebound tonometry principle, with a disposable probe. It should be mentioned that the Triggerfish by Sensimed is also available for continuous measurement however it requires a holter-like for the patient to walk with for the time of measurement (24h), together with a patch to place on the eye. Granted, the Triggerfish provides so called continuous measurement, but the form factor seems to me as less user-friendly, but may be relevant for high-risk patients. We may see some advancements on this front with additional companies targeting the home-on-demand IOP measurement.

Another interesting example comes from Nova Sight which uses eye tracking technology together with AI and big data for a number of possible indications, with the first to be lazy eye treatment. The company also recently shared, during OIS Myopia, its work in the field of myopia. This myopic market seems to me as ripe for home-use devices, especially for children and their worried parents. A lot of research is being done in the field of myopia (monitoring progression or treatment), such as by kubota Vision (who is also developing a home-based OCT) and Aikangte together with more “traditional” approaches such as lenses and low-dose atropine.

Another area I believe is also ready for home-use devices is dry eye. Besides the "traditional" microwave heaters or electric heaters together with massaging the eye, we don't have a lot of options for home use other than Nulids (NuSight Medical) for home treatment of dry eyes and blepharitis and the recently launched iTear 100 (Olympic Ophthalmics) which provides neurostimulation to naturally increase tear production. It is also worthy to mention the decision by Allergan from August last year to stop manufacturing the TrueTear. One assumption points to the fact the device was too expensive to manufacture, which drove the decision to take it off the market. 

Shifting to the retina, an interesting device, yet in clinical studies, is by Notal Vision. Notal is developing an AI digital diagnostic device for patients with neovascular retina diseases, which is essentially a home-use OCT, firstly for AMD. The company shares success stories by doctors in detecting the switch between dry to wet AMD, which is a nice marketing stunt to show the effectiveness of their device.

One company probably even people outside of this industry are familiar with is OrCam with its portable, AI device for visually impaired people to understand text and identify objects through audio feedback. The product is commercial across a number of countries around the world.

Robotics and such, mainly in research

Let's start with OR-related development:

ForSight Robotics, an Israeli company, which in March this year raised $10m seed, is developing a robot to support ophthalmic surgeries. Quite interesting to see what will come out of this, as it is still to be determined what indications will be used with this technology. Some papers speak about specific retinal indications for surgery, where high precision is needed, however additional applications should be developed to justify such systems.

Keranova is another company which develops an all-in-one surgical device, to enable a complete cataract surgery with a single device, with a new generation femtosecond laser. The company already showcased its technology during cataract surgery in a number of presentations.

on the diagnostics side, we have MacuLogix which developed VR-type goggles to measure the ability of the eye to adjust from light conditions to dark ones, which can be impaired in patients with AMD and other retinal conditions. The use of dark adaptometry to diagnose AMD until now has been limited due to lengthy and burdensome tests. This is a nice example of how technology can ease cumbersome tests.

Examples for a wider range of diagnosis is Tesseract which is building a portable device for monitoring of retinal-related diseases. Based on its PR after an $80m round, their technology “combines chemical sensors, imaging technology and artificial intelligence analyses to inspect the back of the eye”. Another example is Mikajaki, a company developing an automated diagnostic platform using digital technologies, robotics and artificial intelligence. Heru is developing an AI vision diagnostics and augmentation platform designed to provide real-time diagnoses and personalized vision correction using a wearable device, which looks similar to VR goggles. These diagnostics devices are most probably aimed for health kiosks and many are based on VR-lookalike goggles.

Another interesting technology comes from Mojo Vision with its augmented reality (AR) lens, which can present data through the lens itself. The company recently raised $51m. I will also mention here that I deliberately did not mention other smart lens or bionic lens as this article is long enough and these technologies are known by now.

An interesting company from Israel is Blink Energy developing a device using eye movements to generate wireless energy, to eliminate the use of batteries and external charging sources for smart ocular devices. This can support smart lens applications being developed today and can serve as an enabler for additional applications. 

AI and ML are two acronyms going with almost every “smart device” today. As such, I’ll mention a few interesting examples. 

Obviously there are the 2 pioneers of AI diagnostics tools who received FDA approval for diabetic retinopathy, IDx-DR and EyeArt. There are additional companies operating in Europe, such as RetMarker (Critical Health) and iGradingM (Digital Healthcare). Other companies are in different development stages, such as AEYE Health with its AI-based retinal screening system integrated into Optomed’s handheld fundus camera Aurora, or Retina-AI.

An interesting approach to an AI application is iSlit, developing an AI-based slit lamp, which might be most relevant for developing countries. Novai is an interesting company combining a biological marker and AI: developing its DARC (Detection of Apoptosis in Retinal Cells) technology which is an exploratory retinal biomarker with AI technology for a number of indications, such as glaucoma and retina-related.

Pr3vent is developing an AI tool for newborn screening. It is nice to see the few apps/ devices which focus on this segment of the market (newborn, children, the blind). 

This list is obviously not a full list, and quite frankly, it is a bit difficult to determine all the AI applications with the proliferation of the acronym “AI”.

Is the future here already? not quite, but we're getting there. One can already imagine what we will be able to achieve once communication bandwidth will be higher and better, together with miniaturization capabilities and computation advancement. Though we can't make predictions, closing the technological gap has a good chance of changing (disrupting?) the ophthalmic world, which to date have seen little progress where it comes to digital tools and home-use applications.

As always, feel free to contact if you have any comments or thoughts on this