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Peter Gehlbach, Department of Ophthalmology, Director of Echography Center, Johns Hopkins MedicineThe last two decades have witnessed historic technological innovation in Ophthalmology. No subspecialty area of ophthalmology, (e.g. retina, cornea/ cataract, glaucoma, uveitis, oculoplastic, pediatric ophthalmology etc.), has been left behind. In fact, the pace of new technology development and translation may be accelerating in these areas. As a retina specialist at the Wilmer Institute at Johns Hopkins Medicine, I have the opportunity to participate as a clinician innovator and early adopter of emerging technology that is applicable to diseases of the vitreous and retina.
"Robotic surgery in the eye takes specific advantage of a robot’s capability to perform single micron precision, maneuvers"
Ophthalmology has not historically been a point of emphasis in most medical school training programs. Therefore, it may be surprising to not only third parties and patients, but also some doctors, that the field of Ophthalmology is one of the most advanced with regard to technological innovation, notably in the areas of diagnostic imaging and microsurgery. Ophthalmology has also been a leader in the conduct of clinical trials and now serves as a model of evidence-based decision making, in clinical practice. Having “the data” on efficacy and safety continues to provide a position of strength as we enter into the era of value driven healthcare. It also provides a rationale and support for the introduction and continued use of technology in each phase of its development.
In the field of retinal microsurgery, there are macro technological trends that appear to be gaining traction globally. The first of these relates to simply seeing the micron scale surgical target in new and potentially better ways. Two potentially transformative examples of this trend include real time, 3D, heads up, digital imaging as a primary viewing source (potentially supplanting traditional microscopes); and the introduction of intraoperative optical coherence tomography into real time surgical decision making (providing single micron scale imaging capability during surgery). Although each of these technologies is in the early adoption phase, users and developers are actively pursuing next generation technology in this wide-open space.
Given an enhanced ability to see micron scale surgical targets, a logical development is the emergence of technology that provides novel micron-scale capabilities to the surgeon. Human physiological limitations have historically imposed fundamental barriers to the performance of “ultra-micro”-surgical tasks (e.g. accurately and precisely grasping a 3-micron target with a 100-micron hand tremor, or precisely holding a microneedle in a 50-micron space for an extended period of time, etc.). Reported in Nature Biomedical Engineering (September 2018) is the first in human, robotic retinal surgery performed at Oxford University. While robotic surgery is not a novel concept, robotic surgery in the eye takes specific advantage of a robot’s capability to perform single micron precision, maneuvers. As with other robotic applications in medicine, the value proposition is not yet clear. What is clear is that robotic technology overcomes fundamental human limitations and extends human capability.
Gene and cell based therapies have the potential to have the greatest impact on retinal diseases that now lack effective treatment, namely the hereditary retinal degenerations and dry macular degeneration. While the FDA approval of a new form of gene therapy for a rare inherited blinding retinal disease (October 2017) will not benefit a large number of patients, it has provided an important pathway to future gene therapies for an array of eye diseases. A support technology associated with gene therapy delivery is emerging, including but not limited to intraoperative OCT imaging and the high precision of robotics. The promise of stem cells in retinal disease continues to emerge with preliminary reports of occasional successes in treating retinal conditions. The field is working towards reliably reproducing results in this regard.
The human machine interface continues to be a point of interest in retina. In 2011 European approval was allowed for an electrode array implanted onto the retinal surface that receives input from an external camera, thereby providing visual patterns to the patient who must learn to interpret them. Fewer than 100 retinitis pigmentosa patients are implanted with this device each year. Novel devices continue to emerge in the “bionic eye” and direct cortical stimulation space.
There are iterative improvements in the core systems that allow ocular surgery as well as novel niche instruments that improve the performance of routine surgery. Nanotechnology, retinal organoids, cell transplants, implantable devices all have potential retinal applications and are in development and vying for a foothold.
Ophthalmic drugs are a multibillion-dollar industry and throughout ophthalmology, novel drugs, drug delivery platforms, extended formulations, combination therapies, generic and biosimilar drugs continue to enter and influence the market to the extent that their efficacy, safety and cost allow. The impact of value-care on drug and device selection will be evident and will play an increasing role in the use of next generation therapeutics.
In brief, the torrid pace of innovation across the field of Ophthalmology parallels that in retina. During this period of rapid innovation and discovery, novel approaches will become instrumental in delivering high-value care, and in driving new trends in healthcare.
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