2023: What awaits ophthalmology in the year ahead

Cataract

Prof. Goes: I started my surgical career as an anterior segment surgeon using a head loupe with a magnifica­tion of ×4 and without the possibility of IOL implanta­tion. A 180° opening of the eye with a knife, suturing it after expression of the cataract, was the rule.

Impressive improvements have been made but there are still obstacles to overcome.

The discovery of a short-acting (15–30 minutes) mydriatic would enable the patient to function nearly normally immediately after the procedure, and cataract surgery being performed in the upright position would also be beneficial to some patients. Most importantly, immediate sequential bilateral cataract surgery has many potential advantages such as fewer hospital visits for the patient, faster visual recovery and lower health care costs.

Dr Kermani: IOL/capsular bag dislocation decades after cataract surgery is an increasing problem. An estimated 1% of all cases will need to be revisited.

In the meantime, there are numerous variants of sulcus fixation. However, these are time-consuming, technically challenging and not without a certain poten­tial for complications.

I am working intensively on a simple, safe and effec­tive solution to the problem. I cannot reveal more yet, but the first clinical applications will start soon. That is my personal biggest challenge for the coming year and I hope to be able to report on it by the end of 2023.

Refractive Surgery

Dr Kermani: The biggest challenge for our refractive surgery department in 2023 will be the incorporation of SMILE—or, better, call it laser lenticular extraction.

With the market introduction of new technical­ly competitive laser systems, the time seems to be ripe for this. Whether femto-LASIK will lose its gold standard status remains to be seen. It is the results that count, not the specifications from marketing depart­ments. However, it is quite possible that patients will decide which procedure will prevail in the end. Either way, laser lenticular extraction is an incredible enrich­ment to laser vision correction.

Cornea

Prof. Augustin: Endothelial keratoplasty such as Descemet membrane endothelial keratoplasty (DMEK) is the standard treatment for Fuchs endothelial corneal dystrophy and chronic corneal oedema.

However, surgical treatment without endothelial ker­atoplasty may serve as an alternative and could reduce the need for corneal transplantations. Recently, promis­ing results were presented for the injection of endothelial cells into the anterior chamber or Descemet stripping only, with or without Rho-kinase inhibitors, as well as for the implantation of an artificial endothelial layer.

Upcoming randomised controlled trials are necessary to evaluate and compare the results with those for cur­rent treatments such as DMEK.

Prof. Augustin: Wearing a face mask has become routine. We are currently experiencing an increased prevalence of patients suffering from dry eye syndrome. Some of the symptoms can be directly connected to wearing face masks, thereby affecting all age groups, with an increased emergence being reported among the paediatric population.

While wearing a face mask, the exhaled air flows upwards, especially when the mask sits loosely around the nose and cheeks. Until now we have had no scientific proof for the cause of those symptoms. This needs to be evaluated because we have to educate our patients on how to avoid such symptoms.

Retinal Disease

Dr de Silva: The field of inherited retinal diseases has, over the past decade, seen an explosion in different therapeutic strategies being investigated to slow disease progression or even potentially restore visual function in end-stage disease.

One approach aims to use gene therapy to restore light sensitivity to remaining inner retinal cells once rods and cones have degenerated, with the aim of restoring vision in advanced disease. This method, known as optogenetics, has shown great advances in recent years, with four clinical trials now underway evaluating different gene therapy approaches, some in combination with visual prosthetic devices that augment the light stimulus to optimise responses. The patients who would benefit from these therapies are those with advanced visual loss (acuity of hand move­ments only or perception of light) but with preservation of inner retinal structures on optical coherence tomog­raphy scans.

Preliminary data from three of the ongoing trials have been released, with no serious adverse effects reported; two out of three trials report some improve­ment in visual function. Further data from these trials are keenly awaited, to determine whether optogenetic strategies may be able to restore visual function in blind patients.

Glaucoma

Prof. Goes: For around 15 years I have been supporting the non-governmental organisation Light for the World,¹ which is a global development organisation empower­ing people with disabilities and enabling eye health ser­vices in low-income countries. The organisation builds eye hospitals in Africa and delivers, in a very efficient way, eye care in less-developed countries.

We know that glaucoma is the most frequent cause of incurable blindness and must be stopped at all costs. Therefore—specifically for these undeveloped countries, mostly in hot climates—better and longer acting glaucoma eye medication has to be developed.

Using drops twice a day for a lifetime or accessing glau­coma surgery is not straight­forward in these countries. More efficient single doses, long-acting medication and the propagation of cheaper and easier to use glaucoma drainage implants may pre­vent further optic nerve dam­age and keep these people far away from blindness.

Age-Related Macular Degeneration

Prof. Goes: The longer lifespan of mankind is accom­panied by age-related diseases such as cataract and age-related macular degeneration (AMD). Unfortunately, for around 20 years, treatment has been available only for the less-common form, wet AMD.

For the most common form of macular degeneration, dry AMD, which represents about 80% of diagnosed cases, there is no efficient treatment yet.

Estimations are that, in the USA alone, 11 million peo­ple have dry AMD, while 1.5 million (~15% of all AMD) are affected by the advanced stages of the disease.^2,3

It would be a major challenge to find a way to pre­vent or eventually cure this disease. Millions of people would benefit from such a realisation.

Prof. Augustin: Wet and dry AMD (wAMD, dAMD) is still a major sight-threatening disease. Healing of the disease is still not possible.

Anti-VEGF drugs seem to be a breakthrough. Howev­er, a portion of our patients do not respond adequately and their retinal pigment epithelium is altered as a result of the continous treatment

In the next year we are expecting the first medi­cal treatments for dAMD and several biosimilars for wAMD. We will have to use our complete armamen­tarium (artificial intelligence in combination with multimodal imaging) to critically evaluate these new approaches/drugs.

Dr de Silva: A welcome challenge for retinal spe­cialists in 2023 is the advent of new, and in some cases longer acting, anti-VEGF agents for the treatment of retinal disease.

We have seen through 2022 the licensing and ap­proval of faricimab (Roche), an intravitreal agent that inhibits both anti-VEGF and Ang-2, with clinical trial data reporting a maintenance dosing interval of 16 weeks in approximately 45% of patients with AMD at week 48 after starting treatment.⁴

We now therefore have four licensed anti-VEGF medications (ranibizumab [Novartis], aflibercept [Regeneron], brolucizumab [Novartis] and faricimab), with ranibizumab biosimilars also available, for both neovascular AMD and diabetic macular oedema.

It is now in the hands of retinal specialists to weigh up the relative benefits and cost-effectiveness of these different medications for their patient populations and to implement optimal protocols.

Further real-world data emerging through 2023 will aid and clarify these decisions, and clinical trials are also ongoing for gene therapy approaches to treat neo­vascular AMD, which may lead to even longer acting therapies in the coming years.

The Ageing Population

Prof. Augustin: We are entering a new era of thinking. Senescence is no longer something we are willing to accept as a part of our life. We have enough scientific proof to look at senescence as a disease entity which can be—at least partly—antagonised. Several biotech companies are investigating drugs to help us achieve this goal. Ophthalmology is ideally suited to participate in this new development because we are facing a dra­matically increasing number of patients suffering from age-related diseases such as AMD, diabetes, glaucoma and cataract. Thus, we have to carefully observe the de­velopments and ideally participate as early as we can.

Prof. Goes: Because cataract is age-related, the need for surgery will go up with the rising average life expectancy of people on this planet. Although the cat­aract surgical rate is increasing in some countries—for example, in India the number of operations per million people per year increased from just over 700 in 1981 to 6000 in 2012⁵—there are still significant waiting lists in many countries. The surgery has to be made more affordable and eventually paramedics will have to be included in performing cataract surgery.

Patient Management and Demand for Services

Dr Kermani: We will need to improve perioperative management. Our productivity is insufficient. It starts with the acceptance of patients when we do not have sufficiently efficient telephone and appointment acceptance.

Patient counselling needs to start more effectively before patients come into the clinic. For now, we are just sending information leaflets to the patients. Tele-con­sulting would outsource precious chair time and help us to better pre-select the patients regarding their IOL preferences.

We currently lose too much time during the exam­ination in the clinic. Two to three hours is too much; we want to get to a maximum of 90 minutes. We will review everything that hinders the processes and increasingly focus on multifunctional aperitive diagnostics.

Here, too, artificial intelligence will play an important role. Maybe not in the coming year, but it will not be long before we will be able to compensate for the bottle­necks on the personnel side by significantly increasing productivity.

Dr de Silva: A major challenge we face as retinal spe­cialists is rapidly increasing demand. In the UK, the Roy­al College of Ophthalmologists predicts a 59% increase in cases of neovascular AMD between 2015 and 2035,⁶ and facilitating already stretched services to meet this challenge will require innovation and novel approaches.

Potential solutions include home monitoring of pa­tients with AMD, with the aim of detecting neovascular changes at an early stage. Several devices have shown positive results in clinical trials and are approaching utilisation in clinical practice, which may help to reduce the frequency with which patients need to be monitored in a hospital or clinic setting, as well as being more con­venient for this elderly group of patients.

Dr Kermani: Diabetic macular oedema and AMD con­tinue to increase. One of the major challenges in 2023 will be coping with the large number of patients in diag­nosis and therapy. We very much hope that the support of diagnostics by means of artificial intelligence and the approval of long-acting drugs will support us in this.

Dr de Silva: A further and ongoing challenge remains in delivering high-quality care across different patient populations who may have a range of barriers prevent­ing engagement with health care.

A prime example is that of diabetic screening: the UK is fortunate to have a national, population-based screening programme to detect diabetic eye disease, and if patients are detected to have significant or po­tentially sight-threatening changes of pre-proliferative or proliferative retinopathy, or maculopathy, they are referred to hospital eye services for further evaluation and treatment.

As we reported recently,⁷ in 2018/19, 2.8 million people with diabetes in the UK were invited to diabetic eye screening, 82.6% of whom attended their appoint­ments, with 74% to 92% uptake across different regions of the UK.

Given that 48% of people with type 1 diabetes and 28% of people with type 2 diabetes may develop retinal changes, it is essential to keep engaging with our patients with diabetes to improve screening uptake to enable early detection of potentially sight-threatening changes.

It is known that multiple factors influence screening uptake including social deprivation, being of an ethnic minority background, poorer blood sugar control, smoking and a lack of awareness of the risk of visual loss. We must therefore endeavour to overcome these barriers in conjunction with our physician colleagues by continuing to provide better education regarding the importance of screening.

Other documented barriers have been reported as accessibility, time (such as competing demands), sched­uling and doctor–patient communication, and although it is challenging to address these factors, with limited resources in many areas, the benefits of doing so are clearly evident.

Artificial Intelligence and Robotics

Prof. Goes: Robot-assisted surgery has made its entrance in ophthalmic surgeries but, compared with other disciplines in medicine, we ophthalmologists— with some exceptions—are lagging behind in its use.

With robotic instrumentation, a precision of 1 mm may be provided and tremor can be avoided. The inte­gration of robotics in complicated surgical procedures has a long way to go, and the limited availability and high cost are challenges to be overcome. Higher effi­ciency and faster surgery in complicated cases could be the outcome.

The use of existing robots (such as the da Vinci sys­tem telemanipulator used for anterior and posterior interventions) has to become more widespread once some existing limitations have been addressed.

Prof. Augustin: Artificial intelligence (AI) is rapidly finding its way into the health care systems around the world. The greatest challenge is to make AI as practical as possible. Different systems need to be combined to achieve a performance that is clinically acceptable.

Thus, the most significant technical challenge arises from the need for adequate training data and external validation. A further challenge is what happens in the case of misclassification or practical mistakes in gen­eral in terms of liability, i.e. whether the AI provider or the clinician is responsible.

In addition, many of these challenges are associated with the usual differences in access to health care.

Sustainability

Prof. Goes: Robot-assisted surgery has made its entrance in ophthalmic surgeries but, compared with other disciplines in medicine, we ophthalmologists— with some exceptions—are lagging behind in its use.

With robotic instrumentation, a precision of 1 mm may be provided and tremor can be avoided. The inte­gration of robotics in complicated surgical procedures has a long way to go, and the limited availability and high cost are challenges to be overcome. Higher effi­ciency and faster surgery in complicated cases could be the outcome.

The use of existing robots (such as the da Vinci sys­tem telemanipulator used for anterior and posterior interventions) has to become more widespread once some existing limitations have been addressed.

Prof. Augustin: Artificial intelligence (AI) is rapidly finding its way into the health care systems around the world. The greatest challenge is to make AI as practical as possible. Different systems need to be combined to achieve a performance that is clinically acceptable.

Thus, the most significant technical challenge arises from the need for adequate training data and external validation. A further challenge is what happens in the case of misclassification or practical mistakes in gen­eral in terms of liability, i.e. whether the AI provider or the clinician is responsible.

In addition, many of these challenges are associated with the usual differences in access to health care.

Personal Challenges

Prof. Goes: After 30 years of clinical practice, I will slowly but surely prepare for retirement. Ophthalmology will then increasingly be more research and development for me.

But I will also have more time to take care of my personal well-being and that of my family, and I will have more time for writing. I am especially looking forward to that.

References

1. www.light-for-the-world.org

2. Joachim N, Mitchell P, Burlutsky G, et al. The incidence and progression of age-related macular degeneration over 15 years: the Blue Mountains eye study. Ophthalmology. 2015;122:2482-2489.

3. Chou R, Dana T, Bougatsos C, et al. Screening for impaired visual acuity in older adults: updated evidence report and systematic review for the US preventive services task force. JAMA. 2016;315:915-933.

4. Heier JS, Khanani AM, Ruiz CQ, et al. Efficacy, durability, and safety of intravitreal faricimab up to every 16 weeks for neovascular age-related macular degeneration (TENAYA and LUCERNE): two randomised, double-masked, phase 3, non-inferiority trials. Lancet. 2022;399:729-740.

5. Murthy GVS, Jain B, Shamanna B, Subramanyam D. Improving cataract services in the Indian context. Community Eye Health. 2014;27:4-5.

6. The Royal College of Ophthalmologists. The Way Forward: Age-Related Macular Degeneration and Diabetic Retinopathy.

7. Public Health England. Atlas of variation in risk factors and healthcare for vision in England.

8. Pichler PP, Jaccard IS, Weisz U, Weisz H. International comparison of health care carbon footprints. Environ Res Lett. 2019; 14064004)