8/8/2018. The Future of Diagnostics in Eye Care. Knowledge Doubling. Outline and Format. Our Goal

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1 The Future of Diagnostics in Eye Care Paul Batson, O.D. Jill Helton, O.D. Trenton Cleghern, O.D., F.A.A.O In times of change, learners inherit the earth; while the learned find themselves beautifully equipped to deal with a world that no longer exist Eric Hoffer Knowledge Doubling Early 1900 s, knowledge doubled every century 1940 s, knowledge doubled every 25 years By 2020, IBM predicts that knowledge will double every 12 hours Change brings Excitement and Opportunity Retinoscope Autorefractor iphone. Our Goal Provide a small glimpse of the exciting things to come.. Outline and Format First Hour Diagnostics Second Hour Treatments 15 minutes each Paul Batson, O.D. Glaucoma and Cataracts Jill Helton, O.D. Cornea and Dry Eye Trenton Cleghern, O.D. Retina and Uveitis 1

Cataract Diagnostics Scheimpflug imaging of lens opacities and

Clinical applications of Scheimpflug imaging in cataract surgery.

to cloud Glaucoma Triggerfish by Sensimed FDA Approved in 2016

Eyemate Biocompatible sensor implanted at the time of cataract

2 Cataract Diagnostics Scheimpflug imaging of lens opacities and capsule Cataracts Grewal DS, Grewal SPS. Clinical applications of Scheimpflug imaging in cataract surgery. Saudi Journal of Ophthalmology. 2012;26(1): doi: /j.sjopt icare Home self monitoring Measurements obtained by patient and syncs to cloud Glaucoma Triggerfish by Sensimed FDA Approved in 2016 Measures IOP q5 minutes for 24 hours Indirect measurement of IOP Eyemate Biocompatible sensor implanted at the time of cataract surgery Measures IOP continuously and transmits to a reading device which connects to computer Received European approval in May 2017 Direct measurement of IOP Sulcus placement 2

Electrophysiology ERG The pattern ERG (PERG) and the photopic negative response (PhNR) of the cone driven ERG, elicited either by full field, focal or multifocal stimulation of the macula are

3 Electrophysiology ERG The pattern ERG (PERG) and the photopic negative response (PhNR) of the cone driven ERG, elicited either by full field, focal or multifocal stimulation of the macula are objective measures of retinal ganglion cell function and sensitive to glaucomatous damage. Wilsey LJ, Fortune B. Electroretinography in glaucoma diagnosis. Current opinion in ophthalmology. 2016;27(2): VEP Multifocal VEP using VR glasses Dichoptic mfvep not only detects HFA losses, it may identify early defects in areas unaffected on HFA and monocular mfvep while reducing testing time by 30%. Arvind et. al., Dichoptic Stimulation Improves Detection of Glaucoma with Multifocal Visual Evoked Potentials. Invest. Ophthalmol. Vis. Sci. 2007;48(10): doi: /iovs Glaucoma Diagnositics Melbourne Rapid Field Home Monitoring ipad visual field unit Swept Source OCT Longer wavelength (1050nm) vs. current Spectral Domain OCT (840nm) Faster imaging equals improved resolution Longer wavelength allows deeper imaging in to the lamina cribrosa and choroid Allows for improved imaging of the RGC Deeper imaging OCT Angiography Diminished peripapillary, ONH and macular capillary density have been associated with glaucoma Yarmohammadi, et al; Relationship between Optical Coherence Tomography Angiography Vessel Density and Severity of Visual Field Loss in Glaucoma; Ophthalmology 2016;123: Doppler OCT Color Doppler imaging shows significantly lower blood flow velocities and higher resistive indexes in the central retinal artery, short posterior ciliary arteries and ophthalmic artery in patients with clinically worsening POAG. 1 Adaptive Optics AO applied to OCT improves resolution Able to view individual RGC bodies and individual RNFL bundles 1 Lavinsky, Fabio; et al; The Future of Imaging in Detecting Glaucoma Progression, Ophthalmology; 2017;124:S

4 Artificial Intelligence Most work is being done to help identify progression. There is some early work being done to look at diagnosis. Asaoka, et, al, Ophthalmology 2016 Detecting Preperimetric Glaucoma with Standard Automated Perimetry Using a Deep Learning Classifier A significantly larger AUC of 92.6% (95% confidence interval [CI], 89.8% 95.4%) was obtained using the deep FNN (feed forward neural network) classifier compared with all other ML (machine learning) methods: 79.0% (95% CI, 73.5% 84.5%) Biomarkers Direct imaging of apoptic RGC using confocal scanning laser ophthalmoscopy with fluorescently labled biomarkers (annexin 5 or GCaMPs (Genetically encoded calcium indicators) Genetics Risk Alleles Not Pathogenic Variants but risk National Eye Institute (NEI) research has identified 133 genetic variants that predict with 75 percent accuracy a person s risk for developing glaucoma Future Diagnostic Trends: Anterior Segment A. Jill Helton, OD VisionAmerica Jill.Helton@EyeHealthPartners.com Disclosures No financial disclosures Researchers from Technical University in Spain have developed a new corneal volumetric analysis to detect incipient cases of keratoconus Uses combination of optical and volumetric data Morphogeometric model of the cornea created using CAD tools and raw topographic data from the Sirius system (Costruzione Strumenti Oftalmici, Italy) 4

These images make for an easy diagnosis; but it can be very difficult to detect the subtle changes in the early stages Previous studies

asymmetry, as focal changes occur first Volumetric parameters: VOLmct Corneal volume contained in a cylinder of revolution with radius x

5mm) and its axis defined by the points of minimum corneal thickness Volumetric parameters VOLaap Corneal volume contained in a cylinder of

5mm) and its axis defined by a straight line perpendicular to the tangent plane to the anterior corneal surface apex Volumetric parameters

5 These images make for an easy diagnosis; but it can be very difficult to detect the subtle changes in the early stages Previous studies calculate global volumes centered on the geometric apex of the cornea This study calculates volumetric parameters at a local point of asymmetry, as focal changes occur first Volumetric parameters: VOLmct Corneal volume contained in a cylinder of revolution with radius x (ranging from mm) and its axis defined by the points of minimum corneal thickness Volumetric parameters VOLaap Corneal volume contained in a cylinder of revolution of radius x ( mm) and its axis defined by a straight line perpendicular to the tangent plane to the anterior corneal surface apex Volumetric parameters VOLpap Corneal volume contained in a cylinder of revolution with radius x (ranging from mm) and its axis defined by a straight line perpendicular to the tangent plane to the posterior corneal surface at the apex Results: VOLmct was lower in keratoconic eyes vs. control eyes Demonstrated at every radius for the cylinder of revolution, from 0.1mm up to 1.5mm in 0.1mm increments 5

6 Results: VOLaap was lower in keratoconic eyes vs. control eyes Demonstrated at every radius for the cylinder of revolution, from 0.1mm up to 1.5mm in 0.1mm increments Results: VOLpap was lower in keratoconic eyes vs. control eyes Demonstrated at every radius for the cylinder of revolution, from 0.1mm up to 1.5mm in 0.1mm increments Significant differences in volumetric changes in a small area around the points of minimal corneal thickness and the anterior and posterior corneal apex in the early stages of keratoconus compared to healthy eyes will help diagnose incipient disease This technology will inevitably be incorporated in topographers Researchers from Bascom Palmer Eye Institute have developed functional slit lamp biomicroscopy (FSLB) to assess conjunctival vasculature Readily available digital camera (Canon 60D) attached to a traditional slit lamp microscope (Nikon FS 2) High imaging rate of 60 frames/sec with a ~210x high magnification 6

$Generates non invasive bulbar conjunctival microvascular perfusion maps (nmpms) Analyzes fractality of the microvascular network of the bulbar conjunctiva Evaluates microvascular hemodynamics (blood$ bulbar conjunctival redness Can be used to study how ocular diseases affect microciruculation Has implications to study systemic small vessel disease (heart, kidney, brain) over time in vivo The top

bulbar conjunctival redness Can be used to study how ocular diseases affect microciruculation Has implications to study systemic small vessel disease (heart, kidney, brain) over time in vivo The top

7 Generates non invasive bulbar conjunctival microvascular perfusion maps (nmpms) Analyzes fractality of the microvascular network of the bulbar conjunctiva Evaluates microvascular hemodynamics (blood flow velocity and rate) of the bulbar conjunctiva Used to assess bulbar conjunctival microvascular responses to contact lens wear Is a quantitative measurement and far more precise than grading of bulbar conjunctival redness Can be used to study how ocular diseases affect microciruculation Has implications to study systemic small vessel disease (heart, kidney, brain) over time in vivo The top row is prior to contact lens wear The bottom row is after 6 hours of contact lens wear while still wearing the lens Dry Eye Disease Sandbank epitheliopathy of the conjunctiva (SEC) Distinct ripple pattern of bulbar conjunctival staining observed in eyes with tear film insufficiency Easily seen with NaFl dye and a blue light with a yellow barrier filter Increases with the severity of dry eye Dry Eye Disease Dry Eye Disease SEC ripples are signs of increased friction due to a lubrication deficit Non invasive, inexpensive, easily performed and easy to interpret = No Brainer 7

UABSO No financial disclosures Diagnostic Retina Retina Artificial intelligence retinal

8 Thanks for your attention! Future Diagnostic Trends: Retina and Uveitis Trenton Cleghern, OD FAAO VisionAmerica UABSO No financial disclosures Diagnostic Retina Retina Artificial intelligence retinal screening A. I. and Retinal Imaging OCT detection of neurodegenerative diseases tech.com/wpcontent/uploads /2014/09/AIgovernancelead.jpg 8

Retina A.I. Poplin R, et al. Prediction of Cardiovascular Risk Factors from Retinal Fundus Photographs Via Deep Learning.

FDA approval 2018: Idx DR Eyenuk EyeArt India Age Gender Smoker Blood pressure BMI Risk of cardiac events Google Brain Retinal

does optometry fit in? OCT in Neurodegenerative Diseases www.blogs.va.gov/vantage/wpcontent/uploads/2017/11/jwt_va_ NOLA2016 4096.

9 Retina A.I. Poplin R, et al. Prediction of Cardiovascular Risk Factors from Retinal Fundus Photographs Via Deep Learning. Nature Biomedical Engineering. Volume 2, pages (2018). FDA approval 2018: Idx DR Eyenuk EyeArt India Age Gender Smoker Blood pressure BMI Risk of cardiac events Google Brain Retinal camera Non eye practitioners Idx DR Smart phone Diabetic retinopathy EyeNuk EyeArt FDA approval 2018 University of Iowa Where does optometry fit in? OCT in Neurodegenerative Diseases NOLA jpg and Vision Examination Products/6419 Optical Coherence Tomography OCT Equipment Optical Coherent Tomography Machines/ /article.aspx?articleid=

Alzheimer s dementia Potential Conditions Uveitis Parkinson disease Multiple sclerosis Huntington s disease www.sciencedirect.

10 Alzheimer s dementia Potential Conditions Uveitis Parkinson disease Multiple sclerosis Huntington s disease article/pii/s Uveitis Retina and Uveitis Idiopathic vs undifferentiated Immunogenetics Earlier lab testing? OCT A A.I. retina screening amazing potential, but still need competent clinicians OCT in neurodegenerative diseases not current but soon Uveitis and OCT A: fascinating but not clinically useful yet 10

OCT Angiography: The Next Step in Retinal Imaging Jonathan Zelenak D.O.

OCT Angiography: The Next Step in Retinal Imaging Jonathan Zelenak D.O. Hillsdale Hospital Michigan State University Overview Evolution of OCT How does OCT angiography work? Clinical examples Potential