The Future Of Vision And Eye Care

3D printed digital contact lenses, bionic eye implants, augmented reality: the future of vision and eye care is full of science fiction-sounding innovations.?Here is?where digital health will take ophthalmology in the future!

More than 80 percent of perception comes through vision

Researchers estimate that 80-85 percent of our perception, learning, cognition, and activities are mediated through vision. Compared to that, our hearing only processes 11 percent of information, while smell 3.5 percent, touch 1.5 percent and taste 1 percent. Don't you think that’s possible? Renowned scholars, L.D. Rosenblum, Harold Stolovitch and Erica Keeps explained these numbers with the following, rather convincing story.

Imagine you are in an open field, the sun shines on you, with the bees humming softly in the air. How far can you see and hear? When it comes to vision, it’s around 50 miles, talking about hearing, it’s only 1-2 miles at best! What about the smell of the flowers? Without the wind blowing, only 10-20 metres. How about touching or tasting? Well, it depends on your arm’s length, but obviously not further than that. And the same goes for your tongue and tasting.

It is almost a cliché to emphasise the importance of the eyes and vision, but it’s a luminous example to illustrate how the eyes are our most important sensory organ. Hence, if you catch an eye disease or have to face a serious eye condition, you feel very motivated to get better immediately.

Eye conditions affect way too many people worldwide

The latest figures from the International Agency for the Prevention of Blindness estimate that 43 million people are blind, and 295 million people suffer from moderate or severe distance vision impairment. Globally 1.1 billion people were living with vision loss in 2020, and it is forecasted to reach 1.7 billion without serious interventions and investments by 2050.

Data source: the Vision Loss Expert Group

Some of the necessary investments and improvements will arrive from the digital health field, progress in technology, for example in surgical techniques and?treating eye infections.

Yet, digital health still has a lot to do for lessening plenty of suffering which comes from not being able to see the world clearly. In the last couple of years, it actually started to undertake the task to transform the field of ophthalmology, offering its innovative solutions for the broadest spectrum of eye conditions. Treating less serious ailments gets faster, more targeted and more efficient, while the means for curing more serious and life-altering illnesses improve. Here, I outlined the way technology delineates the future of eye care and vision.

Most pioneers did not do great in the long term

Disruptive technologies gave a huge boost to the creative minds of ophthalmology. Types of conditions causing blindness, such as AMD or retinitis pigmentosa, an inherited eye condition causing loss of sight gradually and causing blindness for an estimated 1.5 million people worldwide, have been treated successfully with mind-blowing innovations.

The California-based firm, Second Sight, the German company,?Retina Implant AG, and the French venture, Pixium Vision were the forerunners of the field, developing implantable visual prosthetics to restore vision to patients who are blind as a result of the rare condition of retinitis pigmentosa.

In 2016, The Guardian reported that a blind woman suffering from this disease was fitted with the implant labelled “bionic eye” in the UK as part of a trial at the Oxford Eye Hospital. She spoke of her joy after being able to tell the time for the first time in more than six years. That must have been truly amazing!

In 2015, surgeons in Manchester, UK have performed the first bionic eye implant for an AMD patient using Second Sight’s innovation. The 80-year-old Ray Flynn lost his central vision entirely, but with the help of the retinal implant, he could make out shapes on the computer screen. Researchers say that the implant cannot provide any highly detailed vision - but it can help patients detect distinct patterns such as door frames and shapes.

However, things are moving fast, and success doesn't come easy for the pioneers of any medical field. In the past few years, Retina Implant AG decided to shut down its business activities, while Second Sight has stopped offering support for its Argus I and II retinal implant systems, leaving 350+ blind people around the world with Second Sight’s implants in their eyes in complete uncertainty, and a vast number of potential medical complications should anything go wrong with their implants.

Developing bionic eyes with fractal-patterned electrodes for reversing blindness

We have seen fascinating developments as well.

University of Oregon researchers have grown rodent retinal neurons on a fractal-patterned electrode, a form mimicking the repeating branching pattern in which neurons naturally grow, Futurity reported. It’s a step closer to making a bio-inspired bionic eye. The team, led by physicist Richard Taylor, hope their electrodes can someday be implanted in human eyes to restore lost vision.

The paper, recently published in PLOS, summarises three years of data. The new work provides experimental evidence supporting a hunch the team has been pursuing for years, that neurons, which themselves are fractals, will connect better to a fractal-patterned electrode than they do to more traditionally shaped electrodes, allowing better signal transmission between the implant and the brain.

To successfully send signals to the brain or the eye, an implanted electrode needs to be able to connect to a network of existing neurons. Neurons naturally grow in a tree-like fractal pattern, leading to ever-finer branches.

Taylor thought why not coax the neurons to connect to an electrode in a pattern that fits their tendency? Then, they tracked how mouse retinal neurons grew on the chips, using cells cultured in a petri dish.

Neurons attached more prevalently to the textured fractal branches than to the smooth gaps between the branches, the experiment showed. And glia, important support cells for neurons, are packed tightly into the smooth gaps. The fractal design was the most effective at this ‘herding’ of neurons and glia.

The work is still early-stage, Taylor emphasises. Running trials in animals will take additional engineering and safety tests. But eventually, the researchers hope their design will turn into a real-world device that can help people with vision loss.

Brain implants and artificial retina instead of bionic eyes?

Instead of “bionic eyes” that stimulate brain cells with lights coming from a tiny video camera or stimulate the visual cortex directly through electrodes, the Italian Institute of Technology has developed a new approach for treating retinal degeneration, with a prosthesis implanted into the eye that serves as a working replacement for a damaged retina – basically an artificial retina. Their research showed promising results for lab rats, and they plan to carry out the first human trials in the second half of 2017 and gather preliminary results during 2018.

The Stanford Artificial Retina Project shows great promises. The project's main focus is on ganglion cells, the output neurons of the retina, which largely survive the retinal degeneration process. Ganglion cells generate visual representations of light inputs and transmit these encoded representations toward specific target areas in the brain. By first learning how patterns of activity in many ganglion cells represent a visual scene, they can mimic the neural retinal code using their artificial implant. If they accurately reproduce the retinal code, the brain can accurately perceive the visual image.

The unique feature of the Stanford research is that instead of using large electrodes - employed in other projects -, the team proposes using 10 μm variant?electrodes?that can excite a small number of cells in the epiretinal region of the eye. The aim is not to "confuse" the brain's signals with activating cell clusters in aggregate.

The Hong Kong University of Science and Technology (HKUST) researchers have taken a distinctly divergent path from the previous research candidates and?generated an artificial bionic eye composed of?analogous elements to a real eye.?

The journal?Nature?provided a?commentary report?on HKUST's research into the bionic eye. The study indicated that?this eye has a comparable photoreceptor sensitivity response to the human eye.?This sensitivity is principally due to the novel use of perovskite materials, which have favourable properties in the next generation of optoelectronic signals.

The miraculous CRISPR and other gene therapies for regaining vision

CRISPR-Cas9 or as used in plain language, CRISPR, the breakthrough gene-editing method, has already shown its potential future use in eye care. Experts even say the eye is an ideal place to start for the first clinical use of CRISPR. Compared to other parts of the body, the eye is easy to access for surgery, readily accepts new tissue and can be noninvasively monitored.

Scientists at Columbia University Medical Center and the University of Iowa used CRISPR to repair a genetic mutation responsible for retinitis pigmentosa in induced pluripotent stem cells derived from a patient with the disease. The team reported a 13 percent success rate at converting the mutated gene variant into the normal one, which is way better than previous studies. In February 2017, experts at the Center for Genome Engineering, within the Institute for Basic Science (IBS) reported the use of CRISPR in performing "gene surgery" in the layer of tissue that supports the retina of living mice. After the intervention, the mice showed signs of improvement from AMD. It is a ground-breaking experiment suggesting that CRISPR can not only be used to correct mutations causing hereditary diseases but also in the case of non-hereditary degenerative diseases.

Beyond CRISPR, other gene therapies also have a great chance to become a common treatment method for specific eye conditions in the future. In early October 2017, the FDA’s advisory panel approved a gene therapy called Luxturna, which targets a rare condition called Leber congenital amaurosis. Thus, the treatment method got one step closer to full FDA approval. The agency will make its final decision by next January. If the verdict is positive, this gene therapy will be the first approved treatment in the US to correct an inherited genetic trait – but it might be followed very soon by much more.

And the latest CRISPR breakthrough is also connected to Leber congenital amaurosis. The team of Dr.?Mark Pennesi,?professor of ophthalmology at the Casey Eye Institute at the Oregon Health & Science University carried out a project in which they injected CRISPR directly into cells that are still in patients' bodies. This was the first time researchers worked with CRISPR this way. Earlier experiments had removed cells from patients' bodies, edited them in the lab and then infused the modified cells back into the patients.

Eye care patients will also become the point of care

With the advancement of smartphones and other smart gadgets at lightning speed, it is only a matter of time before portable devices will appear on a large scale in ophthalmology as well. The tiny, well-designed and connected instruments and the accompanying apps make it possible to undertake eye examinations anywhere in the world – making patients the point of care.

For example, Peek Retina is the flagship product of Peek Vision, a UK-based company and foundation, a portable ophthalmoscope that enables you to view and capture retinal images on your smartphone wherever you are. The venture also offers smartphone-based vision eye tests, e.g. for measuring visual acuity. It greatly helps physicians in remote areas such as Sub-Saharan Africa diagnose and treat patients.

The MIT-spinout company, EyeNetra developed a diagnostic device for signalling refractive errors fast and accurately. The device, called Netra, is a plastic, binocular-like headset to be used with an app which calculates the difference between what the user indicates as “aligned” and the actual alignment of various patterns. This signals any refractive errors, such as near-sightedness, farsightedness, and astigmatism. The app then displays the refractive powers, the axis of astigmatism, and the pupillary distance required for eyeglasses prescriptions. EyeNetra will make school or workplace eye examinations in the future a lot easier than today.

Photo credit: Rolex/Joan Bardeletti

The Newark-based?EyeQue has an MIT patented technology?based on instruments and charts used in vision testing for years. They offer two products enabling low-cost and accessible eye tests for everyone.?The Personal Vision Tracker?measures an individual’s refractive status, including near-or-farsightedness and astigmatism, while the?EyeQue Insight?determines visual acuity or the sharpness of vision.

Are 3D printed and digital contact lenses the future?

Digital contact lenses sound like science fiction: the translucent layer on your eye transmitting special information about your body to an outside device. Yet, it might be a reality soon. For example, Google teamed up with Novartis to produce digital, multi-sensor contact lenses which are designed to be able to measure blood sugar levels.

Google and Novartis said the lens would contain a tiny and ultra slim microchip that would be embedded in one of its thin concave sides. Through its equally tiny antenna, it would send data about the glucose measurements from the user’s tears to his or her paired smartphone via installed software. Originally, the companies promised to put the digital contact lens on the market around 2020. However, in March 2017 Novartis Chairman Joerg Reinhardt talked down the chances of the project bringing visible results in the next couple of years. I truly hope this is just a temporary setback.

Meanwhile, researchers at the University of Washington have created a contact lens with an LED display built into it – with the help of a 3D printer! While it is really difficult to manufacture a contact lens, which is one-third of a millimetre in diameter, a 3D printer sandwiches together different layers of interacting material, which makes it easier to match tiny pieces. While it was only an experiment, the research has important implications to improve the display technology of small devices. Maybe Google will 3D print the next generation of digital contact lenses, who knows?

Healing the eye faster

Innovation in regenerative medicine is flourishing: dentistry, dermatology, and ophthalmology. A few specialties which can take pride in healing injured or diseased body parts faster and in a more efficient way.

For example, researchers in Turkey developed a regenerative medicine that can heal the front of the eye in as little as two days after surgery. The drug called Cacicol stimulates faster tissue repair, and appears to relieve eye pain, burning, and light sensitivity following an invasive intervention. Scientists treated patients suffering from a rare disease called keratoconus who went through a surgery known as corneal cross-linking with Cacicol. The drug helped decrease the initial healing from 5 days.

Artificial Intelligence for detecting eye conditions in time

Image recognition algorithms have the capacity to transform diagnostics based on medical imaging. In 2016, Google developed an eye-scanning technique for looking at retinal images and detecting diabetic retinopathy as well as a trained ophthalmologist. The disease is quite common among diabetes patients, and if it is not spotted early enough, it may cause blindness. The machine-learning algorithm uses Google’s method for labelling millions of Web images as it examines photos of a patient’s retina to spot tiny aneurysms indicating the early stages of diabetic retinopathy. A year later, the search giant announced they have begun working on integrating the technology into a chain of eye hospitals in India.

Google is not the only one working on A.I. solutions for eye care, though. A teenage girl from India, whose grandfather in India was diagnosed with diabetic retinopathy, developed a smartphone app that can screen for the disease with the help of a specially trained artificial intelligence program and a simple 3D-printed lens attachment. A truly disruptive innovation: smart, cheap and potentially life-changing!

A fresh study, published in April 2022 in the Lancet found that a deep-learning algorithm was able to detect vision-threatening diabetic retinopathy with an accuracy of 94.7%, sensitivity of 91.4% and specificity of 95.4%. This was compared to the retina specialist over-readers who performed with an accuracy of 93.5%, a sensitivity of 84.8% and a specificity of 95.5%.?

Eye conditions through augmented reality

Patient education is key in prevention and it also gives the best chance for physicians to arrive at the most accurate diagnosis based on their patients’ explanation of their symptoms.

The use of Orca Health’s EyeDecide could bring exactly this result. The innovative, Utah-based mobile software company’s medical app uses an augmented reality camera display for simulating the impact of specific conditions on a person’s vision. EyeDecide can fully demonstrate the consequences of cataract or AMD and thus help patients understand their actual medical state.

Cyborgization is upon us?

I’m hopeful that eye conditions, visual impairment, and blindness will be entirely treatable in the future, even if that would mean a replacing the eye with a bionic device or replacing the natural process of vision with a brain-computer interface. I believe the biggest ethical challenge of eye implants or devices replacing visual functions could be that they might facilitate cyborgization.

What if healthy people would like to live as Neil Harbisson? As someone whose vision is extended through an external technology? What if the average user will ask for bionic eyes as it does not get tired, you can zoom with it, browse and search online, even take photos that no one else could see?

Neil Harbisson is actually an artist born with achromatopsia or extreme colorblindness meaning he could only see in black-and-white. Harbisson received a specialised electronic eye, his “eyeborg” to be able to render perceived colours as sounds on the musical scale. He is capable of experiencing colours beyond the scope of normal human perception: Amy Winehouse is red and pink, while ringtones are green. In his view, cyborgization might start with a third eye on the back of the head or an implanted sensor indicating whether there is a car behind you.

If you are entirely freaked out by now, I have to tell you, we are rather far from implanting third eyes into people. However, we have to start to contemplate about the possibilities of such scenarios as we will arrive at the boundaries of privacy, ethics – and the ultimate merging of the human body with technology. We have to be ready for that!

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