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Eye Health 2019

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E Y E H E A L T H 6 Five exciting developments in eye health research Accurate diagnostics with AI Pain-free, cost-cutting laser treatment Gene therapy to fill a therapeutic vacuum Bionic eye A remarkable piece of eye health research reported in Nature Medicine has shown that an artificial intelligence (AI) pro- gramme can make the correct referral decision for more than 50 eye diseases with 94 per cent accuracy. This matches world-leading experts. The DeepMind system could revolu- tionise the management of eye tests, ena- bling hea lthcare professiona ls to spot conditions earlier and prioritise patients with the most serious diseases before irreversible damage sets in. Pearse Keane, consultant ophtha lmol- ogist at London's Moorf ields Eye Hospi- ta l NHS Foundation Tr ust and clinician A simple, safe, pain-free laser treatment not only works better than eye drops at preventing glaucoma from deteriorating, but could also save the NHS tens of mil- lions of pounds a year, according to eye health research at Moorfields Eye Hospi- tal and UCL Institute of Ophthalmology. Gus Gazzard, glaucoma service direc- tor at Moorfields and reader in glau- coma studies at UCL, says: "These results strongly suggest that laser should be the first treatment for glaucoma in all newly diagnosed patients." The results could potentially improve global glaucoma treatment while saving the NHS up to £1.5 million a year in treat- ment costs for newly diagnosed patients. If the treatment proves to be as effec- tive with previously diagnosed patients, Moorfields estimates annual savings to the NHS could reach up to £250 million. Reported in The Lancet, the three- year trial is the largest ever of its kind. It involved 718 patients, newly diagnosed with glaucoma or ocular hypertension (higher than normal pressure in the eye). The first gene therapy for inherited blind - ness represents a potential triumph for retinal and eye research, but it is gen- erating extensive global controversy. Recently approved for use in Europe, it had an initial US price tag of $850,000, making it one of the world's most expen- sive treatments. Luxturna can restore vision in peo- ple with a rare RPE65 genetic mutation that causes progressive vision loss which begins in childhood. The RPE65 gene provides instructions for making a pro- tein that is essential for normal vision. A five-year study of a bionic eye tested by five patients with little or no sight marks a big step for ward in eye health research, according to preliminar y reports. But the researchers stress they are a long way from achieving full vision for their research subjects. For example, a patient may be able to see an object with- out knowing if it is a mug or a baseball. Some of the most important technological and treatment innovations over the past 12 months could transform the future of eyecare R E S E A R C H John Illman scientist at University College London Institute of Ophtha lmolog y, says: " The number of eye scans we're performing is growing at a pace much faster than human exper ts are able to interpret them. There is a risk this may cause delays in diagnosis and treatment of sight-threat- ening diseases, which can be devastating for patients. " T he A I technolog y we're developing is desig ned to pr ior it ise pat ient s who need to be seen a nd t reated urgent ly by a doctor or eyeca re professiona l. If we ca n dia g nose a nd t reat eye condit ions ea rly, it g ives us t he best cha nce of sav- ing people's sig ht. Wit h f ur t her resea rch it cou ld lead to g reater consistency a nd qua lit y of ca re for pat ient s w it h eye problems in t he f ut ure." 1 Robot-assisted eye surgery The first eye health research to deter- mine whether robots can perform eye surgery safely and effectively has been acclaimed a success. Carried out at Oxford's John Radcliffe Hospital, the study involved 12 patients. Six received robot-assisted surgery and the remaining six standard manual surgery to remove a membrane from the back of the eye. Using the robot, the surgeon was able to perform the procedure as effectively or better than with the traditional manual approach. In the trial's second phase, the team used the robot to insert a fine needle under the retina to dissolve blood in three patients who had age-related macular degeneration. All experienced an improvement in their vision as a result. Robert MacLaren, Professor of ophthal - mology, says: "This is a huge leap forward for delicate and technically difficult sur- gery, which in time should significantly improve the quality and safety of this kind of operation." The trial was conducted by the University of Oxford, supported by the National Insti- tute for Health Research Oxford Biomedical Research Centre. Results were published in Nature Biomedical Engineering. The trial builds on earlier pioneering work at the John Radcliffe Hospital, which in 2016 carried out the world's first robotic eye operation. 2 3 4 5 Patients receiving laser therapy more regularly achieved the target intraocular pressure (pressure in the eye) than those having standard eye drops. Laser patients were also less likely to need treatment for glaucoma and cataracts. Most patients are blind by the time they become young adults. There is no other treatment for the disease. Treatment con- sists of injections of the RPE65 gene into the retina. An estimated 337 people in the UK have inherited retinal disease. Mutations in both copies of the RPE65 gene are estimated to affect about one in 200,000 people. Dr David Rind, of the US Institute for Clinical and Economic Review, says: "While the evidence is clear the therapy improves vision for patients over several years, the long-term duration of this ben - efit remains unknown. Assuming a ten to twenty-year benefit period, at list price the treatment does not meet standard cost-ef- fectiveness thresholds." William Bossing, assistant professor of neurosurger y at Baylor College of Medi- cine, in Houston, Texas, says the research was designed to enhance optimal inter- face between the Orion bionic eye and the brain to enable the research participants to see forms and shapes. Su r g ic a l ly i mpla nte d i n t he bra i n, t he Or ion i nclude s a c a mera mou nte d on a pa i r of i ma ge - c apt u r i ng eye g la s s e s . It del iver s pat ter n s of s t i mu lat ion d i re c t ly to t he v i su a l pa r t of t he bra i n; i n ot her word s, it c a n by pa s s broken opt ic a l ner ve s . Daniel Yoshor, Baylor professor of neu- rosurger y, explains: When you think of vision, you think of the eyes, but most of the work is being done in the brain. Impulses of light projected on to the retina are converted into neural sig- nals that are transmitted along the optic ner ve to parts of the brain." When Mary Booth made an appointment at her local Didcot opticians for a routine eye examination, she had no idea that the visit would ultimately help to save her sight. Mary, 78, a regular customer of Specsavers in Didcot, made the appointment for a sight test earlier this year. She'd not been experiencing any unusual symptoms, but thought she might need a new pair of glasses as her vision had deteriorated a little. She was seen by optometrist and store director Rukhsana Bi, who quickly picked up that Mary's optic disc in her left eye looked different from her previous visits. Further tests using an optical coherence tomography (OCT) machine, which uses a laser light source to produce a structural scan of the eye, along with field and pressure tests, led Rukhsana to believe that Mary had the early signs of glaucoma. Rukhsana urged Mary to contact her GP to arrange an appointment at the eye hospital. "I managed to get an appointment with an eye consultant within a month and he confirmed Rukhsana's suspicions about glaucoma," says Mary. "The consultant was also amazed that this had been picked up at all during a routine eye examination at such an early stage and praised Rukhsana for her professionalism." Fortunately, as Mary's condition had been caught early, she was prescribed with special eye drops to reduce any damage to her eyes. She'll also continue to have regular check-ups at the hospital. "The thought never crossed my mind that I might have glaucoma," adds Mary. "I'd not had any symptoms and there's no history of the condition in my family. So, if I hadn't seen the optician when I did, I could ultimately have lost my sight. At least my two children, now in their 40s, can be monitored early as a result, as glaucoma can be hereditary. I'd recommend everyone visits their opticians regularly, irrespective of whether they think they need new specs or not." "Mary's story really does demonstrate how important it is to keep up to date with your eye examinations," Rukhsana concludes. "Glaucoma is a progressive disease, so the earlier it's picked up the better. We're just thankful Mary came in to see us when she did." ccording to research by the Royal National Institute for Blind People (RNIB), 14 million people in Britain are not having their eyes tested every two years as recommended by the College of Optometrists. And, although according to a 2018 YouGov poll 70 per cent of people value their sight more than any other sense, there are up to one million people in the UK with some degree of preventable sight loss. One of the main causes of avoidable sight loss is something that seldom pre- sents symptoms in its early stages and is often called the "silent thief of sight", the condition known as glaucoma. The most common form of glaucoma progresses slowly causing the death of nerve fibres in the optic nerve, which connects the eye to the brain. This results in a gradual loss of peripheral vision in the affected eye that often goes unnoticed at first. "People often won't know they have it until it's fairly advanced and by that time any vision loss is pretty much irreversible," says Dr Nigel Best, Specsavers' clinical spokesman. "We are encouraging people, but especially the over-40s, to have regular eye examinations every two years to check for early signs of glau- coma so they can be referred for early treatment to protect their sight." The RNIB advises a biennial eye exam- ination even if there is no change in vision, but its figures show that 14 mil- lion adults in Britain have not had their eyes tested for more than two years. The International Glaucoma Association (IGA) estimates 700,000 people in the UK have the condition, but around 50 per cent are unaware they have it and glaucoma worsens if not detected. At the point of diagnosis, men are 16 per cent more likely than women to have signficant sight loss, probably because of a traditional male reluctance to engage with healthcare. "The vision loss is so gradual that people don't notice it; you can lose up to 40 per cent of vision before it becomes apparent," says Karen Osborn, IGA chief executive. "Glaucoma is characterised by misty, patchy vision in the periph- eral field. One of the reasons it goes unnoticed is that the brain is wonderful at filling in the gaps from images provided by the optic nerve, while the eyes work together with over- lapping fields of vision which compen- sates for weaknesses." IGA is funding research to develop treatments, cures and improved testing methods that will deliver earlier diagnoses. "Glaucoma is complex and there is no cure at the moment, which makes having regular eye examina- tions so important," says Ms Osborn. "Losing your sight can have a huge impact on your life and your inde- pendence. One of the things I'd love never to hear again is 'I wish I'd had my eyes tested'. The impact of delaying can be profound." Specsavers is now spearheading a national programme to reduce avoida- ble sight loss drastically by introducing optical coherence tomography (OCT) scanning equipment in all its stores. The non-invasive imaging machine enables optometrists to detect minute changes in the retina and optic nerve that can highlight glaucoma up to four years earlier than traditional methods. "OCT can measure down to a couple of microns – a micron is a millionth of a metre – to give us an accurate assessment of the thickness of the retinal nerve fibre layer, which is a very good indicator of glaucoma," explains Dr Best. "Glaucoma can be difficult to diag- nose, but this technology is a game- changer as it significantly enhances our ability to spot glaucoma, and other sight-threatening conditions, at an earlier stage. The OCT scans the optic nerve and measures the thickness of the nerve fibres present. "It then compares this thickness measurement with measurements taken from thousands of similar patients to indicate to an optometrist whether the thickness is as expected or thinner than expected, which can indicate glaucoma. "An optometrist will consider the OCT findings in conjunction with other more traditional signs of glau- coma, for example eye pressure, and decide whether referral for further investigation is necessary. "It is a quick, easy and painless examination. The patient simply positions their chin on a rest and feels nothing as the machine takes less than a minute to scan each eye. "If we can start treatment at an early stage, then vision loss will hopefully be minimal and most glaucoma patients will have no disease progression. However, most patients will need to put in eye drops daily for the rest of their lives to preserve their sight." Specsavers is committed to rais- ing awareness of preventable sight loss and making it easier for people to have regular eye examinations that can protect their sight. For more information please visit specsavers.co.uk Understanding glaucoma A regular eye test does more than ensure you have the right prescription glasses; it could save your sight or even your life Commercial feature A Glaucoma can be difficult to diagnose, but OCT technology is a game-changer as it significantly enhances our ability to spot glaucoma at an earlier stage of glaucoma in the community remains undiagnosed; previously undetected cases are largely identified at routine sight tests by community optometrists of people with glaucoma are registered blind Royal College of Ophthalmologists 2016 50% 10% Routine sight test picks up potentially sight-threatening condition

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