Optometry Technology: What to Expect? 

For this article, we surveyed eye care professionals on which optometry technology appears most promising to them. The answers were divided among AI for more precise diagnostics, advanced contact lenses, and new iterations of OCTs.

Of course, this is not the whole list of possible new tech in optometry, but these are the topics that draw the most attention today. 

The article delves deeper into each of these technologies, as well as explores oculomics, the new way of understanding the correlation between eye pathology and overall human health.

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New tech in optometry: AI for Medical Image Analysis

AI has blossomed in recent years, transforming not only how we work and relax but also how we manage our health. It’s no surprise that our survey of professionals revealed AI as the most promising technology in optometry.

The most immediate and practical AI implementation in optometry is the analysis of medical images, such as fundus photos and OCT scans.

They require no additional equipment beyond the OCT and fundus cameras many practitioners already own, are cost-effective, and add huge value to a practice. 

There are many companies that detect a number of biomarkers and help with diagnostic decision-making already, and their number will only increase from year to year for several reasons:

• AI systems for medical image analysis speed up patient triage
• AI systems help to detect early, minor, and rare pathologies which sometimes can be missed
• AI systems help with complex cases when a second opinion is needed
• Quantitative analysis of biomarkers improves treatment results monitoring making it more efficient

For instance, AI today can assess the early risk of glaucoma based on the GCC asymmetry measurements. Here is how AI-powered OCT workflow would look. 

AI-assisted readings of OCT scans are already helping not only with pathology detection but also with the analysis of its progression or response to treatment. This represents a new approach to monitoring, where practitioners no longer need to sift through various patient notes but can directly compare reports from previous examinations and observe how, for instance, shadowing has changed in micrometers.

AI programs are becoming even more invaluable with an aging population, as diseases prevalent in older individuals become increasingly common while ophthalmology and optometry face a shortage of specialists. This situation will transform the optometrist’s role, with AI empowering practitioners with the diagnostic capabilities to manage many conditions without referral. This will benefit patients, enabling timely routine screenings and diagnoses and preventing months-long waits that can sometimes lead to irreversible blindness.

AI systems are also being implemented in ophthalmic trials for biomarker detection, exploring the relationship between imaging biomarkers and underlying disease pathways. For instance, a recent study linked levels of various cytokines, including VEGF, MCP-1, and IL-6, with specific OCT-derived biomarkers like fluid parameters and outer retinal integrity. 

This significantly accelerates the research process, assisting in identifying the right target audience based on OCT scans, eliminating manual data annotation, and revealing the subtlest changes, progression or regression, and patient responses during trials. 

While material advancements allow us to build more precise machines, the new tech in optometry likely won’t involve some unheard-of device. Instead, AI software will enable us to extract the maximum potential from the technologies we already use.

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Optometry Trends: New Iterations of OCT

Even though OCTs entered the market relatively recently, they swiftly became indispensable ancillary tests in ophthalmic practice for many professionals. The primary reason is their high-quality imaging of the retina, nerve fiber layer, and optic nerve, offering a near in-vivo “optical biopsy” of the retina.

However, the technology continues to evolve – partly due to technological advancements and partly due to the ability to extract even more data from OCT machines through sophisticated software.

SD-OCT is undergoing continuous development, expanding its range of applications. Multimodal imaging, which combines SD-OCT with other imaging techniques like autofluorescence and angiography, now allows for improved diagnosis and management of a wider array of diseases. 

Several prominent OCT evolutions combine technological advancements and promise widespread adoption. They are:

Optometry Trends: En-face OCT

En-face OCT in current systems is based on software reconstruction of OCT images. Image slices are selected retrospectively from full recorded volumes or calculated by depth projection along specific depth ranges, enabling three-dimensional data visualization in a fundus projection. This technique allows the projection of specific retinal and/or choroidal layers at a given depth onto an en-face view.

While we are more accustomed to working with cross-sectional images (B-scans), microstructural changes and the retinal and choroidal vasculature morphology are challenging to evaluate using B-scans alone. En-face OCT offers numerous advantages, including the ability to precisely localize lesions within specific subretinal layers using their axial location on OCT cross-sections and to register projected OCT images to other fundus imaging modalities using retinal vessels as landmarks.   

Currently, en-face OCT is being applied to various specialized areas within the eye, encompassing the anterior segment, glaucoma, infectious diseases, and the retina.

Optometry Technology: SS-OCT

Like SD-OCT, swept-source OCT (SS-OCT) utilizes Fourier domain technology to optimize higher-quality wavelength transduction within the frequency domain. This enables rapid sweeping scan patterns across a broad bandwidth.

However, instead of a broad-bandwidth light source projected all at once, as in SD-OCT, SS-OCT employs a single tunable laser that sweeps through different frequencies to cover the entire spectrum swiftly. The light reflected from the eye is captured by a photodetector significantly faster than the charge-coupled device (CCD) camera used in SD-OCTs. This difference translates to a faster scanning speed of up to 400,000 axial scans per second, eliminating the typical depth-dependent signal drop-off associated with SD-OCT. Additionally, the faster scanning speed reduces image distortions caused by eye movements and allows for wider B-scans, facilitating widefield imaging.

Furthermore, many SS-OCT systems utilize a light source centered at an approximately 1050 nm wavelength, providing better tissue penetration than SD-OCT. This allows for visualization of structures like the choroid, lamina cribrosa, and structures at the anterior chamber angle. This enhanced penetration is crucial in diseases like Central Serous Chorioretinopathy, where evaluating the entire thickness of the choroid can be challenging.

Moreover, volumetric analysis of the choroid and various pathological features can aid in monitoring the progression of Wet AMD, CSCR, and Diabetic Retinopathy, as well as assessing the response to treatments such as anti-VEGF agents, laser photocoagulation, and photodynamic therapy (PDT).

Optometry Trends: OCT Angiography

Given that many ocular diseases are associated with vascular abnormalities, the ability to visualize and quantify blood flow in the eye is crucial. Traditionally, fluorescein angiography (FA) and indocyanine green angiography (ICGA) have been used for this purpose, but these procedures require intravenous injection of contrast agents, which is not only time-consuming but may lead to allergic reactions or potentially serious side effects.   

OCTA, on the other hand, produces high-resolution, 3D angiograms of the retinal and choroidal vascular networks, taking advantage of the eye’s unique characteristic as the only organ allowing noninvasive, direct observation of its blood vessels’ structure and function. OCTA detects blood flow using intrinsic signals to capture the location of blood vessels. While it has limitations such as insensitivity to leakage and a relatively small field of view, the development of OCTA has the potential to significantly enhance our understanding of the eye’s physiology and pathophysiology, providing depth-resolved angiographic maps of the tissue’s vascular structure down to the capillary level.

OCTA is particularly valuable in clinical settings where pathologies like diabetic retinopathy, age-related macular degeneration, retinal vein occlusions, and macular telangiectasia are frequently encountered. These conditions often alter blood flow or the blood vessels themselves in the retina, making imaging these vessels essential for diagnosis and management.

Wide-Field and Ultrawide-Field OCT (WF-OCT and UWF-OCT)

While OCT is a powerful ocular imaging tool, it has traditionally been limited by a relatively narrow field of view (FOV) – typically around 20 degrees × 20 degrees. To address this limitation, two advancements have emerged:

• Wide-field OCT (WF-OCT) with an FOV of approximately 60-100 degrees captures the retina’s mid-periphery up to the posterior edge of the vortex vein ampulla.
• Ultrawide-field OCT (UWF-OCT) with an FOV of up to 200 degrees, mapping the far periphery of the retina, including the anterior edge of the vortex vein ampulla and beyond.

WF-OCT provides additional information compared to routine 6-9 mm scans in conditions such as diabetic retinopathy (DR), central serous chorioretinopathy (CSCR), polypoidal choroidal vasculopathy (PCV), peripapillary choroidal neovascular membrane (CNVM), or uveitic entities. It facilitates easier visualization of anatomical details of peripheral retinal changes like ischemic areas in DR, retinal vein occlusions, or sites of retinal breaks, peripheral retinal detachment, retinoschisis, and choroidal lesions (melanoma, nevus, hemangioma, choroidal metastasis).   

As with other OCT iterations, WF and UWF OCT will likely provide the most significant insights when routinely combined with other modalities, such as OCT angiography.

New Tech in Optometry: Advanced contact lenses

In our lifetime, contact lenses have evolved from mere corrective devices to sophisticated optical instruments. There are several ways that contact lenses (CLs) continue to advance:

• Manufacturing optimization: Automation and robotization of the process for higher precision and a shift towards a more environmentally friendly approach.
• Design: More precise designs tailored to the wearer’s eye with the help of 3D printing.
• Material advancements: Nanotechnology/surface modifications for improved wettability, lubricity, and antimicrobial properties. Increased focus on biomimetic design.
• Technological advancements: Smart lenses with thin and ultra-thin transistors capable of reacting to or registering the wearer’s stress levels, glucose levels, etc.

Let’s take a closer look at a few examples of Smart Contact Lenses (SCLs) that combine some of the characteristics mentioned earlier.

SCLs are wearable ophthalmic devices that offer functions beyond vision correction. These devices are integrated with sensors, wireless communication components, and microprocessors to measure biological markers. They can treat ocular pathologies by delivering drugs, light, heat, and electrical stimulation, or they can aid in diagnosing. Currently, some SCLs can help manage glaucoma, cataracts, dry eye syndrome, eye infections, and inflammation. In development are lenses to treat age-related macular degeneration (AMD), diabetic retinopathy (DR), retinitis, and posterior uveitis. An artificial retina (retinal prosthesis) is in its early developmental stage, with the potential to restore vision to some degree for specific types of blindness caused by degenerative diseases.

Scientists from the School of Medical Sciences in New South Wales have implanted epithelial stem cells (ESCs) from a healthy eye into a contact lens. This innovation has shown promise in repairing vision loss caused by a damaged cornea. In another breakthrough, scientists from Oregon State University have utilized ultra-thin transistor technology to design SCLs that can monitor the wearer’s physiological state. While this futuristic contact lens is still in the prototype phase, several biotech companies have already expressed interest in its development.

Smart lenses also show great promise in drug delivery. One of the main challenges with eye drops is their low bioavailability (less than 5%), primarily due to high tear turnover rates, blinking, nasolacrimal drainage, non-productive absorption by the conjunctiva, and the cornea’s low permeability. Therefore, improving bioavailability by increasing the drug’s residence time on the ocular surface remains a critical research focus. 

Additionally, drug delivery via SCLs can offer more precise dosing. With traditional eye drops, dosage accuracy relies on the patient’s ability to tilt their head and squeeze the inverted bottle correctly, leading to inconsistent application. Consequently, compliance rates for eye drops are low. In contrast, the drug delivery process with SCLs involves lenses loaded with medication for a day or several days, potentially enhancing compliance, especially for individuals accustomed to wearing contact lenses as part of their routine.

Just as artificial intelligence is merging with ophthalmic devices for detection and analysis, opening new possibilities, optometry trends are also venturing contact lenses into the multidisciplinary field of theranostics, which combines therapeutics and diagnostics. This field is uncovering new avenues of research, shedding light on disease mechanisms, and driving drug and medical device development. Theranostics leverages knowledge and techniques from nanotechnology, molecular and nuclear medicine, and pharmacogenetics to achieve goals such as in vitro diagnostics and prognostics, in vivo molecular imaging and therapy, and targeted drug delivery. This approach is shifting patient care towards proactive strategies and predictive treatments.

Optometry Technology: Oculomics

For decades, researchers have sought to measure retinal changes to identify ocular biomarkers for systemic diseases, a field now known as oculomics.

As mentioned earlier, the eye provides a unique opportunity for direct, in vivo, and often non-invasive visualization of the neurosensory and microvascular systems:

• The eye shares a common embryological origin with the brain, and the neurosensory retina and optic nerve are considered extensions of the brain, allowing direct observation of the nervous system.
• Due to the length and continuity of the visual pathway, along with trans-synaptic degeneration mechanisms, damage to the central nervous system often manifests as changes in the inner retina.
• The blood-retina barrier, similar to the blood-brain barrier, selectively allows the transport of essential substances to these metabolically active structures.
• The aqueous and vitreous humors are plasma-derived and transport lipid-soluble substances through diffusion and water-soluble substances through ultrafiltration.
• The lens, which grows continuously throughout life, accumulates molecules over time, providing a potential map of an individual’s molecular history.

The link between the eye and overall human health is not new. However, with the increasing availability and complexity of large, multimodal ocular image datasets, artificial intelligence-based ocular image analysis shows great promise as a noninvasive tool for predicting various systemic diseases. This is achieved by evaluating risk factors, retinal features, and biomarkers. Thanks to the massive datasets generated through recent ophthalmic imaging, which are now being used for deep learning and AI training, oculomics is starting to yield more precise answers. For example, the NHS alone has been conducting eye tests for over 60 years, resulting in databases containing millions of images, complete with patient records and long-term health outcomes. These datasets have been fed into AI algorithms, leading to models that can already predict cardiovascular risk factors with accuracy comparable to the current state-of-the-art methods.

It’s a significant opportunity because, with the aging population, a primary healthcare focus will be not only extending lifespan longevity but also maintaining crucial healthspan functions. The primary obstacles to both longevity and healthspan are chronic diseases, referred to as the “Four Horsemen of Chronic Disease” (Cardiovascular disease, Cancer, Neurodegenerative disease, and Metabolic disease). Many of these can be, if not entirely prevented, at least minimized in terms of progression through timely detection and intervention.

One major advantage of discovering biomarkers that can predict diseases is that eye screenings are generally less intimidating than other procedures. For example, a person might regularly visit an optometrist for prescription glasses but avoid routine cervical screenings. A less anxiety-provoking and familiar procedure could significantly impact healthcare engagement. Such screenings could also make a substantial difference for chronic conditions like dementia, diabetes, and cardiovascular disease, which constitute a significant portion of the “burden of disease.”

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Summing up

Artificial intelligence has already significantly impacted our lives. It holds immense promise in optometry technology, as its primary capability—analyzing massive datasets—aligns perfectly with eye care, where thousands of images are generated daily. Training on such vast amounts of data will lead to breakthroughs in pathology and biomarker detection and their correlation with overall human health. It will enable us to take a giant leap towards proactive and predictive medicine, helping our patients live longer, healthier lives.