A decade of fine-tuning proven therapies and embracing advancing clinical technology has put ophthalmology in a rare space.
Never has a series of developments bettered the field of ophthalmology more than what’s transpired over the past decade. With new treatments, advancing research, and strengthened knowledge, the field has advanced as quickly—if not ahead of—most other specialties in medicine.
Most of this progress since 2010 comes from physicians embracing progress made in the previous decade. With the onset of anti-vascular endothelial growth factor (VEGF) therapies, realization of the potential in new technologies, and a continued commitment to research, ophthalmologists from all aspects of work have collectively provided to the significant strides made in preserving the vision of an aging population.With the US Food and Drug Administration (FDA) approval of pegaptanib sodium for wet age-related macular degeneration in 2004, the landscape of treating retinal disease shifted completely. Anti-VEGFs very quickly became standard treatment for a slew of vascular and exudative retinal diseases.
Fifteen years since that market breakthrough, anti-VEGFs have retained their status in ophthalmology—for the foreseeable future. Treatments including aflibercept and ranibizumab have expanded beyond their original indications for wet AMD, and are now approved for macular edema, retinal vein occlusion, diabetic macular edema, and diabetic retinopathy—covering a huge gamut portion of the blindness-risk disease population.
With their steady spread to every common condition, anti-VEGFs are driving physicians further away from lasers and steroids—the former staples in ophthalmologic care.
“There's been a major shift away from these older styles of therapies which were tried and true for many years and primary therapy,” Carl Regillo, MD, director of retina service at Wills Eye Hospital and professor of ophthalmology at Thomas Jefferson University, said in an interview with MD Magazine®.
Though these clinical developments have better aided physicians, the field still seeks means to reduce treatment burden for patients. Anti-VEGFs could guarantee a patient improving or preserving their vision, yet requires monthly injections. Trends show that great benefit may not outweigh the charge—at least in the eyes of the patient.
This is what Regillo believes has driven development of the recently-approved and continuously developed therapies such as brolucizumab and the Port Delivery System (PDS)-capable ranibizumab. He foresees the most important hurdle for these therapies will be if they can retain previously-set standards for efficacy while significantly reducing treatment burden and frequency.
“They work as well and last a little bit longer and that's going to help with this unmet need of limited durability of the drugs,” Regillo said. “We certainly welcome all that, but that alone is probably still not sufficient. We're looking for ways to really deliver these drugs over much greater timeframes.”Every specialty in medicine has had its own unique relationship with technology and its embrace—or lack thereof—has defined the progress clinicians have witnessed. In ophthalmology, that embrace has put clinicians years ahead of other fields in potential benefit from artificial intelligence and machine learning.
In addition to contributing to advances in treatment, like those necessary for development of PDS with ranibizumab, this embrace has landed ophthalmologists on the cusp of incredible advances in the near future. Presentations and studies on AI and machine learning systems for use in identifying conditions through imaging have gone from few and far between, to hot topics of discussion on the floors of major conferences such as AAO and ARVO.
Once an idea akin to science fiction, machine learning algorithms are now boasting great levels of specificity in detecting conditions such as diabetic retinopathy from OCT. Meanwhile, investigators working with artificial intelligence have also demonstrated ability to identify diabetic macular edema using CFP.
At AAO 2019, Louis Pasquale, MD, professor of medicine at Icahn School of Medicine at Mount Sinai, shared his belief ophthalmology has always been on the cutting edge of new technologies and laid the foundation for treatment of an aging population.
“It would be wonderful if AI could predict—and I think that it could predict—which patients are going to be rapid progressers, which patients might need surgery, what would be an appropriate target intraocular pressure for treatment of the disease, etc.,” he said. “So, there's tremendous amount that I believe AI still can do in our field.”Retina specialists were not the only ophthalmologists to benefit from advances in the past decade. Uveitis and glaucoma specialists also saw their fair share of changes.
In glaucoma, the onset of prostaglandin analogs in the last 5 years has paid dividends. The medicated eyedrops are already considered first-line treatment for glaucoma. Minimally invasive glaucoma surgery has also come to the forefront, after a series of great advances were made.
In uveitis, a commitment to research and analyzing real-world data has led to advances that have altered the course of treatment for most patients. Led by the SAKURA 1, POINT, and MUST studies, clinicians have a greater idea than ever before on how to effectively treat and manage a patient’s uveitis.
In addition to guidance on proper treatments, uveitis specialists also benefitted from a notable increase in the amount and variety of treatments available for their patients. As with other ophthalmic conditions, uveitis specialists sought to improve on the treatments and options available to them—with patient burden reduction being the central focus.
Since the 2006 approval of retisert, numerous intravitreal fluocinolone acetonide implants have made their way to market and are used for treatment. But the most significant advancement may have come when adalimumab broke into the space. The monoclonal antibody received FDA approval for non-infectious uveitis in 2016.As the field steps into the next decade, many will be waiting with bated breath to see where the next monumental advance will arise—whether it be screening systems using smart phones or an alternative that allows fewer injections, the next decade will surely hold a bounty of advances that will lay the foundation for the decade the proceeds it.
As medicine advances forward into this exciting, but uncertain future, the only thing guaranteed is ophthalmologists will continue to make sure their field is at the forefront of that change.