ARVO 2022 – Closing keynote address

Frank Ma, MD, PhD
PGY-3, University of California San Francisco

ARVO closing keynote: Accelerating ophthalmic discovery and technology translation through team science

To conclude a successful meeting in beautiful sunny Denver, Dr. Maureen Maguire, ARVO President, introduced the closing keynote as the last opportunity at ARVO 2022 to see how real-world problems can be solved by team science. In the spirit of teamwork, we were treated to a joint lecture by Dr. Cynthia Toth and Prof. Joseph Izatt, both from Duke University. It was a treat to watch as they bounced ideas and stories off each other, describing a collaboration that’s lasted for 20 years and has focused on “seeing” eye tissue in detail when detail has been most needed.

Bringing technology to bedside takes many steps: from research, to product development, to undertaking clinical studies, to building commercial products. But it always starts with finding a gap in clinical care, according to Dr. Toth. She gave the example of first identifying the value of optical coherence tomography (OCT) and the need for clinically relevant OCT at the point of care. The current paradigm is to bring the patient to the instrument, but their teams have been working to reverse this, bringing the instrument to the patient. Drs. Toth and Izatt showed us how they did this with two groups of patients who would not have been able to sit still or fixate for conventional OCT– one being infants, the other being patients undergoing surgery.

Our whirlwind tour of the history in the development of the hand-held OCT (HHOCT) starts in 1996 when the first time-domain OCT units were used for research on adults at Duke Medical Center. In 2001, Dr. Izatt joined Duke University and worked on developing the spectral domain OCT that was released in 2004. After identifying the need for better visualization of the pediatric retinal anatomy, the team at Duke worked on bringing the faster acquisition times of spectral domain OCT to hand-held devices in order to image neonates for the evaluation of ROP (retinopathy of prematurity). Collaboration between the clinical and engineering teams led to FDA clearance of their device for the imaging of supine children and neonates in 2012.

They highlighted 3 major advantages of using the handheld device for ROP: dilation is not mandatory, there is no contact with the eye, and infrared is more comfortable to the baby. This work also resulted in important new findings: typical OCT bands of outer retina are absent at birth due to immaturity of the foveal cones, high prevalence of macular edema in infants, thin choroid is associated with lower growth velocity, and thinner RNFL thickness is associated with poorer 9-month grating visual acuity, just to name a few.

The future is bright for infant OCT: giving us noninvasive access to monitor developing neurovascular tissue and effects of treatments on ROP. Dr. Izatt concluded this part by showing us the capabilities of a combined adaptive optics HHOCT: being able to visualize cones within 2 degrees eccentricity to the foveal center and in 3D.

Intra-op OCT started in 2009 with taking before and after surgery OCTs in the OR, but that required re-scrubbing and the process was clunky. They brought swept-source OCT-guided surgery to the OR in 2014. To highlight its utility, Dr. Toth described a case where she saw a macular hole after doing vitrectomy for vitreous hemorrhage – and because of OCT, she was able to identify it as a pseudohole and did not do additional surgery. Further advances in bandwidth allowed their team to introduce 4D microscope integrated OCT, which is live 3D OCT updated over time. Now the system has been updated to project OCT on the NGENUITY system; allowing the surgeon to judge volume and placement of subretinal therapeutics. Dr. Izatt highlighted the next steps of integrating the surgical field and the OCT views using image fusion. One challenge that remains is on how to extract and communicate relevant OCT data for research and to help surgeons perform. Looking ahead, Dr. Izatt presented the possibility of a virtual reality headset in the OR and showed us a robotic OCT machine capable of following head movement and taking OCT autonomously; an opportunity for huge future strides in tele-ophthalmology.

In true team science fashion, the duo finished by thanking all of the numerous trainees, colleagues, and collaborators and left the audience with 5 lessons learned:

  1. Find and treasure collaborators that you enjoy working with
  2. Address real world problems
  3. Keep the needs, rights, and protection of patients and human subject as a top focus for the whole team
  4. It’s all about the students/trainees
  5. Listen and respond to each other! Accept feedback

It was an honor to have both Dr. Toth and Prof. Izatt here at ARVO this year and an inspiration to hear about all they have done in bringing access to this valuable imaging technology to more and more patients!