Science Fiction No More

AI and telemedicine are here to stay post-pandemic

by Tan Sher Lynn

At the recently held 15th Congress of the Asia-Pacific Vitreo-retina Society (APVRS 2022), held in Taipei, Taiwan, experts explored artificial intelligence (AI) and telemedicine as potential mitigators in the post-pandemic world, as well as discussed gene therapies and new drug approvals for retinal diseases.

While the pandemic has disrupted various aspects of our lives, it has also promoted increased use of AI and digital health solutions. For example, exciting technologies that emerged during the pandemic include the Johns Hopkins COVID-19 dashboard, AI for risk modeling in COVID-19, and AI for CT imaging for COVID-19 — noted Dr. Daniel Ting from Singapore during his presentation.

He mentioned that machine and deep learning studies on PubMed have been showing exponential growth over the past years.

Dr. Ting also shared that in Singapore, for example, DR EYE was created to harness the power of AI and the Internet of Things (IoT) to promote eye health among patients, especially migrants who don’t speak good English. The app empowers patients to be more health conscious by keeping their own eye records and promotes better communication with patients and external partners

(e.g., community optometrists or opticians). The aim is to integrate state-of-the-art deep learning technologies with digital solutions, leveraging the IoT to deliver eye care via the cloud.

When it comes to the use of AI in ophthalmology, the sky is the limit. The various new technical areas of AI include federated machine learning, blockchain, adversarial attacks, driverless AI, segmentation AI, and synthetic AI with human-in-theloop. Meanwhile, digital innovations include remote monitoring; augmented, virtual vs. mixed realities; and the Metaverse, Dr. Ting further shared.

Hybrid telemedicine for outpatient eye care

During his presentation, Dr. Xuejing Chen from the Boston University Eye Associates (USA) noted that telemedicine is not a new thing in ophthalmology. Traditionally, the store-and-forward model was used in age-related macular degeneration (AMD), retinopathy of prematurity (ROP), diabetic retinopathy (DR), and glaucoma, which bridged access due to distance or workforce limitations.

“However, during the pandemic, telemedicine assumed a new purpose, which is to provide care for patients while limiting physical contact. This allows vulnerable patients to seek the care they need,” she shared, noting that many centers had quickly developed virtual protocols to serve patients during the pandemic. However, a virtual-only telemedicine platform has its limitations, which include the absence of examination elements.

“The hybrid ophthalmology telemedicine was developed to address the shortcomings of a virtual-only telemedicine platform. This model includes an in-person imaging appointment administered by a trained technician (to perform necessary tests), followed by a virtual-only appointment with the doctor on a separate day,” she continued.

Dr. Chen described the implementation of the hybrid model in 889 patients in a hospital-based eye clinic in Boston from April 9 to December 30, 2022. The hybrid model was primarily used for retina and glaucoma patients. At the end of the virtual appointment, most hybrid patients continued the same plan, but at least 9.7% required a change in management (procedure, change of medication, or consult), indicating that even ‘stable, non-procedural’ patients need follow-up and should not be continuously postponed.

She also noted that according to a survey done by the hospital, hybrid visits and in-person visits did not have any difference in terms of patient satisfaction. However, older patients were less satisfied than younger patients with hybrid visits, but were equally satisfied with inperson visits.

Moving forward with novel therapies

Meanwhile, there was another good news from Dr. Elliott Sohn from Iowa, USA. He shared that the technology and surgery needed to treat most inherited retinal diseases are available nowadays. However, he emphasized that clinical trials and pre-clinical work with RNA, DNA, and cell-based therapies are under intense investigation.

“The various gene therapy trials and approaches available nowadays include gene replacement, which is especially for recessive disorders (such as voretigene neparvoves for RPE65 mutation), CRISPR-based gene editing strategies, RNA-based therapies, and delivery of a gene to produce a protein necessary for cell or physiologic function — mainly for inherited retinal disease (IRD), AMD, and DR,” he shared. He noted that over 750 trials of gene and cell therapies have been carried out in 30,000 patients in medicine.

According to Dr. Sohn, it is important to mention that COVID-19 has accelerated innovations and unexpected solutions, such as the automation of induced pluripotent stem cells (iPSC) production with robotics, which increases throughput for cell generation.

New drug approvals for retinovascular diseases

“The pandemic has affected us in many different ways, but it also brought us closer as one world, one globe, one humanity,” said Dr. Judy Kim from Wisconsin, USA. “For me, all the clinical trials that have been going on came to a halt. We could not see any research patients at all.”

She noted, however, that despite the pandemic, drug development and approval continued to be carried out. One of the drugs approved is the faricimab-svoa (VABYSMO™), the first bispecific antibody that acts through dual inhibition of both angiopoietin-2 and vascular endothelial growth factor A.

She mentioned that the 2018 ASRS PAT survey of US and international retina specialists revealed that the greatest unmet need with regard to neovascular age-related macular degeneration (nAMD) treatment is the need for reduced treatment burden, followed by long-acting/ sustained delivery.

As such, faricimab potentially meets the need for durability.

The TENAYA and LUCERNE trials showed that the acuity outcomes of faricimab on nAMD patients were non-inferior to aflibercept. In fact, with faricimab, about 45% of patients were able to be treated until Q16W, and almost 80% were able to be treated up to Q12W and longer.

Meanwhile, the YOSEMITE and RHINE trials showed that vision gains with faricimab Q8W and personalized treatment intervals (PTI) up to Q16W were non-inferior to aflibercept Q8W and maintained through year 2. The trials also showed that over 60% of diabetic macular edema (DME) patients were able to achieve Q16W dosing at week 96.

“Based on these favorable results, FDA approved faricimab for nAMD and DME treatment in January 2022,” she said.

She also mentioned that brolucizumab-dbll (BEOVU®) was approved for DME treatment in June 2022.

Dr. Kim also talked about biosimilars — biologics that are highly similar to the (originally licensed) reference product, noting that they have a different development pathway and approval process than drugs.

“It takes a company over 10 years and about $2.6 billion to bring a new drug to the market. But for biosimilars, it only takes five to nine years and $100 million,” she shared, noting that the first ophthalmology biosimilar approved by the FDA was ranibizumab-nuna (BYOOVIZ™) in September 2021 for nAMD, myopic choroidal neovascular membranes (CNVM), and macular edema from retinal vein occlusion.

Editor’s Note

The 15th Congress of the AsiaPacific Vitreo-retina Society (APVRS 2022) was held on November 18 to 20, 2022 in Taipei, Taiwan. Reporting for this story took place during the event.