Ophthalmology is rooted in a rich history of imaging and equipment-assisted examination. Ancient dissections of the human eye by polymaths such as Aristotle and Rufus of Ephesus disclosed a cascading complexity of the organ—a knowledge of which continues to be enhanced in stunning detail today with sophisticated imaging technology. ^, Despite being an organ-specific specialty, ophthalmology and ophthalmic examination are broadly relevant: from red reflex checks at birth to the monitoring of common ocular diseases in older patients, eyecare is a ubiquitous component of sound medical practice.

Thus, understanding trends in the implementation of the current suite of ocular imaging technology has wide-ranging implications and numerous stakeholders, most importantly those large patient populations afflicted by common vision threatening retinal disease. We recently undertook a group of projects assessing patterns in ophthalmic imaging specific to vitreoretinal clinical practice. These studies were focused to answer two questions: who is using retinal imaging technology and how are they using it? The who question will be answered in forthcoming work from our group. The how was explored in a study published in this journal.

Significant temporal and regional trends were discovered in the Unites States Medicare Fee-for-Service population among those patients receiving care from retina specialists. Among the modalities assessed (Optical Coherence Tomography (OCT), Fundus Photography, Indocyanine Green Angiography (ICGA), Intravenous Fluorescein Angiography (IVFA), B-scan Ultrasonography) from 2012 to 2016, increasing volume of services provided was observed most strikingly with OCT. Correspondingly, the relative usage of OCT grew significantly over this time period, while IVFA and fundus photography declined. These trends remained true when assessed at the US Census region level. While OCT technology was introduced to clinical practice two decades ago, it seems that the upper threshold for utilization of OCT in clinical practice has yet to be realized. This hypothesis may prove even more salient if OCT-A becomes a more commonly employed imaging modality.

The correspondence from Dr. Pontikos and colleagues notes similar trends from the Moorfields Eye Hospital European eyecare centers within the UK National Health Service and affirms and broadens the context of our findings. This analysis found concurrent trends in OCT usage: persistent growth was noted between 2008 and 2016. Furthermore, usage of OCT among other ophthalmic subspecialties increased over the time period assessed. Taken together with our data, these findings suggest generalizable trends in ophthalmic imaging across diverse patient populations and healthcare systems. The sheer volume appreciated in these studies (on the order of hundreds-of-thousands and millions of imaging services provided), indicates the importance of efficient and effective ophthalmic imaging for patients and providers.

Why has OCT become a standard of care in modern eye care and why is its growth so explosive in ophthalmology and more recently in other fields of medicine and manufacturing? Above all it is informative, safe, noninvasive, efficient and patient friendly. OCT allows the trained user to diagnose disease and monitor disease progression. For example, OCT imaging measures macular volume and can distinguish between subretinal and sub-retinal pigment epithelial fluid. OCT image registration allows detailed point-to-point comparison of clinically useful information over time and therefore can help determine response to therapy. Interestingly and despite these capabilities, Dr. James Fujimoto remarked (personal communication, Retina Society London September 2019) that OCT imaging would not have been broadly adopted, clinically relevant and commercially successful without the advent of anti-VEGF therapy for conditions such as neovascular AMD and diabetic macular edema. The importance of OCT imaging data in the treatment of these common retinal diseases fuels the absolute and relative growth of OCT utilization compared to other fundus imaging technologies.

With this massive data volume arises the question of how such vast repositories of information will be interpreted by ophthalmologists. Consider this major factor in the future of ophthalmic imaging and medical imaging as whole: artificial intelligence (AI). The capacity of this technology, even in its relative infancy, has proven relevant to clinical practice in specific instances such as retinopathy of prematurity (ROP) and diabetic retinopathy screening. It is beneficial to frame the potential incorporation of this technology into ophthalmic practice on medium and long-distance timelines. In the medium outlook, systematic appraisal will be needed to generate effective modes of implementation in which AI algorithms efficiently enhance the physician’s clinical decision making. Just as is the case with multimodal imaging interpretation, AI may provide another tool, which can be employed in the context of important clinical exam findings and other imaging studies. Subsequently, the long-term outlook for the role of AI in ophthalmic imaging will require sophisticated, interdisciplinary oversight, which will introduce a slew of safety ( ex. automation bias), logistic, legal, and moral challenges. All future implementation of this technology should be rooted in the ethos of patient-centric care.

From a patient-centric perspective, reliable and accurate AI may also improve therapeutic outcomes with more frequent and remote imaging data assessment (and therefore timely treatment) and paradoxically ameliorate the major burden of frequent office visits as “at home” ophthalmic imaging moves from the medical office to the patients’ home. Currently, at home OCT hardware and associated cloud-based AI algorithms are already in beta testing. This potential reality will require validity testing but may be relevant in the near future as new longer lasting anti-VEGF injection therapies, port hardware delivery or even gene therapies aim to provide not only improved safety and efficacy to contemporary monthly or bi-monthly intravitreal injections but also strive to reduce burden of treatment characterized by frequent office visits. It is possible that these events will help deliver more convenient and cost-efficient care. Imaging is likely to continue to drive clinical ophthalmic practice and new technology may enhance diagnostic and prognostic capacities. Diligent assessment of the large data generated by these imaging services offers the opportunity to provide more cost-effective and outcome-driven care, conferring significant benefit to healthcare systems, providers, and patients. Security and health privacy will need to evolve.

It is important to encourage development of the diagnostic and therapeutic technologies which improve vision care and to educate diverse stakeholders. Dr. James Fujimoto describes the concept of an “ecosystem” consisting of research, government funding, collaboration and competition, clinical studies, innovation, entrepreneurship and industry, and impact–all of which must work synergistically to move the bar higher. Further, non-invasive, efficient and ultrahigh resolution ophthalmic imaging technology–for example, OCT and OCT-A–lead the way for other clinically important diagnostic imaging modalities across diverse medical fields such as cardiology, gastroenterology and oncology. The importance of vision and improving vision with new cutting-edge diagnostic and therapeutic technologies leaves a halo effect for all of medicine.

What will be the next upward trending imaging technology to integrate into transformative vision care? Refined autoflourescent fundus imaging for cell or complement-based therapy for atrophic AMD? Noninvasive in vivo ocular genetic assessment for diagnostic and therapeutic refinement of gene therapy? A neurodegenerative imaging tool that determines which patients will benefit from an injectable neuroprotective agent? Only time and careful clinical trial execution supported by Fujimoto’s “ecosystem” will reveal the next chapter.