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Is the best still to come in OCT technology?

Few technologies have had such a swift and profound impact on eyecare as much as optical coherence tomography. Insight takes a deep dive into the evolution of OCT and the bearing this may have on future models.

Since its development in 1991, OCT has become a cornerstone in the diagnosis and assessment of most vision-threatening diseases and has helped transform vision research.

As to be expected, there were many early adopters in ophthalmology – and to a lesser extent optometry – from the beginning. But as the utility of OCT became undeniable, and often despite the lack of a financial incentive to incorporate OCT into a practice, uptake of the technology began to trend upward.

Today, its ubiquity in Australia’s ophthalmic sector is perhaps best demonstrated by its increasing prevalence in both independent and corporate optometry practices and its inclusion in MBS items for ophthalmology (but not optometry) since November 2016.

OCT’s developmental path started with time-domain (TD)-OCT, followed by spectral-domain (SD)-OCT, and ultimately swept source (SS)-OCT models. The technology is advancing through its next major evolutionary step in the form of OCT-angiography (OCTA), introduced in 2014, with other variations also inching closer to commercialisation.

And eyecare isn’t the only sector benefitting, with the technology now extending into oncology, cardiology and dermatology.

Engineer and Massachusetts Institute of Technology alumni Mr Eric Swanson is a co-inventor of OCT technology and a co-founder of the first ophthalmic OCT company, later acquired by Zeiss. He is also editor of OCT News, a notfor-profit website providing the latest news in the field.

Mr Eric Swanson.

In a presentation he gave at a conference in Singapore in 2017, Swanson says OCT continues to benefit from “tectonic advancements” in other fields, such as augmented reality, and says high-speed lasers, integrated photonics, and computer-aided detection and diagnosis are among the most active areas of OCT research and design.

He also notes that the commercialisation and growth of OCT during the past 25 years has had enormous scientific, clinical, and economic impact. To illustrate the latter, he cites statistics that between 2008-2015, OCT-guided anti-VEGF therapy in age-related macular degeneration saved more than US$9 billion (AU$12.6 b) by avoiding unnecessary injections.

In a paper he co-authored in Biomedical Optics Express, Swanson estimated there was more than US$500 million (AU$693 m) of venture capital and corporate research and development investment developing OCT related products, and more than US$500m (AU$693 m) of government funding towards OCT research.

But despite the tremendous accomplishments in advancing OCT technology and clinical applications, Swanson believes the best of OCT technology is still to come.

“We’re still at the beginning of this technology – we’re not even at an inflection point.”

Building on breakthroughs

With the relatively recent introduction of OCTA, eyecare professionals now have access to an additional imaging modality for the retinal and choroidal microvasculature, helping inform decisions in glaucoma and retinal diseases.

Compared with the gold standard fluorescein angiography, it has unique benefits as well as certain disadvantages. However, software and hardware improvements are evolving to mitigate these limitations.

Two recent projects, reported in Biomedical Optics Express in July this year, have published findings that could assist greater translation of OCTA into ophthalmology clinics.

In one project, a group at Boston University School of Medicine has developed what is said to be the first visible light OCTA (vis-OCTA) for human retinal imaging.

The other project, involving a team of researchers at Oregon Health and Science University (OHSU) in Portland, including Swanson’s OCT co-inventor Dr David Huang, devised a prototype to improve OCTA image quality without excessive sacrifice in field of view and device complexity, which they believe may have potential for clinical translation.

“Over the past decade,” the authors note, “we have witnessed the rise of optical coherence tomographic angiography (OCTA) in retinal imaging. Unlike fluorescein angiography, OCTA does not require intravenous dye injections and uses intrinsic motion contrast provided by the flowing blood cells. OCTA is acquired within a few seconds; making it ideal for translation into routine ophthalmic clinical practice.”

While OCTA can image the retinal blood flow, they argue that visualisation of the capillary calibre is limited by the low lateral resolution.

The researchers developed a sensorless AO-OCTA prototype with an intermediate numerical aperture (NA) to produce depth-resolved angiograms with high resolution and signal-to-noise ratio over a 2×2 mm field of view (FOV), with a focal spot diameter of six microns, which is about three times finer than typical commercial OCT systems.

“Despite OCTA’s advantages over fluorescein angiography, a historical limitation of OCTA has been the smaller field of view. Because of the constraint imposed by the shorter depth of focus, adaptive optics instruments restrain OCTA’s field of view even further,” they note.

“Designs like ours based on intermediate-NA imaging beams alleviate this problem and present a potential to either achieve a clinically useful field of view in a single scan or to reduce the number of acquisitions needed for larger field of views by montaging partially overlapping scans.”

Translating research into real-world

Speaking from her clinical experience, optometrist Ms Janelle Tong at the Centre for Eye Health (CFEH), says while some retinal vascular abnormalities can be difficult to visualise on funduscopy, photographs and routine OCT, OCTA can be invaluable in identifying these subtle changes.

“In particular, the ability to detect both retinal and choroidal neovascularisation and areas of ischaemia, associated with diabetic retinopathy for example, means that it can definitely improve the way in which retinal diseases are diagnosed and managed. Research into the applicability of OCTA in optic nerve disease is also showing great potential,” Tong says.

Ms Janelle Tong.

Prior to joining the CFEH, Tong worked in a full-scope private practice in Sydney, where she developed her interest in managing posterior ocular disease. She is involved in both clinical and research aspects of CFEH, with her current research looking at modelling normal ageing changes to the eye using advanced imaging.

She says that while OCTA is not often seen in clinical practice settings, current models are rapidly evolving through faster scan speeds and subsequent wider fields of view.

“Combined with ongoing research in this field, it is likely that the uptake of this technology will expand rapidly in the future.”

She says Huang’s OHSU prototype is interesting because it presents an option which combines higher resolution imaging of the retinal capillaries with a wider field of view than most adaptive optics-based OCT scans.

“This presents a key concern of commercially available OCTA, which uses a slightly different principle to adaptive optics, where despite the larger field of view the resolution is often too coarse to visualise the retinal capillary networks in detail,” Tong says.

“However, it is important to recognise that acquiring imaging using adaptive optics techniques and scan montaging are skill-intensive and time-consuming procedures, so without further developments to improve ease of use it is difficult to see it translating to routine clinical practice at this stage.”

She adds: “Nevertheless, I am excited to see what this research holds for the future, and there is lots of potential to facilitate better detection of vascular anomalies in the eye.”

Addressing limitations

Ms Kylee Hall is the vice president of sales and marketing at Cylite, a Melbourne-based start-up taking on the giants of ophthalmology with its own device that aims to address some of the longstanding shortcomings of OCT.

Previously manager of Zeiss Australasia’s medical division, Hall took time away from the profession to pursue an Executive MBA.

On her return to Australia last year, she saw an Insight article about Cylite’s debut patented hyperparallel-OCT (HP-OCT), which she says stood out in an otherwise entrenched and saturated field.

Ms Kylee Hall.

The device’s key differentiating feature is its so-called hyperparallel optical basis that allows the instrument to take an OCT volume ‘snapshot’ image of the subject’s eye – rather than scanning a single spot across the eye, the modus-operandi of current commercial OCT products – thereby negating the effects of eye movement.

Currently, the company is in the final stages of the process of applying for CE certification that indicates Cylite HP-OCT conforms with health, safety, and environmental protection standards for products sold within the European Economic Area.

Once it has CE, the company will start the process of applying for Therapeutic Goods Administration approval.

Shortly after Hall joined Cylite as their first non-engineering appointment in February, the coronavirus outbreak disrupted the industry and resulted in the cancellation of several international and national conferences. However, they have demonstrated their device to ophthalmic professionals both locally and around the globe via Zoom.

Generally speaking, Hall says OCT scanning technology is getting faster, reducing some motion artefact, but not all.

“The eye is constantly moving, for accurate OCT measurements this movement issue needs to be addressed. It is an inert issue that motion artefacts cannot be overcome with just faster lasers or better software algorithms,” she says.

“The majority of advancements in OCT technology have been in the posterior segment, such as OCTA, where the individual B-scans are each aligned into a volume image by using the blood vessels as landmarks. For the anterior segment, OCTA is in its development infancy.”

These shortcomings of OCT technology planted the seed for Cylite to reinvent the engineering behind OCT.

The Australian-developed Cylite HP-OCT.

Hall says the Cylite HP-OCT has been received positively once eyecare practitioners understand the technology behind it and what sets it apart from other forms of the technology.

Time and space constraints 

Tong says the wider range of models and decreasing costs have resulted in OCT becoming much more widespread in optometry practices within Australia, to the point where both corporate and independent optometry clinics are marketing availability of OCT in their practices.

Hall agrees, adding that some devices, like the Optos Monaco, that combine OCT and ultra-widefield imaging are popular in practices where space is a determining factor.

“Footprint is a big cost for practitioners, it’s cost-effective if you can combine multiple instruments and reap the advantages of more functionality in one device,” she says.

Through an abundance of education on the technology, Tong, at the CFEH, says optometrists now have a solid understanding of when OCT imaging would be beneficial and subsequently can arrange appropriate referrals if one is not available in their practice.

She says at this point in time it is more common for optometrists to have access to an OCT device that is either stand-alone or combined with fundus (posterior pole) photography.

“Typically, practices offering ultra-widefield photography have a separate machine to perform this. Current common OCT models, in conjunction with standard and other widefield photography options, are generally able to easily image diseases affecting the central retina,” she says.

She says that while OCT devices incorporating OCTA or ultra-widefield photography are commercially available, they are relatively recent developments that are not yet widespread in Australian optometry practices.

“In particular, combined widefield technology and OCT shows great potential for investigating and managing peripheral retinal pathologies, and OCT models are increasingly incorporating additional widefield scanning options. Furthermore, several software options are currently available to help colocalise scans from cameras and OCTs,” she says.

Both Hall and Tong have their ear to the ground in their respective fields and see different futures for OCT technology.

Hall says one of the more recent talking-points in ophthalmology and optometry circles is the slit lamp.

“A slit lamp examination is the current gold standard of eyecare, but with the recent pandemic it has eyecare practitioners asking: ‘How do we offer the same level of clinical care but be at a safe distance? When will OCT technology, especially for the anterior segment, be advanced enough to replace the slit lamp examination?’.”

In contrast, Tong says a recent ‘hot topic’ in the research world is adaptive optics OCT, where methods enabling visualisation of the cellular structures of the retina are being developed.

“It would be very interesting to see the clinical applications of adaptive optics OCT and, in turn, its translation to a commercially available device,” she says.

Currently, Tong says, there are improvements in OCT technology with each new version released. She predicts future developments are likely to incorporate faster scan acquisition, new methods to analyse the data and application of machine learning for automated identification of anomalies within acquired OCT scans.

“In addition to OCTA and combined ultra-widefield imaging/OCT becoming more widespread, I also believe future versions of OCT will place a greater emphasis on capturing a wider field of view, as many commercially available OCTs are hampered by the same limited field of view as OCTA,” she says.

In contemplating how OCT will fit into the future of optometry in Australia, Tong points to Optometry Australia’s Optometry 2040 project which she says highlighted that a focus towards detection and management of ocular diseases was the most preferred future for currently practising optometrists.

“With a greater emphasis on disease management comes an increased need for collaboration with other health practitioners, and the concept of optometrists being part of integrated care networks to ensure best-practice patient care is an exciting prospect,” she says.

“An example of this is screening for retinal toxicity secondary to hydroxychloroquine (Plaquenil), which would require collaboration between the patient’s rheumatologist, GP, optometrist and ophthalmologist should referral be required. OCT certainly would facilitate the expansion in this scope of practice by enabling more accurate diagnosis, monitoring and management of ocular diseases.”