Well, welcome everyone to another episode of AI and I care innovators where we feature leading experts in fields related to AI and I care and I'm So pleased today to welcome dr. Jonathan Lee who is a foremost expert in in myopia Jonathan, you know the first time I met you you were giving a talk a ao and I was just blown away by the amount of data that you had And after after talk I remember I ran up and I was like just tell me everything about my ok So I'm really pleased to have you here And I just sort of want to set the stage a little bit by by telling the audience a little bit about yourself dr. Jonathan Lee It was a professor at UCSF and runs a very busy myopia practice and actually Day myopia fellowship after his ophthalmology residency and so I'd love to hear a little bit about that dr. Lee Sure, right?
And it's it's great to see you again You know that time at ao it was Exciting because I've been on the podium multiple times for myopia topics And you can see the audience become fuller and fuller every year And that's an American conference so you can see the interest really building it the years go on and that's a really exciting thing to be a part of So a little bit about me I did my residency at UCSF as well and while I was a resident I was interested in myopia and I actually went to Singapore to do research during my research blocks second year And I just cold emailed people from Singapore because at that time No one from America or really non from East Asia and this was back in 2018 was thinking about Oh, I want to do long-term research in myopia and so they were very happy for me to come Gave me data. I brought my own funding we presented at Arvo and everything and I published in ophthalmology actually my first paper about 20 year follow-up so That kind of data is so robust in Asia and we are behind and that we don't have that data So I was passionate about bringing that kind of research and bridging the gap to America and so when I came back and I finished I was finishing up residency I was thinking well, what do I want to do I actually Don't know that I want to do surgical retina, which is what I applied in and then Singapore National Eye Center reached out to me because we had such a successful past collaboration and they said hey We're opening up our my hope the fellowship to international candidates We have one local candidate each year and then we're gonna have a second International candidate starting this year because of the interest and we feel like you'd be a great candidate So I immediately dropped my Reginald retina Aspirations, which I'm so happy the timing worked out great and went to Singapore and did a fellowship there their myopia center is so So sub-specialized I rotated with their glaucoma myopia specialist their retina Hi myopia specialist refractive surgery for high myopia and then of course a lot of pediatric myopia control So it wasn't just one subspecialty it was all the subspecialty in the frame of treating high my ups so For our audience myopia of course refers to nearsightedness That's when you have a minus number in front of your glasses or contacts prescription and for I bet a lot of our audience Probably not our audience, but maybe lay people are thinking, you know, okay any classes or contacts big deal Like why is you know, why is myopia a problem? That's a question one and then question two is why am I hearing about it all the time now? Where I feel like, you know when I was in residency, you know now like almost protein like two decades out there for me, you know Yeah, you know it was never I mean you heard about some stuff really smart But like why am I hearing about it all so why is it a problem?
And I'm sure you get these questions all the time and why am I hearing about it all the time? Yeah, so You know even in my residency as I said people were not that interested in myopia and it was felt like it was maybe More of an optometric problem or a refractive error problem So basically myopia is when or at least axial myopia Which is what we're talking about here is when the eye continues to grow longer and longer when it's not supposed to and as the eye grows longer and longer you become more and more Nearsighted that is you see Things well at near but distance targets become blurrier and blurrier Which is the most predominant form of refractive error nowadays and so before The numbers the minus numbers so you might see that number with your contacts or your glasses They were around minus two minus three minus four Especially in America and so with that kind of number you could just put glasses or contacts on a kid And then they would walk around the world and everything would be fine And so that's sort of how we approach the problem in America for a very long time However, what was happening in Asia across the ocean was totally different Which is that you now have a problem where 90% of the children are now myopic and they already are demonstrating pathologic myopia which is Some manifestations which are the result of the eye becoming too long which can permanently cause blindness and so now it's gone from just a glasses problem to a medical disease problem, which is why it falls into our category, right? Because now we might have to do surgery or injections or lasers or things like that to prevent people from becoming blind and so Putting glasses or contacts in these children was not enough and so we're not far behind Asia And so as we start seeing this happen to our population We're looking over at Asia and seeing what's happening over there and we're saying wow we really need to Get behind this problem before it becomes as bad or worse and so we need to have it not cause Our huge amount of potential vision loss in our own population And we're really lucky actually because Either has pioneered so much research that we can sort of borrow from them and take all the learnings that they have and bring it over here And that's why I was so passionate about bringing that research over here because we are behind in terms of the treatments Even as you said we're behind in the attitude that we have towards myopia now You're hearing a lot about it because it's exciting because it's a white space I think it's the least mature of the subspecialties and ophthalmology so there's so much innovation going on and it's a great intersection of medical devices pharmaceuticals tech AI and so there's a lot of exciting opportunities to Have a lot of stakeholders come in and try to innovate and Show the world that we can also be a player in terms of helping progress myopia research and preventing it from causing vision loss Yeah, I think that point about Protecting your future vision that is such a key point that I care providers have to make when parents come in with their kids And recently I saw I think she's 31 or 32 and she had a Tofunnel RD She's a minus 10 and you know a young age I'm sure you see complications like that all the time and you know 20 years ago if or 25 years ago Maybe if her you know if she got appropriate treatment she may not be in the situation So it's a chronic sort of long-term type of thing So but why are we do you feel like that is a problem getting worse in the States now and is that are we showing is there proof of that Do we know that's happening? Yeah, it's definitely getting worse in the States.
So I live in San Francisco, which is an epicenter of East Asian populations and South Asians who have higher genetic risk, but in terms of if we look at the world globally the prevalence of myopia of any myopia was just around 22% in the 2000s now it's about a third so 33% or so and it's gonna be half of the world by 2050 so estimated Five billion people will be myopic and that's from our meta-analysis that everyone quotes in our field which is the hold in the meta analysis And then so if you look specifically at either or North America High-income countries like the United States We are also moving really quickly. So we were far behind Asia in the 2000s We were around 28% and not a big deal in terms of myopia And then we've reported almost a doubling of that in the 45% range in 2020 and then we're expected to have about 60% my hopes in 2050 so we are also going to have more than half of our population being nearsighted and That includes the whole population. So if you look at the children their prevalence will also be higher as they age throughout What's really devastating about that number is that there's gonna be one billion high myups in the world those are the people Who are defined there's variable definitions? You can say minus five or more some people say minus six or more Those are the people that are at high risk of losing their vision permanently like you said Whether it's through retinal detachment whether it's through our form of macular degeneration myopic macular degeneration Glaucoma, they're all at higher risk of this high myoves can be at 40 60 times risk for something like myopic macular degeneration That is irreversible Currently and we have no way to bring vision back in my myopia clinic Sometimes I see adults and children side by side and just like you said these adults It's really devastating for them to see the children Being treated right next to them because they're going blind as an adult And they see that these children have the opportunity to prevent this and often the first time they leave really emotional and it's hard because They see that it could have been prevented.
It's a really difficult thing to To have that emotion and see like I didn't have to go through this if only we had that at the time Yeah, as if maybe there's something they could have done to prevent it And so what I guess the natural the natural sort of next question is well. Why is it getting worse? I mean, I'm gonna say it's because of this right and other behaviors, but what's what's what's behind this? Yeah, so Well a lot of things are behind it But definitely what you just held up is a culprit and that got much worse during COVID So it's a little sore listening because we do have a listening audience.
I held up my phone. So a screen time basically Yeah, so screen time not just screen time but near work. Yes, something that causes increased myopia progression. So basically urban living lack of outdoor time increased near work and increased screen time have all been shown to increase myopia and Not just incidents but progression as well.
So development of myopia and also how quickly it gets worse all these things Unfortunately in the modern environment have all gotten worse children are not really like riding their bikes outside for four hours after school anymore They're just scrolling on their phones, right? So these mechanisms that used to protect us from Perhaps G underlying genetic tendencies to get myopia are not there anymore. So we always say it's about 5050 lifestyle and genetics So the lifestyle part that part is definitely exacerbated We saw this especially during the COVID pandemic when there was a lockdown and Home-based learning because you've now taken all of the high risk factors. So no time outdoors and All this learning which is required to be on your laptop.
I've had or your phone Well, so increased near work screen time no outdoor time. I had children who jumped like three diopters in a year during You know, I you know, I have a seven-year-old a five-year-old and a two-year-old and You know, we they don't watch much TV. I mean when they're on screen time But it's like it's all on the phone or a tablet And as much as it's like man when I was young we would be walked up with a giant TV We thought that was so bad, but now they have this thing just a couple inches from their face essentially So it is ultra type of near work and for you know a long time potentially Yeah, so it's tough. I mean the children do not like it when they come in I tell them they have to get off their phones That's no one likes a doctor who tells them But this is a strange thing so this is the obviously the AI and I care podcast and so here I mean, maybe technology is having a dual a dual Role here on one hand.
It's it's the purveyor of what the issue is I mean, maybe it's it's probably the most significant impact Why this problem is getting worse in the sense of having near time and not being outside and obviously COVID pandemic is a very interesting example but there are potential solutions out there so in terms of Diagnostics you mentioned something that you know if you're not everyone will get pathologic myopia or high myopia My outfit that we should you know in any way need to treat but there's gonna be a subset of people who are maybe in a progress faster than those who don't so I Am I'm really interested. Are there any ways of determining either through AI or maybe non AI technologies? Who is going to progress? Yeah, that's a great question.
So I actually remember this moment at our we have a by we have a every two years there is a large myopia conference where everyone in the world gathers and I remember this paper getting a standing ovation when it was presented It was a paper by one of my colleagues from Singapore lily and foo who Using fundus photos They were able to predict very accurately which children in five years would be at what spherical equivalent so what prescription and what axial length the axial length being the underlying risk factor of Causing all these complications and so what they did was they are so lucky because 20 25 years ago they were already Doing school based screening and having their cohorts having a cycloplegic auto refraction Fundus photos they didn't know AI was coming but they had the foresight to gather as much data as they could so they could actually Use this to train their systems because they now have the results of these children that they were screening in say 1990s or 2000s, right? So these fundus photos they also plugged in some really important clinical data to improve the deep learning algorithm So for example, how many of your parents have? Myopia, that's another big risk factor So sort of a proxy for genetics and they were able to get 0.98 a UC or area under the curve so their prediction was really really accurate So now they've taken that and they've actually now Both in Singapore and China try to deploy this which is that they're screening and we have screening in America Which is just how are you doing in terms of your vision? If you're not seeing well, you get a sense of the eye doctor, right?
For glasses there they take fundus photos they run a prediction and they say oh you need to go see a myopia Specialist because you're at high risk in five years of developing high myopia So they're able to deploy this large population level screening based on AI and so you're right It's really a paradox because it's it does cause technology is causing Worsening of this myopia epidemic, but it is also presenting some really innovative and interesting solutions as well Yeah, that's that's super interesting that they had the insight to to capture all that data And it just goes to show we often talk about on this podcast You know data being the new oil and sometimes you just have collected Even before not totally sure like why are why you're collecting and that's you know This is sort of the power of Aquilomics and in just tying various factors that may or may not be related to various eye Eye images and so I think this is a great a great example of that Certainly, I'm sure you could look at you know just your parents you know me I so I'm a I've high axial length and my wife does too So we're you know obviously really concerned about our kids and I think I think I will every Couple weeks all the way to texting I said from a friend saying hey, you know my doctor recommended my eye doctor recommended a New type of classes that I haven't heard about or new type of contact lenses And so we talked a little about about diagnostics and maybe that that's interesting But let's talk about I think one of the main reasons we're having this conversation and that there was a major announcement a few months ago of A different type of therapy. So give us those were the lay of the land As a myopia specialist on what treatment options are there for for people? Yeah, so I assume that your your friends are talking about these special complex or glasses for their children and not for themselves Yeah, yeah for their kids and saying hey Like I haven't heard about this before you know is this just a scam to the day that's when it's like hey Is this a scam or what like I just thought I just came in for glasses and right now I'm being upsold right. Yeah.
Yeah. Yeah. So Yeah, the announcement is very exciting. So let me give you a brief overview so far So they're the mainstay in many countries is pharmacological treatment.
So all of this is trying to prevent the progression of myopia there are sometimes uses for preventing the onset, but that's a little bit more controversial so let's just first talk about preventing the progression of myopia so Atropine is an eye drop that has been shown to Slow the progression of myopia was sort of an accident how they found it, but It's been used since the 1970s in Asia to safely prevent the progression of myopia. So that is a very common decision that The parent and the children will come to it can come in various doses from 0.01% all the way up to what we commonly use in our practice for dilation, which is 1% The 1% is overkill because as you know, it causes a lot of side effects your pupils are way dilated You have a lot of glare you have lots of accommodations So you can't read and what's really interesting is that they found that 0.025 0.05 these ultra low doses actually still are Effective in preventing the progression of myopia. So that works not to get off too much topic, but yeah So there there's a lot of there's still debate about this, but there is I think the most common thought is that it acts on a cold-nurgic receptor in the sclera to prevent the remodeling of the sclera and less actually elongation Yeah So that's Atropine and then there are optical solutions. I like to clump these together So usually the contacts and the glasses they do something called myopic defocus which is that there is a correction of the Image that the child will see very clearly which lands right at the retina, but in front of that will be a shell of the focused images which Normally when you fully correct a child's amotropic in the periphery actually the image will be behind the retina So then there's a hyperopic defocus which causes a drive for the eye to keep elongating so by Offsetting this and making it a myopic defocus as an it's now landing inside the eye It has this drive from the eye not wanting to pull it the retina or where the light is supposed to land further and further back So it slows down the growth of the axial elongation So contacts do that.
There's ones called my site and then very exciting way just a few months ago The Stellists made by Ecelore are glasses which are non-invasive. They don't involve eye drops They don't involve contacts very safe. They just come out as well and been approved There's also ortho K which is a another optical solution where you can wear hard contact lenses overnight and these also work by Housing a defocus as well as contrast that is pivoting loss so that is a different kind of lens the sight glass also has this theory which is that high contrast images such as screens can cause worsening of Myopia, so those are all different solutions that are out there finally. There's also a red light therapy And that is basically yeah, that's that's actually the most effective Therapy that we know of however it is controversial and how it works we think is by Increasing cordial perfusion, which is the blood flow to the sclera and causing the sclera to have more oxygenation less drive to elongate because a thinner sclera will be less protected by the eye In terms of FDA approved treatments Which one of those and I know this is in the US obviously You know which ones are FDA approved Yeah It's kind of a loaded question We're really hoping that atropine would would have gotten the approval this fall, but it didn't so It that one's not approved.
It's off label and we use compounding pharmacies for it and the only ones that are approved to To my knowledge right now are my site contact lenses as well as Stellist Stellist classes I think Cooper vision might be working on so Cooper vision rebranded site glass to my site Classes, but that I don't believe that's approved in America yet. Gotta In terms of interventions that parents can do I suppose a kid comes to you with some early Myopic changes at a you know, you're not it's kind of like the early stages because obviously I'm sure when patients come to you You have the whole bag of tricks that you can talk about from pharmacologic to lenses to potentially other behavioral changes because you had mentioned Some of the factors that this is become more of an epidemic is kind of you know stuff our moms told us about like 30 years ago Yeah, so what what are some behavioral changes? That can be done and are there options there? Yeah, absolutely.
So for me and I think a lot of my opioid practitioners first line changes is lifestyle prevention because Like what we just discussed all those risk factors not all Patients or parents know exactly the date of a high net and they don't know definitively that they're right right They might feel this inkling of oh, I don't want my child on the screen all the time But when they come in and they hear yes, we should make these lifestyle changes first one Which is I recommend an average of two hours of outdoor time per day or 14 hours a week So if you can get your child into a sport that it's outdoors that they really like that's a great thing for them less near work and less screen time so you can even just say okay, we can move phone To ipad or ipad to laptop or laptop to tv so all of those are steps in the right direction Also having things well lit so if you're in a Bedroom that's dark and you're going through your phone. That's not a good thing for my opia But if you can sort of be by a window with bright lighting with the desk there that's all better. So all of these changes are Um very doable to families who first hear okay. This is real we are are Thought that this stuff is causing my kids eyes to get worse Is happening and let's make all these changes first and see what happens I think that's a completely reasonable thing to do because once you start treatment with iJobs for example You're committing to several years of iJobs and so that's also and I would say like, you know Four to eight year olds.
They do not like having drows put in their eyes every night. So I think it's a wonderful thing that we can Both educate them parents in the first visit give them some solutions to try so that when they come back They have Prepared themselves mentally or maybe having to try an actual myopia treatment such as glasses contacts or iJobs They know that they failed lifestyle first However, that being said As a physician you don't always know that they failed lifestyle interventions because it's a very subjective thing for them to come back and say Oh, yeah, we decreased three time and you know Their eyes are still getting worse. I don't really know if that's true or not. So I just have to currently Take the family's word at how they're doing I know we are both Advises for really innovative come up called blink frames, which are these Innovative products or they have cameras that instead of pointing Outside like the other smart glasses that we're doing so much about but have cameras that are pointing in words and and monitor various parameters like outdoor time sun, you know, how much out in the sun screen time activity levels so Tell me about your experience with with with blink frames And you know where you see that type of monitoring sort of a device Monitoring type of solution.
Is that is that something You know you would be keen to look at particularly, you know, maybe how it is involved with some of the the lens based treatment options Yeah, I think the visual diet and things that measure that as well as all these lifestyle factors These are things that the my other community by at large are very interested in at this moment Um, so I wouldn't really be advising for blink on us I felt like oh this could really change the world and so like you said there are many things that it does really well differently than other Um wearables on the market it so there are wearables that go on your wrist or around your neck Those don't measure along the line of sight So those don't accurately measure a lot of the things that we want to measure in terms of like lux Which is the amount and intensity of light that's reaching me retina? um And also other things that Actually, let me back up or just talk about blink a little bit more. So Basically, it is a smart frame that is very sleek. It doesn't really have increased um Weight of the bridges and it doesn't have any cameras that are visible that point out And it also has a lot of um monitoring that just happens On the frame itself and it also pairs with any lens on the market, right?
So all of these things are really helpful in terms of you can just put them on and they'll look like other glasses And so when you're using these what information do you get you can get Lux you can get amount of time outdoors Even if it's borderline illumination because there's a chromatic spectrum analysis that tells me the difference between indoor and outdoor time You can get um New York and screen time as two different variables And then as you said frame wear time, especially if frame wear time is correlated um with the success of myopic controlling lenses and so currently myopic controlling lenses They say you have to wear them 12 hours a day And so you're not sure if children are compliant or not with that 12 hours Sometimes you have children who get new glasses go to school, mainly take them off right because they feel they see fine And so most I have been unsure all the time. Yeah, all the time, right? So this 10% Non-efficacious rate that's being quoted in the literature for Spectacle lenses that are controlling my opiate. We don't know if this is non-compliance Um, a lot of people suspect that at least part of the 10% is or people aren't wearing it the 12 hours They're wearing it maybe eight hours because they think that's good enough, right?
And so What's really exciting about this is that A child can wear this smart frame come in and I can look through all the data and say how much outdoor time did they actually get how much screen time when they actually using What is it trending in either direction? If they're wearing the stellist lenses or different ones in other countries, are they actually wearing the Dose dependent Lenses at the correct dose, which is in the literature 12 hours, right? So then you can really confidently tell the parent, okay lifestyle interventions are or are not working So we can keep trying because the lifestyle interventions are not quite at the level we want them to be at yet Or let's go ahead very confidently say we need to move on and let's start Eyed drops or combination therapy Um, but for me as a researcher another super exciting thing about this is that the research will also become so much better because our research depends on Questionnaires and questionnaires are very unreliable And so now that we have all these things being able to be measured objectively Then we can really start parsing out the effects of each of these lifestyle interventions On my opiate progression, which is great. And then we can also get a dose response curve So I get questions all the time from parents Can they just wear it six hours like they have sports afterwards?
So they're gonna wear a contest, right? Can I answer that question confidently not really I can say, you know, the more you wear it the better So maybe put them on again after but if we have a dose response curve saying eight hours gives you 90 percent of the effect or something like that that would be wonderful Then I can confidently tell the parents what they need to do In terms of wearing these spectacle lens my opiate control Um, it's very interesting. Uh now I'm curious about your sort of like looking forward future thoughts like putting on your prediction cap here a little bit So in the next it seems like this field is ripe for a lot of innovation. There's been a lot of innovation Uh, just in the past few years and now the public is becoming much more aware of it You know, the apple ifle is talking people are talking about screen time where they really weren't talking about it a few years ago So what are you hoping for in terms of either diagnostics or therapeutics or monitoring?
What is you know, where is my opiate going? Um particularly how it relates to AI is it, you know, detection and fast progressors or slow progressors? Is it new types therapeutics? Um, how are you sort of seeing this this future of my opiate management with with the sort of AI lens?
Yeah, that's a really good question. I think um When you combine a fast moving field like AI and a fast moving field like my opiate then you're kind of um really just guessing and so I think part of it is going to be I think the The possibilities are can be you know, really really large and it comes down to how much are we going to accept AI being? I guess Such a such a large part of health care and so are we going to accept a virtual clinic because it could be something like that, right? Uh, I've seen myopia in entire myopia clinics being Sold by say, Zai's or larger companies like that that are pitching things like that So a child can walk in get their fund this photo taken get set uh cycloplegic auto refraction all done by you know attack with machines there, right?
And then maybe the AI will spit out. Okay, you're at intermediate or moderate or high risk This is what we would recommend. Let's say they recommend one modality of treatment And now there is AI that can also predict, okay Which individualized treatment option of all the ones that I mentioned might be the most effective for you. So The problem with this right now is they their numbers are not perfect yet and also it's only trained on some small sets of Uh, the population so it's not generalizable But if we make this and see down the line, that's something that we can do as well Then I don't have to pick between or guess between classes or idrops or contacts or or if okay or red light therapy It might say okay These two things are not going to work as well for you as this so start with this And so then you might come back in a week pick up your idrops start the i drops and then Have regular monitoring done by this virtual clinic.
So It could be something like that. You could imagine that working Um, but of course I think With the current state of AI there's still a lot of individuality And so I think you would still have to have a practitioner oversee all of that Um, but maybe the follow up duration would be much shorter or much longer than what I currently do So I follow up every three to four months for high risk children. Maybe I don't need to do that Um, when I have a i helping me and therefore I'm more confident in the decisions that we made we can have longer follow ups I think in Singapore the follow ups are getting longer and longer six months eight months because They're able to use more and more technology to do things like what i've discussed Right exact in terms of monitoring them and I totally agree that the AI enabled clinic, but still having that human touch there especially When you have parents there with their kids Um, it would be hard for me to just sort of listen to the spit out of an AI analysis No matter how intelligent it sounds or it actually is but to have Um, a doctor there to say hey your your kids really at high risk to have something Not maybe this year next year next five or so maybe in 20 years and we were talking about really long time frame So trust I think it becomes Um, really important and this is where I think an AI named to clinic Like you sort of very eloquently said makes a ton of sense to have that clinician be empowered with the various tools that They talked about super fascinating field and For for me who knew very little other than I was mappic and I had a high axle length I'm so happy we met and And able to sort of learn a lot from you and and I know you have a lot of um Projects and various announcements coming up, uh, Jonathan so uh really excited for your for your um, you know all the innovations and um contributions you've made some I hope you feel and look forward to all the more that you're gonna make in future Thanks so much rahad it's it's been great to spend time with you and I always Appreciate platforms to educate more people about my opia and get this disease out there so that people know that it's something really important to address and um get interested in so yeah, it's been great spending time with you Well, you're gonna watch this podcast and all our other podcasts at ai and iCare.com and please subscribe to us again that website's ai And iCare.com and you could feel free to reach out to me at rayhan at ai and iCare.ai For for all of us here. Thank you so much for listening and look forward to chatting with you next time.
Thank you