Eyeworld

I ARTIFICIAL INTELLIGENCE N FOCUS 36 | EYEWORLD | AUGUST 2020 by Liz Hillman Editorial Co-Director and biomechanical data. At the 2020 ASCRS Virtual Annual Meeting, Dr. Ambrósio present- ed a paper that showed a significant improve- ment in accuracy with an optimized machine learning algorithm, including the sensitivity of 85.6% (compared to TBI at 75.7%) in a series with more than 500 VAE-NT cases. Furthermore, assessing the impact of sur- gery on the corneal structure has also been de- veloped with AI, Dr. Ambrósio said, mention- ing the Ectasia Susceptibility Score, 3 which is available on the website of the Brazilian Study Group of Artificial Intelligence and Corneal Analysis (BrAIN). The next step is the devel- opment of the Enhanced Ectasia Susceptibility Score, Dr. Ambrósio continued, as one of the main projects of the BrAIN. He also described a new machine learning tool (Relational Tissue Altered) that represents the impact of LASIK when assessing ectasia risk, which was described in another paper from the ASCRS Virtual An- nual Meeting. David Wallace, MD, thinks that AI could help identify the early risk factors for kerato- conus. Dr. Wallace is helping develop a smart- phone-based, Placido corneal topography system (Delphi, Intelligent Diagnostics) that is more affordable, portable, and accessible than existing topography systems. Delphi will ag- gregate data in cloud servers to enable assisted analytics, intending to incorporate AI shortly after product launch. R efractive surgery screening, ectasia risk detection and diagnosis, recom- mendations for corneal crosslinking, improving refractive surgery out- comes—these are just a few of the areas where clinician-scientists are hoping to employ artificial intelli- gence to enhance doctors' decision making. And, in some respects, artificial intelligence is ready to deploy in the realm of the cornea. As Lopes et al. put it in a 2019 paper in the open-access journal Current Ophthalmology Re- ports, the cornea subspecialty was a "pioneer in aggregating technology to clinical practice," and the "tremendous amount of information from complementary multimodal imaging devices" is "perfectly suitable for AI." 1 Recognizing ectasia Renato Ambrósio Jr., MD, PhD, and colleagues have been conducting research that focuses on developing AI indices for describing the suscep- tibility of the cornea to ectasia and determining the impact of laser vision correction. "Considering the vulnerability or suscepti- bility of the cornea for biomechanical decom- pensation and ectasia progression, multimodal imaging is a factual revolution in evolution," Dr. Ambrósio said. Dr. Ambrósio started working with artificial intelligence in 2008, helping design the Belin/ Ambrósio Enhanced Ectasia Display for Pen- tacam (Oculus). Other indices Dr. Ambrósio mentioned on this front include the Pentacam Random Forest Index, and the tomography and biomechanical index (TBI) that combines the data from Pentacam and Corvis ST (Oculus). According to a review article that included a meta-analysis of the published studies involving the TBI, it "had the highest accuracy for the detection of subclinical keratoconus compared to all other parameters tested." 2 However, there are published reports of a lower sensitivity of TBI for detecting abnormalities on very asym- metric ectasia-normal topography (VAE-NT) cases. These cases demonstrate the opportunity and need for optimizing artificial intelligence for the combination of corneal tomography How AI applies to cornea At a glance • Artificial intelligence (AI) helps to predict ectasia risk factors prior to refractive laser vision correction procedures (PRK, LASIK, SMILE). • Datasets for AI need to be carefully curated in order to deliver an accurate algorithm. • AI is likely to be used, in addition to the diagnosis, for the prognosis and treatment, including crosslinking. "We all know machines have extraordinary memory and processing power, but they don't have intelligence. They have the ability to execute instructions programmed by humans." —David Wallace, MD

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