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Ong AY, Hogg HDJ, Kale AU, Taribagil P, Kras A, Dow E, Macdonald T, Liu X, Keane PA, Denniston AK. AI as a Medical Device for Ophthalmic Imaging in Europe, Australia, and the United States: Protocol for a Systematic Scoping Review of Regulated Devices. JMIR Res Protoc 2024; 13:e52602. [PMID: 38483456 PMCID: PMC10979335 DOI: 10.2196/52602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 02/10/2024] [Accepted: 02/20/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Artificial intelligence as a medical device (AIaMD) has the potential to transform many aspects of ophthalmic care, such as improving accuracy and speed of diagnosis, addressing capacity issues in high-volume areas such as screening, and detecting novel biomarkers of systemic disease in the eye (oculomics). In order to ensure that such tools are safe for the target population and achieve their intended purpose, it is important that these AIaMD have adequate clinical evaluation to support any regulatory decision. Currently, the evidential requirements for regulatory approval are less clear for AIaMD compared to more established interventions such as drugs or medical devices. There is therefore value in understanding the level of evidence that underpins AIaMD currently on the market, as a step toward identifying what the best practices might be in this area. In this systematic scoping review, we will focus on AIaMD that contributes to clinical decision-making (relating to screening, diagnosis, prognosis, and treatment) in the context of ophthalmic imaging. OBJECTIVE This study aims to identify regulator-approved AIaMD for ophthalmic imaging in Europe, Australia, and the United States; report the characteristics of these devices and their regulatory approvals; and report the available evidence underpinning these AIaMD. METHODS The Food and Drug Administration (United States), the Australian Register of Therapeutic Goods (Australia), the Medicines and Healthcare products Regulatory Agency (United Kingdom), and the European Database on Medical Devices (European Union) regulatory databases will be searched for ophthalmic imaging AIaMD through a snowballing approach. PubMed and clinical trial registries will be systematically searched, and manufacturers will be directly contacted for studies investigating the effectiveness of eligible AIaMD. Preliminary regulatory database searches, evidence searches, screening, data extraction, and methodological quality assessment will be undertaken by 2 independent review authors and arbitrated by a third at each stage of the process. RESULTS Preliminary searches were conducted in February 2023. Data extraction, data synthesis, and assessment of methodological quality commenced in October 2023. The review is on track to be completed and submitted for peer review by April 2024. CONCLUSIONS This systematic review will provide greater clarity on ophthalmic imaging AIaMD that have achieved regulatory approval as well as the evidence that underpins them. This should help adopters understand the range of tools available and whether they can be safely incorporated into their clinical workflow, and it should also support developers in navigating regulatory approval more efficiently. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/52602.
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Affiliation(s)
- Ariel Yuhan Ong
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Henry David Jeffry Hogg
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, United Kingdom
| | - Aditya U Kale
- Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Priyal Taribagil
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Eliot Dow
- Retinal Consultants Medical Group, Sacramento, CA, United States
| | - Trystan Macdonald
- Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- NIHR Birmingham Biomedical Research Centre, Birmingham, United Kingdom
| | - Xiaoxuan Liu
- Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- NIHR Birmingham Biomedical Research Centre, Birmingham, United Kingdom
- Centre for Regulatory Science and Innovation, Birmingham Health Partners, Birmingham, United Kingdom
| | - Pearse A Keane
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
- Institute of Ophthalmology, University College London, London, United Kingdom
- NIHR Moorfields Biomedical Research Centre, London, United Kingdom
| | - Alastair K Denniston
- Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- NIHR Birmingham Biomedical Research Centre, Birmingham, United Kingdom
- Centre for Regulatory Science and Innovation, Birmingham Health Partners, Birmingham, United Kingdom
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Nath S, Rahimy E, Kras A, Korot E. Toward safer ophthalmic artificial intelligence via distributed validation on real-world data. Curr Opin Ophthalmol 2023; 34:459-463. [PMID: 37459329 DOI: 10.1097/icu.0000000000000986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
PURPOSE OF REVIEW The current article provides an overview of the present approaches to algorithm validation, which are variable and largely self-determined, as well as solutions to address inadequacies. RECENT FINDINGS In the last decade alone, numerous machine learning applications have been proposed for ophthalmic diagnosis or disease monitoring. Remarkably, of these, less than 15 have received regulatory approval for implementation into clinical practice. Although there exists a vast pool of structured and relatively clean datasets from which to develop and test algorithms in the computational 'laboratory', real-world validation remains key to allow for safe, equitable, and clinically reliable implementation. Bottlenecks in the validation process stem from a striking paucity of regulatory guidance surrounding safety and performance thresholds, lack of oversight on critical postdeployment monitoring and context-specific recalibration, and inherent complexities of heterogeneous disease states and clinical environments. Implementation of secure, third-party, unbiased, pre and postdeployment validation offers the potential to address existing shortfalls in the validation process. SUMMARY Given the criticality of validation to the algorithm pipeline, there is an urgent need for developers, machine learning researchers, and end-user clinicians to devise a consensus approach, allowing for the rapid introduction of safe, equitable, and clinically valid machine learning implementations.
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Affiliation(s)
- Siddharth Nath
- Department of Ophthalmology and Visual Sciences, McGill University, Montréal, Québec, Canada
| | - Ehsan Rahimy
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Ashley Kras
- Save Sight Institute, Sydney University, Sydney, Australia
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Edward Korot
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Retina Specialists of Michigan, Grand Rapids, Michigan, USA
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Nakayama LF, Kras A, Ribeiro LZ, Malerbi FK, Mendonça LS, Celi LA, Regatieri CVS, Waheed NK. Global disparity bias in ophthalmology artificial intelligence applications. BMJ Health Care Inform 2022; 29:bmjhci-2021-100470. [PMID: 35396248 PMCID: PMC8996038 DOI: 10.1136/bmjhci-2021-100470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 03/03/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
| | - Ashley Kras
- Retinal Imaging Lab, Harvard University, Cambridge, Massachusetts, USA
| | | | | | - Luis Salles Mendonça
- São Paulo Federal University, São Paulo, SP, Brazil
- Tufts Medical Center, New England Eye Center, Boston, Massachusetts, USA
| | - Leo Anthony Celi
- Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | | | - Nadia K Waheed
- Tufts Medical Center, New England Eye Center, Boston, Massachusetts, USA
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Leng T, Gallivan MD, Kras A, Lum F, Roe MT, Li C, Parke DW, Schwartz SD. Ophthalmology and COVID-19: The Impact of the Pandemic on Patient Care and Outcomes-An IRIS® Registry Study. Ophthalmology 2021; 128:1782-1784. [PMID: 34144077 PMCID: PMC8213986 DOI: 10.1016/j.ophtha.2021.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Theodore Leng
- Verana Health, San Francisco, California; Byers Eye Institute at Stanford, Stanford University School of Medicine, Palo Alto, California
| | | | | | - Flora Lum
- American Academy of Ophthalmology, San Francisco, California
| | | | - Charles Li
- American Academy of Ophthalmology, San Francisco, California
| | - David W Parke
- American Academy of Ophthalmology, San Francisco, California
| | - Steven D Schwartz
- Verana Health, San Francisco, California; Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
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Abstract
Age-related macular degeneration (AMD) affects nearly 200 million people and is the third leading cause of irreversible vision loss worldwide. Deep learning, a branch of artificial intelligence that can learn image recognition based on pre-existing datasets, creates an opportunity for more accurate and efficient diagnosis, classification, and treatment of AMD on both individual and population levels. Current algorithms based on fundus photography and optical coherence tomography imaging have already achieved diagnostic accuracy levels comparable to human graders. This accuracy can be further increased when deep learning algorithms are simultaneously applied to multiple diagnostic imaging modalities. Combined with advances in telemedicine and imaging technology, deep learning can enable large populations of patients to be screened than would otherwise be possible and allow ophthalmologists to focus on seeing those patients who are in need of treatment, thus reducing the number of patients with significant visual impairment from AMD.
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Affiliation(s)
- Dan Gong
- Department of Ophthalmology, Retina Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA,USA
| | - Ashley Kras
- Harvard Retinal Imaging Lab, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - John B Miller
- Department of Ophthalmology, Retina Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA,USA.,Harvard Retinal Imaging Lab, Massachusetts Eye and Ear Infirmary, Boston, MA
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Marasco S, Kras A, Schulberg E, Vale M, Chan P, Lee G, Bailey M. Donor Brain Death Time and Impact on Outcomes in Heart Transplantation. Transplant Proc 2013; 45:33-7. [DOI: 10.1016/j.transproceed.2012.08.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 08/28/2012] [Indexed: 11/16/2022]
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Prabhu S, Stokes M, Kras A, Arunothayaraj S, Yi H, Kong L, Peck K, Casan J, Blusztein D, Jackson D, Toogood G. Initial Presentation to a Non-tertiary Hospital Results in a Prolonged Pre-operative Hospital Stay and an Increased Risk of Nosocomial Infections in Patients Requiring In-patient Transfer to a Tertiary Centre for Cardio-Thoracic Surgery: A Multi-centre Analysis in Metropolitan Melbourne. Heart Lung Circ 2013. [DOI: 10.1016/j.hlc.2013.05.611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Marasco SF, Kras A, Schulberg E, Vale M, Lee GA. Impact of warm ischemia time on survival after heart transplantation. Transplant Proc 2012; 44:1385-9. [PMID: 22664020 DOI: 10.1016/j.transproceed.2011.12.075] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Accepted: 12/06/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is little data available on the specific effects of warm ischemia time (WIT) as opposed to cold ischemia or storage time. With current research endeavors focusing on warm continuous perfusion, storage of donor hearts, and utilization of hearts from non-heart-beating donors, the impact of WIT on outcomes is increasingly relevant. The aim of this study was to analyze our results in cardiac transplantation with specific focus on the impact of WIT. METHODS A retrospective review of 206 patients who underwent orthotopic heart transplantation at our institution between June 2001 and November 2010 was performed. Donor, recipient, and operative factors were analyzed. The main outcome variables were all cause mortality, survival, and primary graft failure. RESULTS WIT of >80 minutes was associated with reduced survival compared with a shorter WIT of <60 minutes. Multivariate analysis showed increasing donor age to be the most significant variable associated with increased risk of mortality (hazard ratio 1.04; P = .004) per year of increasing donor age. CONCLUSIONS This study has demonstrated a reduced survival in heart transplant recipients with increased WIT. This finding may be of particular relevance to potential future heart transplantation using organs procured from non-heart-beating donors.
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Affiliation(s)
- S F Marasco
- Cardiothoracic Surgery Unit, The Alfred Hospital, Monash University, Melbourne, Australia.
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