Most of us enjoy “Top-Ten Lists”. The first decade of the 21st century certainly has provided a plethora of choices in eye care for such enjoyments. Based on your professional and clinical experiences, your choices and list may differ from others, but that’s what makes them fun for everyone.

Given the vast array of innovations during the first decade of this new millennium in so many areas of eye care including diagnosis, therapeutics, surgery, drugs, etc., an almost infinite amount of “Top- Ten” lists could be generated. Towards that vast, potential compilation, here’s one list (in no special order of priority, but rather in categories) from an ophthalmologist and optometrist who have practiced together through this past decade.

Diagnostically, innovations have occurred in multiple clinical areas related to vision care and eye diseases. The most significant (for us) include the following:

Optical coherence tomography (OCT) has changed the fundamental nature and accuracy of eye care diagnosis. This noninvasive imaging technology produces high resolution (2 to 3 micron accuracy), crosssectional images of ocular tissue which has results in diagnoses of abnormalities associated with the retina, macula, glaucomas and the anterior segment to a level of accuracy never before achieved in imaging techniques. The evolution of this technology through this first decade has created, more than ever before, the ability for earlier diagnoses of many sight-threatening diseases.

Wavefront technology has brought us to a new stage, both diagnostically and in refractive laser applications, in vision care. Its introduction to eye care came in the late 1990s with the advent of “wavefront-guided” excimer laser ablations in corneal refractive surgery. However, in the past decade, wavefront aberrometry’s ability to measure higher order vision through Zernike polynomial terms has expanded its applications in vision and ocular surface diagnosis, refractive and IOL surgeries, and pre- and post-surgical management. This science is rapidly becoming an indispensible tool in both vision and eye care.

Fig. 1.

Electronic, computerized, automated data-gathering instrumentation and documentation continues to change every aspect of our day-today practice and care from the simplest to the most complex clinical, record-keeping and business segments. The international community has advanced in this area much faster than United States practitioners have, but new U.S. legislation and incentives to introduce electronic medical record-keeping and computerized, automated technologies (tax-rebates, payment submission requirements, etc.) will continue to make these 21st century electronic, computerized technologies a routine part of every eye care practice worldwide.

Completion of the Human Genome Project in 2003 introduced a new era in diagnostic (and increasing therapeutic) eye care and, in fact, in all of medical and pharmaceutical (pharmacogenomics) care with advanced genetic mapping of eye diseases and early therapeutic and stem cell applications. Some of these advances may not have impacted some of us directly, but they definitely have begun to guide the development of diagnostic strategies and procedures we all perform (e.g., tissue sampling, laboratory studies, etc.), therapies most of us already use (e.g., drugs, biologics, etc.) and particularly, patient counseling regarding familial inheritance traits and genetic risk factors. Continuing research in this fertile area may well prove to provide the most significant advances we will witness in future preventive, medical and health strategies including ophthalmic care.

Non-surgical and surgical therapies evolved in so many areas during the first decade of the millennium that it’s difficult to identify which ones provided the most innovation.

Our choices include:

Presbyopic-correcting and specialized intraocular lenses (IOLs) in the forms of multifocal optics, accommodating IOLs, aspherics and toric lenses. Traditional monofocal IOLs that result in an absolute dependence on post-operative near correction have been addressed with impressive clinical and commercial results. Whether in the form of multifocal optics or in “translational movement” (accommodating) optics, presbyopic-correcting IOLs have dramatically changed our approach to clear and cataract (now referred to as “refractive lens”) surgeries. And concurrently, monofocal optic IOLs have also continued to advance and improve optically during the decade with the development of aspheric and toric correcting optics.

The femtosecond laser introduced an entirely new level of accuracy in dissection and ablation technology. Its initial introduction as a new method for keratectomy to replace the mechanical microkeratome in the LASIK procedure provided increased safety and accuracy (from 30 to 60 microns with the mechanical microkeratome to better than 10 micron accuracy with the femtosecond laser) in refractive surgery. Through the decade, applications of femtosecond technology have expanded into corneal transplant and lamellar surgeries, intrastromal ablation and now, in cataract surgery.

Though less dramatic than some of the surgical innovations of the decade, from a demographic standpoint, perhaps the most profound and “beneficial” progress in vision therapies has occurred in the area of progressive addition lens (PAL) multifocal optics which serve the exponentially expanding presbyopic population. Advances and refinements in the quality of optics for “no-line” multifocal spectacle lens correction including new applications with wavefront analysis using Zernike polynomial terms have made these correcting modalities the “vision correction of choice” for the majority of our “over-40” patients.

Selecting the “top” innovations in pharmaceutical advancements in eye care during the past decade could be the most challenging of all primarily because of the specific nature of drugs to specialized areas in eye care and more so, due to the enormous progress in drugs and drug categories during the decade. But from a broad perspective and again, from a demographic and epidemiological standpoint, 3 categories seem to stand out (for us):

The introduction of 4th generation fluoroquinolones in the first half of the decade virtually changed the way ocular infection has been treated ever since. Whereas, topical fluoroquinolones were first introduced to eye care in the 1980s, it wasn’t until the 4th generation of the drug category (with the addition of the OCH3 group) in the early part of the past decade that its increased potency against both gram-positive and gram-negative bacteria and its reduced development of resistant strains truly moved it to the forefront of treatment for serious ocular infections, particularly corneal ulcers.

Anti-VEGF (vascular endothelial growth factor) to reduce the growth of both regular and abnormal blood vessels in the treatment of “wet” AMD as well as blocking the angiogenic cascade in cancer treatment was identified in the 1980s and 90s. But it was during this past decade that Anti-VEGF therapeutic actions have been recognized to not only slow vision loss or maintain current visual acuity in the presence of AMD, but also its potential to improve and even restore functional vision. This awareness has changed the approach to the care, if not cure of macular degeneration.

While OCT has improved and increased the diagnosis of glaucoma during the decade, new categories and specific anti-glaucoma medications have significantly expanded treatment options and success in controlling, if not yet curing the disease. Certainly, beta-blockers continue to be the leading topical anti-glaucoma pharmaceutical treatment regime, but they are now frequently supplemented with new drug categories including adrenergic-agonists, carbonic anhyrdase inhibitors and prostaglandin analogs. All of these categories and their combinations have substantially improved glaucoma control through intraocular pressure management and reducing irreversible optic nerve compromise.

Our “Top-Ten List” may or may not be exactly what you would have chosen, but it’s likely that among them, maybe in a majority of them, we would agree. If not, we’ll both, soon enough, be introduced to the others favorites.

Commentary by Dr Edward F. Cherney, M.D., Associate Professor, Vanderbilt University, Nashville, TN

It can be seen that the top ten innovations can be condensed into four general areas. These would be computerized medical technology, genetics, pharmacology, and optics. The modern computers have enabled researcher in many ways. They are used not only for storing medical records, but in research. Also, there are many on line journals, and online atlases, such as “Red Atlas (redatlas.org) and Atlas of Ophthalmology (atlas ophthalmology.com) which are published in several languages. This gives access to examples of common diseases as well as examples of diseases many of us see rarely.

The completion of the mapping of the human genome was just the beginning. Genetic research is expanding our knowledge exponentially each year. The genetic defects of many diseases, such as Leber congenital amaurosis, and retinitis pigmentosa, are being discovered. Then, with the knowledge of the defective gene, and the use of viral vectors to insert the normal gene into the proper tissue, focused genetic therapy will be possible for appropriate patients [1, 2].

Genetics can also identify “non-responders.” Brantley [3] has identified genetic variations in the CHF gene which can account for the different responses to anti VEGF treatment. Patients with a CHF TT gene had the largest age related macular degeneration lesions, but improved vision 57% of the time with anti VEFG treatment. Those patients with the CHF CC gene however, improved their vision only 10% of the time. Identifying the “non-responders” will then lead to more research to develop the specific drug for a patient with a specific gene profile. That is true “pharmacogenetics”.

With the development of more antibiotic resistant strains of pathogenic bacteria, there is always a need for new drug development. Genetics is also used in the development of new drugs as well, as different microbes are genetically programmed to make newer drugs.

New diagnostic tools such as the Optical Coherent Tomographer (OCT) and the wavefront technology help us see ocular structures in vivo that could not be seen before. They help us diagnose diseases earlier, and guide us in the treatment of diseases [4]. The OCT can also be used to help the surgeon predict postoperative vision [5].

Cataract surgery with the postoperative coke-bottle cataract glasses is long gone. No longer so we need to wait for cataracts to “get ripe”. With new and improved optics and optical material, we can now achieve almost normal vision after surgery. Implantable telescopes are being developed to help those who have lost vision secondary to macular degeneration as well [6].