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Oby: From the campus of Harvard Medical School, this is ThinkResearch, a podcast devoted to the stories behind clinical research. I'm Oby.

Brendan: And I'm Brendan. And we are your hosts. ThinkResearch is brought to you by Harvard Catalyst, Harvard University's Clinical and Translational Science Center.

Oby: And by NCATS, the National Center for Advancing Translational Sciences.

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Brendan: Across Asia, 80% of high school students are myopic. The strain from living with nearsightedness can inevitably lead to other vision conditions. But with an overwhelming number of cases globally, there is a need for quality screening at home or at school, without meeting with a physician. In his work developing smartphone apps for the vision-impaired, Dr. Gang Luo, of Mass. Eye and Ear, hopes to make vision screening and visual aids more accessible around the world.

Dr. Gang Luo is an Associate Scientist of Mobility Enhancements and Vision Rehabilitation at Mass. Eye and Ear, and an associate professor of Ophthalmology at Harvard Medical School. Dr. Luo, thank you for joining us and welcome to the show.

Gang Luo: Yeah, my pleasure. Thank you for having me.

Brendan: You work in the area of vision and you study vision impairments. Could you tell us a little bit about the focus of your research?

Gang Luo: So currently, a big chunk of my work is on vision screening, vision therapy, or vision rehabilitation technologies. I have an engineering background and I received a vision science, vision rehab training at Harvard Medical School. So currently, my work is basically a combination of my previous engineering expertise and then my training in clinic.

And we develop technologies for vision-impaired people and even for normally-sighted people. For normally-sighted people, they may have some reading disorder like nearsightedness or some eye misalignment or some fine ocular vision disorders, not as severe as vision impairment-- no one's got perfect vision.

Brendan: Right. So some of the focus of your research is developing smartphone apps. Could you tell us a little bit about a couple of the smartphone apps that you've developed?

Gang Luo: So one group of smartphone apps we develop is for vision-impaired people. So by definition, people with impaired vision means they have a vision loss that is not due to refraction. Someone with refraction, that can be easily corrected by wearing glasses. But for people with low vision or impaired vision, their vision loss cannot be corrected by reading glasses. So they need some visual aids to help. One commonly used visual aid is a magnifier. The commonly used magnifier is an optical magnifier. Nowadays people use electronic magnifier. And the app we've developed is using the smartphone camera to capture the image and magnify the image, showing on the screen. So equivalent as the video magnifier.

Brendan: And there was-- when we spoke previously, you were telling me about a smartphone app that uses the magnifier but also uses speech recognition. Could you tell us a little bit about how that works because that sounded really interesting?

Gang Luo: Yeah. One of the apps we've developed, it's like a Google search in the physical world. So when you type in the keywords, from the internet you can find the information you need. But what about the physical world? Let's see. Those information is out there. They're printed on papers or on signs, but they're not digitized. And our app-- basically, what it does is character recognition. And you just speak to the app what I need to find. And then the app can pinpoint the location where you can find the information.

Just to give you an example, if you go to the restaurant, you want to find particular items on the menu but the menu is very long. You just won't find a type of a seafood. For low-vision people, they already have difficulty to see those traits. People have to scan from top to the bottom, one line by one line. But with our app you just need to speak, "I want to find the particular seafood." And then, the app will guide you or highlight the seafood you want. Zoom in and using magnification to read the print, you don't have to scan the whole pages.

Brendan: Right. So if you were looking for salmon, for example, you'd hold your phone up in front of a menu, say the word "salmon," and it would scan all the text. Anytime it finds it, it would magnify it and show it to you.

Gang Luo: Right.

Brendan: Perfect. And so you've developed all these apps, and these apps that you have developed for vision-impaired people, you make them all available for free for anybody to download. Why do you feel like it's important to offer them for free? And how can you do that?

Gang Luo: For view-impaired people, the view aid is very important, sometimes can be lifesaving. But however, the market is small, so not many people are actually working in the market. So that actually drives the price very high. It's not like a smartphone everyone have. Even teenagers have smartphones. So a smartphone typically costs $100, some are even over $1,000. But can you imagine for view-impaired people, if they want to get a view aid, sometimes that can cost more than $15,000.

So the fundamental reason is that the market is small, not many people working on it. So the price is disproportionately high. So it doesn't have to be that high. Technology-wise, we can make it at a low cost. The way I address this problem is I use the existing smartphone platform, and at a very low cost or sometimes even for free. It's easy. Thankfully, we have some donations from foundations, some philanthropic donors. So we are able to develop those apps and release them for free.

Brendan: So you've received a Catalyst Pilot Grant to evaluate a new smartphone app screening tool that you're developing for myopia or nearsightedness. Before we talk about the app itself, why did you want to work on myopia?

Gang Luo: So this is about another area my lab is working on. Vision rehabilitation is just one of the areas. As I said, normally-sighted people, they may also have some vision problems. And particularly for myopia, it actually has reached alarming academic level. Global-wise, many people are nearsighted. As I know, in some of these cities-- especially in Asia-- in high school, the myopia prevalence is 80%.

Brendan: So 80% of high school students, you said, in some cities are nearsighted.

Gang Luo: Yes, exactly, because they study a lot. They have lots to read. Yeah.

Brendan: Yeah, I was going to ask you if there's-- when we spoke previously, you gave me a number similar to that and I couldn't believe it. I looked it up. Really even worldwide, it's almost 65%-- or something like that-- of people. You just said that you think it's because people are reading more. Is there any research on the increased prevalence of nearsightedness and why it's becoming larger?

Gang Luo: Yeah. The myopia research have shown that there's some genetic reason for that. Some people are prone to have nearsightedness. But there's also some environmental factors. So one is sunlight. So if you spend more time outdoors, you're less likely to get myopia. And another reason is a near vision work. Nowadays, students have to study a lot in this highly competitive world. The prevalence level is not even across the world. It's very high in Asia, especially in high school. In some rural areas, they may be lower. But, as you said, overall it's still very high. So nearsightedness is not just a problem of inconvenience-- you have to move close. If you have a high myopia, your risk to get some other serious eye problems is higher. So one problem is retina detachment. You may get blind.

Brendan: Can you prevent that just by wearing glasses?

Gang Luo: Yes, doctors all believe if you can intervene early, correct their vision early, when they start to have this myopia, it may slow down the progression of myopia. So the problem of the current myopia epidemics is not just more people having nearsightedness. It's also that high myopia is getting more.

Brendan: OK, so not only are people getting it more, but the bad myopia or the high degree of myopia, like you're saying, is more because people aren't getting screened adequately. They're not finding out and being diagnosed, is that right?

Gang Luo: Yes.

Brendan: OK. And that's where the smartphone app comes in because it's a screening tool. So that instead of going to a doctor, which might not be feasible for people everywhere, they can use a smartphone app. So could you tell us how this app works and how it can perform that screening function?

Gang Luo: Our app doesn't require any optical attachment. If you just download the app, you can use it immediately. And the way it works is very importantly to figure out at what distance you can see things clearly. By definition, nearsightedness, you have to get in close to see clearly. And we just measure at what distance you can see clearly, and using that, we calculate the refraction error.

Brendan: OK. Tell us about "refraction error" because that's a term you've brought up a couple times. What does that mean?

Gang Luo: You can't see-- the images can not focus on the retina. For a person who is not myopic, the lights from the far distance can clearly focus on the retina. So they can see images at far distance. But for people with myopia, the lights from the far distance focus at the position before the retina. So the image on the retina becomes blurred. So essentially, you have to move close so that the focusing point moves back on the retina.

Brendan: Could you tell us a little bit more about-- without getting too technical-- the technology that you're using?

Gang Luo: Yeah, as I said, the key is to figure out the distance and how we can use smartphone to measure distance as we analyze the human vision features in eye. And using that feature, we can calculate the distance.

Brendan: So the app can tell how far away the phone is from your face?

Gang Luo: Yes.

Brendan: Got it. OK. OK. I understand now. So the app displays some text or an image on it? On the smartphone?

Gang Luo: We use the selfie camera.

Brendan: OK.

Gang Luo: Capture the image of the patient's face. And we analyze the eyebrow, eye, nose, and sometimes ears, and using that as a reference to calculate the distance from the eye to the screen.

Brendan: OK. And then there's an image on the screen that they have to look at, or it's using the smartphone's camera?

Gang Luo: Yes. We do some images on the screen. We call it a video stimulus. The way we use the app is we want the patient to move closer to the phone until they see the video stimulus or the images on the screen clearly. And at that point we measure the distance.

Brendan: OK and based on that distance, you can assess whether or not they have nearsightedness and how bad it is.

Gang Luo: Correct.

Brendan: Could you tell us a little bit about the grant that you received? Like I said, it was a Harvard Catalyst Pilot Grant, part of the Sight & Science pilot funding series. So could you tell us a little bit about how you found out about the grant and what the process of applying was like?

Gang Luo: Yeah. Harvard Catalyst sent this call for proposal, and this time they specially want proposals about vision. And I believe there are two types of vision grants. One is to study some basic vision questions, another is more applied science. And I believe Johnson & Johnson has a very specific interest in this myopia. So actually in their corporate proposal, they specially list myopia is one area they are very interested in. This happened to be exactly the same as what we have been working on.

Brendan: And so, had you already been working on this idea, and then the grant popped up and you thought it was a perfect fit?

Gang Luo: Yes. We were developing this app and then we found about this grant application opportunities. So what we propose in this project is, we want to evaluate this app.

Brendan: OK. So that's how you're using this grant money, is to perform an evaluation to assess whether it's better than or as good as a visit in a doctor's office.

Gang Luo: Right.

Brendan: Could you talk a little bit more, or more specifically, about why a smartphone app like this is important? Or how you see this type of app, or this app specifically, how you can improve access to care?

Gang Luo: I said early, myopia doesn't seem to be a serious problem. It can be easily corrected by eyeglasses. However, since this is a epidemics-- so many people have myopia-- then it becomes a completely different monster. The one is that how you can provide vision care in time to so many patients, especially for people in the rural area or people stuck at home during the COVID-19 lockdowns.

Brendan: Right.

Gang Luo: Telemedicine or tele-consultation is one way to address this issue. But the problem is that in most tele-consultation, it's not exactly like what they do at the doctor's office-- you have all the equipment to do the measurement. But you're doing the consultation in a home, you don't have any equipment to measure. You can only talk to the doctors. So some vision measurement would be very helpful for the patients. Everybody has a smartphone now, so if we can turn this smartphone into the medical equipment, that would be very useful for the clinician to understand the problems the patient have.

Another is that from the public health perspective, so we'd like to know how many people are myopic. If we implement some intervention, we'd like to know whether it works or not. So you are basically working on hundreds of millions of people, most of them are children. So currently in school, vision screening-- they only measure visual acuity. Why don't they measure the refraction? Because school nurses, typically, who do this vision screening, they don't have the expertise to measure refraction. It can be done with a machine, like autorefractor, but no schools have an autorefractor. So imagine if we have this app available to the school nurse, then the school nurse can measure the refraction error.

Brendan: Yeah, that's a great point. Taking that technology-- that expensive, bulky technology that takes up space-- and if you can put it into something that everybody's carrying around in their pocket, or most people are carrying around in their pocket anyways, then it opens up so many possibilities of people who can access that screening.

Gang Luo: Exactly.

Brendan: Tell us a little bit about the team that you have who develops the apps, your research team. How is your team put together?

Gang Luo: I have an inter-disciplinary team. We have computer vision engineer, so they developed this algorithm to process the images. And then we have a programmer-- the general programmer, they can implement those ideas. And we have collaborating physicians, optometrists. And we also have a research assistant to come back to the clinical studies and do evaluations.

Brendan: Right. So tell us a little bit about how you work together. I just want to get a little bit more information on your process of working together and coming up with ideas and how that works.

Gang Luo: Yeah. In general, the way it works is we work very close to the clinician at first. So the clinician always have some needs. They come to us and say, OK can you solve this problem for me? So then we can use our expertise in engineering and try to find the solution for them. And as I said, the current all-day project we are working on, we don't want to develop a technology that's too complicated for users to use. So we don't want a solution that requires an attachment. If you think about the commercialization, it requires a very long supply chain. Who is going to manufacture it? And where do we need to stock those devices?

I believe that if you really want to develop a cool technology, it has to be a smartphone by itself, so people anywhere in the whole world, as long as they have internet, they can download it and use it immediately. And then, we do some prototype and see if that works. If it works, then we design an app that is user-friendly for clinicians to try out the pilot, to test it. And they give us the feedback and then we keep improving the technology until that can be useful in the clinic.

Brendan: So you're really working closely with clinicians, not just at the beginning of the process looking for unmet needs, but you're getting their feedback as you develop and improve the prototypes.

Gang Luo: Yeah, that's very important. Typically in the early proof-of-concept stage, you may have a perfect model to show, OK, an idea may work. However, we actually use it in clinics. You can come across all kinds of patients.

Brendan: Right.

Gang Luo: And you need to solve all of them. Otherwise, the technology will not be useful in the clinic.

Brendan: You said that this project, you're working towards commercialization. What do you hope the impact is? What do you hope to see going forward if this is proven, if you're successful here?

Gang Luo: Yeah, I think the commercialization is very important. To develop the technology that it is really useful for clinicians, it takes more than one lab. We need a big team. That's not a task that can be done by our small lab. So we need a company that does this commercialization.

Brendan: For something like an app, where you don't have to produce physical things, how does a company help you when you're developing an app?

Gang Luo: I think there's at least the two aspects. One is that if you want the technology to work for all kinds of patients, the technology will become much more complicated. So we need a larger team from the company to do that. Another is activate the marketing, to let all the clinicians know there is such a technology, it exists, and convince them to use it. I never thought that it would be enough for scientists to produce one application and then the whole world will know it and think, this is great, and let's everybody use it. I never thought that can happen.

Brendan: Right. Right. You need the big marketing team and you need a something that people can understand, not just an academic paper.

Gang Luo: Yes. And that is way beyond our research lab.

Brendan: Do you have any final thoughts about the project or the grant process, or anything that you wanted to share?

Gang Luo: Yeah. I want to thank Harvard Catalyst to give us a grant for us to start the clinical studies. And it's the right timing. Just as we've developed this technology, we can have a small grant to do this study and try to show the potential of this app. I'm not saying this technology is already mature or it's going to work perfectly. But without this clinical studies we will never know how to improve it.

Brendan: Dr. Luo, thank you for joining us. It was a pleasure to have this conversation with you.

Gang Luo: It's my pleasure. Thank you.

Brendan: Thank you for listening. If you've enjoyed this podcast, please rate us on iTunes, and help us spread the word about the amazing research taking place across the Harvard community.

Oby: To learn more about the guests on this episode, visit our website-- Catalyst.Harvard.Edu/ThinkResearch

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