Improving eye care diagnostics in India
Beth Mills, based at the Queen’s Medical Research Institute, has worked with Aravind Eye Care Systems (AECS) since 2017, exploring diagnostic strategy for cornea infections using SmartProbes. She shared her experiences and the project’s successes with us.
AECS is based in Tamil Nadu in the south of India. Their mission is to ‘eliminate needless blindness’.
It is the largest and most productive eye care system globally. They currently have 14 tertiary hospitals, seeing over four million outpatients and conducting half a million surgeries per year. They have six outpatient centres, more than 100 primary care facilities and run many eye-camps. Half of all the patients in the hospitals receive care at no-cost.
How were you first involved in researching eye care with AECS?
My first visit to AECS was in 2018, to explore rapid evaluation of corneal scrapes from patients with suspected microbial keratitis – an infection of the cornea caused by bacteria or fungi, which can cause blindness. We were looking at the effectiveness of SmartProbes using fluorescence microscopy. These SmartProbes are specially designed chemical probes which specifically bind to target bacteria or fungi and then light up to emit fluorescence, which we can visualise down a microscope. These were developed as an alternative to Gram stain; a common test that checks for bacteria or the presence of fungi in samples collected from a suspected site of infection, such as the cornea.
Our study found that the Optical SmartProbes enabled fluorescent detection and delineation of microbes, with detection equivalent to or better than Gram stain. Essentially, they provide a rapid, simple, low-cost strategy for diagnosis of the infection.
What impact did your study have?
Microbial keratitis is an ophthalmic emergency, impacting populations worldwide. The longer time taken to receive a diagnosis and start treatment, the worse the outcome. There are over 1 million healthcare interactions in the USA per year related to microbial keratitis, and an estimated 1.5-2 million cases in India each year. In high-income countries, microbial keratitis is mostly associated with contact lens wear, whereas in localities such as India, it primarily affects agriculture workers in rural settings, who, due to climate, type of pathogen that invades and access to healthcare, suffer more complicated infections and have the poorest outcomes.
There is a dire need for improved diagnostics for microbial keratitis.
The current gold-standard diagnostic can take up to 14 days to yield a result and is only successful 50 % of the time, Same-day results can be obtained by Gram-stain and microscopy, but pathogens are only identified 30-60 % of the time.
Our study is the first proof-of-concept that the SmartProbes can work on microbial keratitis patient samples. This is important because it could improve the sensitivity of the test and provide faster, more reliable results.
Fluorescent imaging of SmartProbes for microbial keratitis may enable patients to be prescribed the appropriate antimicrobials quicker, but, we still need to conduct bigger studies and overcome the issues of cost and availability associated with fluorescence microscopes.
Why do you think this work is important?
Microbial keratitis is often described as a “silent epidemic” and leading ophthalmologists from around the world have campaigned for microbial keratitis to receive Neglected Tropical Disease status. Despite this, it has been omitted from policy agendas and focus, resulting in limited research endeavours and few, if any, tangible improvements to the patient care pathway.
This is particularly disheartening because those most affected are the working-rural-poor who often live hundreds of kilometres from a hospital that can diagnose and treat them. For example, communities in rural West Bengal I’ve worked with, have to travel by auto-rickshaw, boat, train and bus to reach Kolkata and their nearest eye-hospital. This delays treatment and adds significant cost in terms of time and financial resource. At AECS, patients have to attend the cornea clinic on average 5-times throughout the course of their treatment, and many patients are lost to follow-up before resolution.
I strongly believe that the poor outcomes for microbial keratitis patients is a result of interlinked challenges in patient access to appropriate care, outdated diagnostic tools, and diagnostic strategy which targets only the pathogen and not the host’s own immune system. All three areas need to be developed in an ecosystem approach to make tangible impact to the patient outcomes.
Our work with SmartProbes is the first step on this important pathway. We are currently investigating how SmartProbes can be used in conjunction with less invasive sampling techniques. This could allow trained healthcare professionals in primary or secondary care facilities to perform initial diagnosis of microbial keratitis within the community and treat the infections earlier, when the outcome is likely to be better.
What has been satisfying for you about the work?
The AECS is the most inspirational and invigorating organisation that I’ve ever had the opportunity to collaborate with. They are a multi-generational family business collectively driven by their mission to “eliminate needless blindness”. This has led them to become passionate global leaders in eye-care-provision and education.
Collaborating with AECS who are at the forefront of the field and have a shared interest in improving the quality of care for microbial keratitis patients is exciting. By placing the patient and the challenge firmly at the centre of our ambitions we can develop useful, creative solutions and have a clear pathway for translation, validation and eventually dissemination. Our work makes full use of our diverse knowledge, backgrounds and skill-sets and is ultimately improving patient outcomes and reducing needless blindness.
How are clinical and commercial applications being developed?
Going from an academic proof-of-concept to a commercial product can be challenging. We have been working to translate our work for clinical applications through a number of approaches. We were able to work with the Healthcare Technology Accelerator Facility at the University and a healthcare consultancy firm in India to generate a report on “The landscape of clinical need and other commercialisation considerations in India for rapid diagnostic device for microbial keratitis” in 2019-2020. This was done in partnership with the AECS, and as a team we were able to provide the consultancy firm with first-hand experience of the situation on-the-ground. We also have had the opportunity to discuss plans with Aurolab, a non-profit manufacturing facility affiliated with the AECS, and efforts to obtain appropriate funding are ongoing.
Low-middle income countries suffer with the highest burden of microbial keratitis and suffer the worst outcomes but here in Edinburgh, around 100 cases are treated each year, and there are over 1 million health care interactions in the USA per year with associated healthcare costs of more than $245m, making this a global issue and broad market for innovation.
What is the hope/intention for what comes next?
I am currently funded on a UKRI Future Leaders Fellowship, with AECS and the Aravind Medical Research Foundation (AMRF) as a project partner. The scope of the work is to develop pathways to reduce the burden on microbial keratitis in India and beyond. This will continue and build upon our previous SmartProbe work and explore new avenues of biomarker discovery from patient samples in India and the UK, to aid in better characterisation of the disease, and in the development of better diagnostics and treatment options. We are also working together to better understand how, why and when patients engage with the healthcare system during their microbial keratitis infection to identify barriers and opportunities to act upon them to improve the whole care pathway.
Collaborate with projects in India
We are hosting an online workshop to disseminate the latest changes in the Indian Higher Education sector.
The workshop will explore perspectives from our Indian partners on how NEP 2020 has influenced their institutional internationalisation strategies and encourage discussion on how to maximise mutually beneficial partnerships opportunities emerging in India.
India partnerships pathfinder workshop (online)
Tuesday 23 August 2022 09:00 - 11:00 GMT (14:30 - 16:30 IST)