When the World Changed Forever

I’m a ‘Xennial’– the microgeneration born between 1977 and 1983. I am not a ‘digital native.’ I remember the time before the all-pervasive Internet, when home computers had cassette drives. As I grew up, I watched the world change: portable music, personal computers, mobile telephones, and the magic that is the smartphone.

The nice thing about consumer technology is that the cost of entry has kept going down. Though it won’t be as sophisticated as an iPhone X, we can now buy a practical smartphone for $30. But when it comes to stem cell and gene therapies (which is incredible stuff), I do worry about how long it will take before they become available to the many rather than the few. The handful of gene therapies on the market today can run into 6 or 7 figure costs – per patient. Cell therapy could cost more; it currently requires cells to be acquired, cultured, engineered, purified (all ex vivo) then placed back in to the patient. If it’s the cornea, that’s relatively straightforward. If it’s in the retina, it’s anything but. Will anyone other than the rich gain access to the best treatments?

If we return to the computer analogy, the ‘PC moment’ happened in 1981 when IBM launched the first PC, which cost $1,565. Just one year earlier, IBM’s cheapest computer cost $5,120, and if you wanted to buy an IBM computer in 1980 that was as capable as the PC, that would cost closer to $20,000. By waiting one year, you got the same power, for less than an eighth of the price. So what might be ophthalmology’s next PC moment?

It might be figuring out the growth factors that can recruit stem cells to repair the damage in the eye, as Sheraz Daya alludes here. If that’s achievable, how many years or decades until it’s possible?

We’re seeing ophthalmic surgical robots with such exquisite maneuverability and precision that it will soon be feasible for almost every retina surgeon to perform some of the most demanding retinal procedures – like those demanded by subretinal application of gene or cell therapies. Wider adoption of these will enable more procedures to be performed, which is followed by some sort of economy of scale. The ex vivo lab-based portion will become a kit that a technician can use, and the robots will certainly speed surgical throughput. Today, such a robot costs about €500,000 (although an intraoperative OCT can cost $450,000, and a femtosecond laser for cataract surgery can cost almost as much). How long will it be before the surgical robots have their own PC moment, dropping in price, so every surgeon can use one? And will that help unlock the gene and stem cell revolution for everyone?

Mark Hillen
Editor