Disclosure: I was focusing on a UFO in order to have my brain examined.
Disclosure 2 (private): aah, you'll hear it by yourself.
You'll also hear about
and
how machine learning and AI can speed up the work of an eye doctor
and the future of diagnosing brain diseases that lies in the eyes
My guest is Dr. Mathias Abegg, Medical Director and the visionary behind machineMD, is a neuro-opthalmologist, connecting neurology and ophthalmology. He has over two decades experience in research, eye surgery and private medical practice. Apart from inventing new ways of diagnosing and treating neurological diseases, he can awesomely explain how human visual system – eyes + the brain – works.
machineMD is a Swiss startup that has just launched the world's first neurophthalmoscope – neos. It's a medical device that can perform 8 fully automated neuro-ophthalmic examinations in 10 minutes.
Be the first to know what's new at machineMD
If you've enjoyed listening, you'll make us happy by clicking "Follow" on X-Health.show and leaving a review.
The information in this podcast is for informational purposes only and should not be considered medical advice. If you have any medical questions, please consult your healthcare practitioner. The opinions on the show are Alex's or her guests. The podcast does not make any responsibility or warranties about guests statements or credibility. While the podcast makes every effort to ensure that the information shared is accurate, please let us know if you have any comments, suggestions or corrections.
Disclosure: I was focusing on a UFO in order to have my brain examined.
Disclosure 2 (private): aah, you'll hear it by yourself.
You'll also hear about
and
how machine learning and AI can speed up the work of an eye doctor
and the future of diagnosing brain diseases that lies in the eyes
My guest is Dr. Mathias Abegg, Medical Director and the visionary behind machineMD, is a neuro-opthalmologist, connecting neurology and ophthalmology. He has over two decades experience in research, eye surgery and private medical practice. Apart from inventing new ways of diagnosing and treating neurological diseases, he can awesomely explain how human visual system – eyes + the brain – works.
machineMD is a Swiss startup that has just launched the world's first neurophthalmoscope – neos. It's a medical device that can perform 8 fully automated neuro-ophthalmic examinations in 10 minutes.
Be the first to know what's new at machineMD
If you've enjoyed listening, you'll make us happy by clicking "Follow" on X-Health.show and leaving a review.
The information in this podcast is for informational purposes only and should not be considered medical advice. If you have any medical questions, please consult your healthcare practitioner. The opinions on the show are Alex's or her guests. The podcast does not make any responsibility or warranties about guests statements or credibility. While the podcast makes every effort to ensure that the information shared is accurate, please let us know if you have any comments, suggestions or corrections.
Anything manifests in the eye that happens in the brain.
Alex X-Health.show:Hi, I'm Alex and welcome to the X-Health.show where I talk to visionaries behind the latest innovations in healthcare. For the eXtra health of the future. We're meeting today in Bern, Switzerland, a few steps away from the University Hospital, called Inselspital, where my guest used to work as a senior physician. Dr. Mathias Abegg, Medical Director and the visionary behind machineMD is a neuroophthalmologist, connecting neurology and ophthalmology, with over two decades of research, eye surgery and private practice. MachineMD has just launched the world's first neurophthalmoscope neos, a medical device that can perform eight fully automated eye examinations in 10 minutes. We test it on me during the show and there'll be some hidden facts revealed. You'll hear about what can eye movements tell about your brain, amblyopia or lazy eye and brain plasticity, strabismus or crossed eye, how AI can speed up the work of an eye doctor. And more. [INTRO ENDS] Mathias, what do you see when you look into someone's eyes?
Dr. Mathias Abegg, machineMD:I see beauty as you do, too, I guess. Beauty for me as a doctor means I see in the eyes if something is not working properly behind the eyes, mostly in the brain.
Alex X-Health.show:So when you look into someone's eyes, you, basically, see the brain and what works, what doesn't work in the brain – is that what you're saying?
Dr. Mathias Abegg, machineMD:Yes, the eye is not an isolated thing but it is connected to the brain. Some say the eye is the most front part of the brain, which is optically accessible. So I can look, truly look into the eyes and see a piece of the brain. But then it is also connected in the sense that the brain guides where the eye is looking next and how the eye is moving around, and how the pupils change their size. And all this is connected to the brain. So if you know how to look at these things in the eye, you can learn a lot about the function of the brain.
Alex X-Health.show:Are you saying also a little bit that we see more with the brain than with eyes alone? I'm asking this because there was this TED talk in in Basel, TEDx Basel, Professor Tania Rinaldi was actually having her talk about hearing with the brain. How we hear is actually modeled by our brain or how our brain was modeled in childhood.
Dr. Mathias Abegg, machineMD:Yes, absolutely. This analogy applies even more, I would say, to the visual system. The eyes – that's a little piece in the front – there are some neurons in there, it's like the photosensitive chip in a photo camera but then it takes a big processor, that is the brain, to analyze the information. And if you actually put on a balance and the weight the number of neurons that process vision, you will find that there are more neurons, more synapses, and more brain weight behind than you will find actually in the eye. So yes, vision happens in the brain, clearly. And the eye is the entry point into this visual system.
Alex X-Health.show:Just out of curiosity, how much of this can you see with just naked eye? So without any medical devices?
Dr. Mathias Abegg, machineMD:All of it, I would say so. But that depends on how you look and what exactly you mean. When I look at the eyes, it's not that I just have a glimpse at someone's eyes– then I cannot say a great a lot. But we look at the eyes when the light is on in the room and when the light is off, and we have people follow things, or I use a lens to have a look inside the eyes. And if you combine these very basic examinations, which basically take a pencil or a piece of paper, when you combine these cleverly, you can learn about the function of almost all areas of the brain. This is not something I have invented and it's not even that I'm the only person who can do that.
Alex X-Health.show:No, no, but you have been practicing it for many years, decades, right? A couple of decades?
Dr. Mathias Abegg, machineMD:Yeah, that's right. It has a name, it's called neuro-ophthalmology. And these clinicians have a focus on trying to see what's not working well in the brain at the level of the eyes.
Alex X-Health.show:So you are both a neuroscientist and an ophthalmologist. And let me just stop here for a moment: ophthalmologist, the name, it used to be an oculist before, and then I'm just thinking, like, someone thought, well, people got used to this Latin-derived name, let's mess up with them a bit, how would that be in ancient Greek? Or, do you know, why suddenly, we use the Latin word here and the Greek word there. There are a lot of ophthalmologic terms derived from Latin and this one is actually from Greek – an eye doctor for simplicity, right?
Dr. Mathias Abegg, machineMD:Yeah, an ophthalmologist is an eye doctor. And as long as I can remember, which is not all that long, an ophthalmologist was always an eye doctor. But I'm no historian at all. This has to do with where the things emerged first. So things from the old past, their medicine was mostly established in Europe and European countries. And they thought that Latin is the language to use for scientific purposes. And then later, certain things have evolved in some countries. Now, for example, North America is very important. So Latin slowly disappears from the medical language and is replaced by English terms. And how the Greek comes in, I don't know.
Alex X-Health.show:Okay, now, you founded a startup but you never gave up your practice of medicine. Could you share maybe, how did eye problems change during your career? Do people come to visit an ophthalmologist or neuro-ophthalmologist with different diseases or different problems now than before?
Dr. Mathias Abegg, machineMD:I would say, it hasn't changed at all. Over the years, the way we practice medicine today has changed a lot. We use different devices, we have different methods, we have a lot of different therapies. It's a very local discipline also. So the way I practice here, in Bern may be quite different to the way my colleagues in Zurich practice the same.
Alex X-Health.show:I thought that you will say, in the States or in Kapstadt.
Dr. Mathias Abegg, machineMD:Even within Switzerland, there are very local flavors of how medicine is being practiced.
Alex X-Health.show:Very interesting.
Dr. Mathias Abegg, machineMD:Even more, of course, when you go abroad to an entirely different country, or different continent.
Alex X-Health.show:What are the differences: Bern and Zurich? You actually practiced in both.
Dr. Mathias Abegg, machineMD:Just the way you manage a disease. So for a certain disease, what kind of work up do you do and how often do you check back on your patient. That changes a lot. And that is why, I think, it is very useful for any doctor to check a bit on different places, how things are being done, because the underlying disease is just the same in Canada, where I was for a fellowship, as it is in here in Bern, or in Zurich, where I practice too. The disease is the same, has always been the same, they barely changed over time. And the prevalence – yeah, this may change and it probably does change but from the doctor's perspective, it does not, that's something epidemiologists can maybe figure out after crunching a lot of data. But we as doctors, we don't feel that, even though some say they can. During the pandemic many doctors would say, Ah, now I see more often myopia in children. But I have very strong doubts that something like that can be felt as doctor
Alex X-Health.show:Because you actually have, I can imagine, the maximum amount of patients a day and they come already with problems, right? You can't have more of them than you can examine.
Dr. Mathias Abegg, machineMD:Well, my efficiency also is getting better, thanks to the help of medical devices, that do things for me. So I may be faster than when I did the things before. Awareness changes a lot, too. Neuro-ophthalmology, my clinical discipline for very long, it was considered a descriptive clinical discipline – we can tell people, what they have, we give a name to their disease and to what will happen next but we could not really treat. This has changed now. And since there are things we can treat and we can treat better than in the past, people have a higher awareness, it's now more important to find this kind of disease.
Alex X-Health.show:So what diseases are we speaking about? Because are you... you're not the ophthalmologist that the person would come to as a first person, right? You are the next-level specialist, aren't you?
Dr. Mathias Abegg, machineMD:Yes, in my function as neuro-ophthalmologist, I'm the next person to go to, but I see regular, normal, comprehensive ophthalmological patients, too – anything between the eye and the brain that affects the visual system somehow. And this is in recruits from two medical fields. One is neurology – these are the brain doctors – and ophthalmology – which are the eye doctors. And I would roughly estimate 50% of the patients come from neurology and the other half from ophthalmology.
Alex X-Health.show:Are these the diseases that there is doubt whether it is an eye disease or whether it is a brain disease? Could you name them, basically?
Dr. Mathias Abegg, machineMD:One very common disease that we get to see is called multiple sclerosis which is an inflammatory disease of the brain. And such an inflammation can happen, for example, at the level of the optic nerve, so people don't see very well for a certain amount of time. And then it is us, neuro-ophthalmologists, or eye doctors who make the diagnosis of inflammation of the optic nerve. So that would be one example. The inflammation can happen at the different parts of the brain and then manifests as a misalignment of the eyes. So inflammatory disease of the brain, tumors in the brain are common or commonly affect the visual system. And then there is a whole lot of other diseases that do that, too.
Alex X-Health.show:So you specialize in eye movement disorders. Eye movements, again, they are not responsible only for seeing at what can we tell them from? Or what can you tell? Because I can't obviously tell anything. What can you tell from seeing how the eyes move?
Dr. Mathias Abegg, machineMD:So eye movements are my research focus. As a clinician, I do also the afferent part of the visual system which is the optic nerve, and that goes all the way back to the visual cortex. And eye movements – we call efferent part of the visual system – there, the information goes from the brain to the eye. And with eye movements is just the same. You can use those to assess certain areas of the brain, namely those areas that are somehow involved in moving the eyes. This is mostly the back lower parts of the brain: brainstem and cerebellum. So that's where the circuitry, the basic circuitry for eye movements are located. And when something does not work there, well, this manifests in the eyes. Some patients are symptomatic, they present complain, they say, I see double, which is one of the very common complaints. But many patients have problems there but don't feel that necessarily as a symptom.
Alex X-Health.show:Could you give an example: they don't see symptoms but there is actually a problem in the brain?
Dr. Mathias Abegg, machineMD:Relatively common example, there may be many others, is if we stick to the MS disease, multiple
sclerosis:there is an inflammation in the brainstem at the level where the left eye is connected to the right eye. That as a symptom creates a situation that when a patient looks to the left for example, normally both eyes move at the same speed, but there it happens that the left eye moves fast and the right eye moves slower. This has, again, complicated Latin terms...
Alex X-Health.show:Go ahead, we love to hear them here on the podcast.
Dr. Mathias Abegg, machineMD:This particular example, with which you can frighten medical students, would be called internuclear ophthalmoplegia, meaning that when the left eye moves to the left, it needs to tell the right eye, please come along. This communication happens through a cable, which is called medial longitudinal fasciculus. If this cable is not working properly, as happens typically in MS, one eye doesn't follow. And these patients, in my experience anyways, are very often asymptomatic, they don't feel that they have this. And when you measure, you can find it, that would be an example of asymptomatic or often asymptomatic sign. And since it's asymptomatic, it is very often overlooked. And only when people start to experience double vision ACO, whenever I look left, first, I see double and then only it's okay, only then is being recognized.
Alex X-Health.show:That's the later stage, is it what you're saying?
Dr. Mathias Abegg, machineMD:Yes.
Alex X-Health.show:If you detect that earlier, what can you do then?
Dr. Mathias Abegg, machineMD:MS– that, again is one of these diseases we couldn't treat in the past, or not really, and today, there are multiple options how this can be treated. And it makes a difference if we start treatment earlier and better, the outcome will be better. So it makes a difference if we detect the disease earlier, in the case of MS. And, probably, it is similar in the case of brain tumor – the earlier you find it, the better, the easier it is to treat.
Alex X-Health.show:Whay would you say are the worrying symptoms that someone should see an ophthalmologist or a neuro-ophthalmologist? Because if someone's asymptomatic there probably are some other symptoms not in the eyes or...
Dr. Mathias Abegg, machineMD:From the patient perspective, also from a public health perspective, I would recommend people to go and see a doctor if something is wrong. They know whether something is wrong, when they don't see on one eye or they experienced double vision, then it's a good time point. I don't think it is reasonable or productive to try to observe yourself to find out whether everything is correct because if you do that, especially in the visual system, you will experience a lot of funny things. One is: look at the blue sky on a clear day. The number of strange things you will observe, maybe make you worry. Too much worry is not good for your health either. So you shouldn't... a patient is a patient, he should go and see a doctor when something is wrong. Or there is pain.
Alex X-Health.show:Again, it is like, the brain is actually saying what the eye should see. And it doesn't see it but we are worrying, right, so we kind of see things. Okay, what is the gold standard for eye examination now? Or, let's say in the neuro-ophthalmologist's office.
Dr. Mathias Abegg, machineMD:The gold standard is the manual examination by an expert and an expert may be a neuro-ophthalmologist or an orthoptist – that's very, very important profession, here in Switzerland anyways, and in many parts of the world. These are the ones who have dedicated skills to examine eye movements at an advanced level, especially when it's getting complicated. The very basic exam – you see almost in any doctor's series on TV, they flash some lights in the eyes, probably they check the pupils there, or they have people follow a pen. What they actually do there is part of a neuro-ophthalmic examination, and they all do it wrong, by the way.
Alex X-Health.show:This is my next question, what are the possible errors? Or things to overlook? How many things can be overlooked? Or are there any statistics about that?
Dr. Mathias Abegg, machineMD:Anything can be overlooked, it's a human factor. Whenever a human does something, he makes errors, and this depends a lot on the level of training. And there are there are numbers to confirm this. For example, this TV test – shining light in the pupils – it has been examined, and I hope I get the numbers right, but if a person without very specific training does this, they get it wrong most of the time. And with an expert, this gets much, much better but still, an expert gets it wrong roughly 20% of the time. We have limitations in our diagnostic capabilities, which involves certainly myself, but then we it's not that we do one examination and we make a diagnosis but actually, we try to confirm by other means what is wrong.
Alex X-Health.show:It slowly brings me to, well, the fact that you wanted to give away your 15 years of training, your 15 years of experience, to people who have not that experience. But let me ask first, what were you missing in your practice?
Dr. Mathias Abegg, machineMD:The way it developed was a bit the other way around. I used eye trackers in research, for research questions, and there I realized, and I always have used those to have a look at interesting patients with funny eye movements...
Alex X-Health.show:What are they? What are the funny eye movements?
Dr. Mathias Abegg, machineMD:there's there is plenty but wiggle eye, for example, which we call nystagmus in medicine. These are fast wiggling eyes and it's very difficult to appreciate with your naked eye what kind of movement pattern do you see. Do both eyes do the same thing? Is it going up or down or just left and right? And is there a fast or slow phase of the movement? If you let an eye tracker look at such wiggly eyes, you can see that the eye tracker is much better. It has a sampling rate, in our case, of about 200 hertz, so it looks 200 times per second, whereas I with my eye – maybe it's 20 hertz or 30, or something. That's one thing. And then it has a much better precision. The eye tracker can tell exactly just by looking at the eye in which direction you look at with a precision of roughly one degree. Whereas we say if you manage to see a deviation of one eye, that's roughly five degrees. So these eye trackers have a an accuracy and sampling rate which are much better. This, I realized during the basic research and from there I started to think, how can we use this in a clinical setting? Because I repeatedly have these questions and where can I buy a device that does that for me? I realized there really is no such device on the market. And that's when we decided to develop that ourselves.
Alex X-Health.show:How did you go about finding a collaborator? You're a doctor and you, I can imagine, needed someone techie.
Dr. Mathias Abegg, machineMD:I've done many things wrong in my life but one thing I did very right. Two things actually: marry my wife – that was one thing I did really well...
Alex X-Health.show:Congratulations for that!
Dr. Mathias Abegg, machineMD:... but in machineMD setting... I always knew, how bad an organizer I am and that I'm not a project manager, and that I have limitations in almost anything, except, hopefully, for the medical part. So I knew I need help.
Alex X-Health.show:You were introduced to me... because now you said you're not organized... you were introduced to me as a visionary already. So I mean, you have your place on the team, a visionary – it's not a bad title, is it?
Dr. Mathias Abegg, machineMD:Yeah, visionary – that's beautiful, that's great but to make it happen, people need to have skills and I knew that that don't have these skills. Not then, not now. So I was looking out for people who have the skills and I was fortunate to bump into them. Or you want to know how can you find good people?
Alex X-Health.show:Yeah, especially your first co founder, Dr. Dominik Brügger. How did you find him?
Dr. Mathias Abegg, machineMD:Oh, I was at the stage where I, in a research setting, wanted to test some of these ideas. And so I managed to convince Dominik to establish the protocols to actually test or to write the code to actually being able to test this in a clinical setting.
Alex X-Health.show:Did you know him or someone introduced you to him?
Dr. Mathias Abegg, machineMD:I got it wrong, I'm not a historian. So I was looking for somebody. And then there was a guy called Jörg Justic, at the Fachhochschule in Biel and he had an eager student who was willing to do that. So with him, we had a collaboration, testing some first things of that device. And that was Dominik Brügger. Later on, he joined my lab and did a PhD in something entirely different. He developed one of those ideas how you can treat amblyopia in an adult.
Alex X-Health.show:Wow, we'll come back to that, guys, we'll come back to that.
Dr. Mathias Abegg, machineMD:Which is untested and still needs a lot of work, but he developed the basics for doing that. And during his PhD, we used the occasion – I was in one room, the lab was right opposite – to test many of the principles that are now implemented into the neos device. We tested on joyful basis. So I tell him, hey, please test this with this patient. We continuously developed these protocols.
Alex X-Health.show:Can you recall any stages of development or how the prototypes changed, or, from your perspective, how they function changed?
Dr. Mathias Abegg, machineMD:The biggest change, in my view, is I had to change my very personal ambitions with this and take the viewpoint of the practical clinician out there in the practice. Because I was... I am interested in basic research, fancy brain functions, which are cool and interesting, but they're rare. And what we as a medical device company want to do is we want to make happy a broader public. We don't want to have a device for some fancy researchers at some labs.
Alex X-Health.show:How many of them are the in the world?
Dr. Mathias Abegg, machineMD:Yeah, exactly, that's the point, not many. They're quite a handful, maybe two handfuls. There's just not so many people that have a big interest in that. And so that was the biggest change, we had to develop protocols that are useful for a clinician who is practicing ophthalmology every day. We have implemented things that I, hopefully, can do better, me, manually. So that was not at the very beginning clear for me, I had to learn that during the process.
Alex X-Health.show:This is neos, the device you've worked on. And this is the 15 years of your experience and your training that you're giving away. This can be automated. And it can be, well, countable, the examination, right? What are the benefits of having this? Maybe we could tell a bit what is it, first? Because this is a VR set, right? This is a VR set supported by AI but I'm sure you can tell that better.
Dr. Mathias Abegg, machineMD:It's a medical device that does full neuro-ophthalmic examination. That's what it is. We do that using eye movements and movements of pupils. How we actually built the device is indeed, we used a VR headset, because a VR headset has screens in front of one eye and also in front of the other eye, which allow us to show something to the left eye but not the right eye, and vice versa. And this device has also eye trackers and pupils trackers built in. So we are not interested at all in the virtual reality at all. We just use it as a tool which allows us to measure the things we're interested in.
Alex X-Health.show:Because eye trackers are so good in it, is it the reason?
Dr. Mathias Abegg, machineMD:Yes. Well, at the time when we started this company, we thought we have to develop the hardware ourselves. Only after some time we found a hardware provider that meets our clinical demands because we have things that must be fulfilled so that we can do what we do. And a long time there was no such device on the market. But now there is this one that saved us a lot of time because we don't have to do the hardware development. Now we're a software company ever since.
Alex X-Health.show:That's the Varjo Aero headset, right?
Dr. Mathias Abegg, machineMD:Yes.[MID-ROLL BREAK] This episode is brought to you by the exhale, show, and B. So if you like this podcast, be generous hit follow, leave a review, that will help me invite more such amazing guests. Thank you. [MID-ROLL ENDS] Okay, so well, I tested the device, or you tested it on me, right, just before we started recording. So I'll tell you a bit about my experience. And then we can ask you about, well, the results, because neither of us, guys, saw the results, so we'll be reading them live. So I put the headset on, actually, Mathias helped me put the headset on, and there was a landscape – it was a very calming experience. Green grass, blue sky, some trees. Actually, guys, I was watching a UFO with one eye, with both eyes, then you know, it was changing. From one eye to the other and then to one eye again. So we always know which eye is looking on the UFO. And from that we can calibrate the system.
Alex X-Health.show:And then there was another thing. The landscape changed into snow. So there was a white landscape and there was an igloo. And then I could see the igloo or there was darkness. So white background, dark background, white background, dark background. And we finished with that, right?
Dr. Mathias Abegg, machineMD:Yes.
Alex X-Health.show:Could we go now and see what you can tell? Or what you can tell about the device.
Dr. Mathias Abegg, machineMD:Of course. The point, by the way, of this landscape, which you may find a bit silly that we use a UFO, but it needs to attract the attention of the one that's being examined. And we think it would be useful if also children can do it. So we try to make it very intuitive. And if you did the full workup, it changes a bit over time, all of a sudden, there is a fairy jumping around or flying from flower to flower. And there's the igloo scenery – we chose that because it must be very bright. You want to have a bright stimulus so the pupils get very small and then there is darkness so that the pupils enlarge. You did only a limited part of the examination.
Alex X-Health.show:The whole examination, it's 10 minutes, right?
Dr. Mathias Abegg, machineMD:Yes.
Alex X-Health.show:Just information for you guys, this is what I read that normally, without this device, it would have taken 45 minutes and with the device, it takes 10 minutes. So, I mean, it saves some time for an ophthalmologist or a neurologist.
Dr. Mathias Abegg, machineMD:The main benefit for a clinician is that it is faster. It does the real clinical exams, even though we would need to say, barely anybody ever does the full examination, just because of lack of time. We select a few things, even though we maybe shouldn't but practically, we barely ever do the full neuro-ophthalmic workup because it's so time consuming. So that's the benefit for the clinician – that he has it faster. And the other benefit is he doesn't need to do it himself, he can ask the technician, please do the exam beforehand. And so he just gets to see either the report or the viewer where he can look at the data.
Alex X-Health.show:Because there's nothing that you should have a doctor during this phase, right? You can move your head, you can just sit and move your eye. And it's just fine. Then you have everything uploaded to the cloud, this is what you said, right?
Dr. Mathias Abegg, machineMD:Basically, anybody should be able to perform this examination, all they are required is to read the manual first. Even without the manual it is basically putting a headset on, position the eyes so that they're centered in the middle and then push the start button, more or less.
Alex X-Health.show:The calibration I can imagine is the important point. But I mean, if you can see it's calibrating, if you know that this is the calibration time, then you should focus on this.
Dr. Mathias Abegg, machineMD: Normally, from the examiner point of view, they only need to hit the start button and then motivate the patient:Please look at the dot if there is one or look at the UFO, and don't look too much around. But that works usually well.
Alex X-Health.show:Okay, so what can you see in the results? I can see some lines, this blue line, this red line.
Dr. Mathias Abegg, machineMD:These lines here – we checked the gaze holding function. Gaze holding – that means how good are you in keeping your eyes on a target, on the UFO. This context is a little bit boring because your eyes stay on the target up until you blink, and then they're back on the target again. So that's good for you because your eyes are steady. But there are diseases where the eye wanders off and they make movement back to the target which would be the nystagmus example. Or there are people who have troubles keeping their eyes on, they jump off and back and that would be called saccadic intrusion. And these are two functionalities we test here. While the patient is looking straight ahead, we check how does that change when they look to the left or look to the right, or look up or look down. In case of a nystagmus, so jiggly, wiggling eye, the way each change is in the different positions tells you what kind of nystagmus it is. Is it the harmless nystagmus, where you don't need to worry that's when both eyes only move horizontally, that would be this upper curve. But when a nystagmus moves vertically up and down, so you see it in this panel here, then you need to start to worry because this might be then a brain disease. In your case, it's boring, because it just shows that your eyes are on the target when you look straight ahead, left and right. What, I'm not sure you want to know, but what one would say here is when you look on the target, one eye is actually on the target horizontally and the other eye is slightly, tiny bit off of the target. So looks not quite on the target.
Alex X-Health.show:So now the disclosure here guys, I have this disease called amblyopia, which is a lazy eye. Can that influence the readings? Is that what you see?
Dr. Mathias Abegg, machineMD:No, I don't see amblyopia. Amblyopia means that one eye does not see well. And that's the part we don't measure. We don't measure visual acuity. So we don't know how good you can see with your eye. But an amblyopia does not appear out of the blue. One common cause for amblyopia is what we call microstrabismus, so one eye looks slightly in the wrong direction. And then the eye that doesn't look on the target does not learn to see well, so we can uncover the cause for an amblyopia with this device.
Alex X-Health.show:This red curve here says there's something with the eye that doesn't look in the same direction as the other eye – is that what you can tell?
Dr. Mathias Abegg, machineMD:That's just a side product of the gaze holding function. I can just see that these two curves are slightly off, one is on target, the other is off. So maybe we should now check the alignment of the eyes, because we measured that specifically, too, so I need to scroll down here. And so here it measures the alignment of your eyes, mostly while you look straight ahead. And then you can see, yes, why I need to check myself. When your right eye looks on the blue dots, your left eye looks slightly more to the right when you look straight ahead, so that confirms what we saw in the upper trace, that not both eyes look perfectly on the target. And that's now important, this is about the same when you look straight ahead, and when you look to the right, and when you look to the left. Because the first thing a clinician asks when the eyes are not well aligned, says, Oh, maybe the nerve that is responsible for the muscle that pulls the eye out is weak. And if that is the case, then the misalignment gets bigger inside the gaze. In your case, we can say, Ah, that's looks very good. It's just the same on the right gaze and on the left gaze.
Alex X-Health.show:So there's nothing about muscles.
Dr. Mathias Abegg, machineMD:So that means your muscle and your nerve is fine. This is usually a childhood kind of strabismus, called microstrabismus. It was invented here in Switzerland or described in Switzerland by a guy called Joseph Lang.
Alex X-Health.show:When was that?
Dr. Mathias Abegg, machineMD:Not so long ago. Always these historical questions... I would say, roughly, 40 years ago, or 50 years ago. So we check for alignment and we discussed a bit why this is interesting for us clinicians – because sometimes you learn something is wrong at the muscle or at dinner for even further in the back of the head. Or it may be a harmless misalignment. Harmless in the neurological sense that it's not a brain disease that causes that and this we can tell well. What else can we see? Here it tested your pupillary function, which is a bit simple, too, Actually all these measures are very simple. It just measured the size of your pupils while you look at the igloo in a bright scenery and how the pupils get bigger in darkness when the light switch is off. And by doing this examination, you can learn the function of the nerve that makes the pupil small and you can learn the function of the nerve that makes the pupil large. There are two nerves that guide the pupils. And you can see whether these work okay. So, congratulations, no Horner's syndrome and parasympathetic deficit.
Alex X-Health.show:Happy to hear that.
Dr. Mathias Abegg, machineMD:I guess it's not so so common that there is a problem at these two nerves but when it appears, it causes always a lot of confusion and anxiety. People look in the mirror and they say, Oh, my left pupil looks a little bigger than the right pupil. And then they type this into Dr. Google and then they find brain tumor, stroke, terrible diseases. So that causes a lot of anxiety. Then they go to a doctor who knows the same thing. He knows, Oh, anisocoria, so this size difference of the pupil that may be severe disease because it may be a tumor in the lungs, it may be a rupture of the blood vessels that feeds your brain.
Alex X-Health.show:And what's on this not scary part? Because I can sense there is the part that is also not scary.
Dr. Mathias Abegg, machineMD:Usually it is harmless. There is a thing called physiological anisocoria. And even in your case, these pupils they are practically the same size but not perfectly-perfectly. So in brightness there is maybe point two millimeters diameter difference and in darkness it's point three millimeters. So they are not perfectly the same size. But if it looks like this, no worry.
Alex X-Health.show:Because we're not symmetrical, are we? Humans.
Dr. Mathias Abegg, machineMD:Never. But that's a problem when you look in the mirror or take a photograph of yourself and then you go and see a doctor in the emergency room, try not to test this. But they will things happen once you do that. And then we test how the pupil react when we shine light into the right eye. And you'll see, okay, the pupil gets a bit smaller, and then it gets back a bit bigger. And how the pupil react when we shine light into the left eye. And this tells us about the function of the optic nerve. Now, I should ask you, how well do you see in your left eye?
Alex X-Health.show:Oh, it's basically like a corner of the eye vision. So it's pretty bad. However, the other eye is better, I mean, it's better than a regular eye. So it's overcompensating.
Dr. Mathias Abegg, machineMD:In your case, one can see that is when the light shines into the good eye, it really it reacts nice and brisk. And when the light shines into the amblyopic eye, it reacts well, too, but just not as fast. And that's known for a deep amblyopia. So when vision is really not good, because of this misdevelopment of visual acuity.
Alex X-Health.show:And then, did we do any other tests? Because it's still about the eye, did we do any tests about what's in the brain?
Dr. Mathias Abegg, machineMD:Oh, this is the brain. Your amblyopia... I'm not sure how much you want to talk about your personalized... but you think my left eye doesn't see and I can tell you, your eye is fine, your eye has no problem at all. It's your brain responsible for the left eye, that's the difficulty.
Alex X-Health.show:Yeah, I learned it's the neuroplasticity of the brain that at some point the neuro path, or you probably can call it better...
Dr. Mathias Abegg, machineMD:It's your visual cortex. So that all back part of the brain that has not learned to see, to use the visual information. So this problem happens in your brain. In your case, it's of course, a healthy brain. But still one part of your brain doesn't work, namely, the one that is responsible for the left eye.
Alex X-Health.show:And this is so interesting! This neuroplasticity of the brain is so interesting, it's like, well, guys, there is some window, when your brain can learn how to see. And then you can't do anything or as we spoke before the recording, there are some people who try to teach the old brain or the brain older than, what you said, seven, ten or thirteen years old, to learn again, or to develop this path that would allow us to see.
Dr. Mathias Abegg, machineMD:This concept that there is a time window where you can learn and once this window is closed, you cannot learn any longer, only holds true for this, for the development of visual acuity. And there were these famous cat experiments where they stitched one eye closed in cats early in development.
Alex X-Health.show:Kittens?
Dr. Mathias Abegg, machineMD:Kittens, yes. And this concept stuck in the minds of pedagogues, of teachers, and of society, too, so that still people think, Ah, when I didn't learn that properly early, I might not learn this later on. Now turns out it has never been perfectly true. And there is more plasticity than we used to think decades ago. And that's even true for the prototypic example, that is the visual acuity. So even though for now, there is nothing we can do in adulthood to make an amblyopic eye see, we know that maybe at one point there will be possibilities. And I've even seen that! I had a patient with amblyopia and then he lost his good eye, and that led, at age 40, to a development of his bad eye.
Alex X-Health.show:That's scary.
Dr. Mathias Abegg, machineMD:No, not scary. It's joyful, hopeful, because he really, even though that's considered not possible, but that was one example where I experienced that myself. But of course, that's not possible to do a clinical study like this.
Alex X-Health.show:Are you saying he started to see on this eye?
Dr. Mathias Abegg, machineMD:Yes.
Alex X-Health.show:Oh, wow.
Dr. Mathias Abegg, machineMD:He had an amblyopia and when he lost his good eye, his bad eye somehow restarted again and he learned to see. And each time I saw him, his visual acuity was better and even better
Alex X-Health.show:Was it by himself or was he supported with any exercise?
Dr. Mathias Abegg, machineMD:All by himself.
Alex X-Health.show:That's amazing.
Dr. Mathias Abegg, machineMD:Exercise don't work, I would say. There are different opinions, too, on that. For now.
Alex X-Health.show:No, no, but that's... I mean, the brain is such a mystery to us, isn't it?
Dr. Mathias Abegg, machineMD:Yes. That's my entire motivation to work in this.
Alex X-Health.show:Yeah, I can see it. Let's see what else we can see because we already covered ocular alignment and pupillary function.
Dr. Mathias Abegg, machineMD:Yes. And the gaze holding. In your case, we didn't do the entire examination.
Alex X-Health.show:So what else is there? Because there are eight, now I'm quoting, "fully automated examinations". So what are the others?
Dr. Mathias Abegg, machineMD:We also measure what we call, eye movements. But there we look at fast eye movements, how quick the eyes jump to the left or to the right, up and down. And we look at pursuit movements, so the ability of our eyes to follow a target. As you can see, these are very, very, very basic things. How do the eyes react to light? How can you look at the dot? How can you follow that? Simple things. We also have implemented a test for visual fields, so we're interested in how well do you see things outside of your actual fixation point or your actual focus.
Alex X-Health.show:Is it this corner of the eye vision or?
Dr. Mathias Abegg, machineMD:Yes, or peripheral vision or we call it visual field. So you look at one dot and then a dot appears outside. And we solve this problem by – people should look at the dot that appears. And when they look at the dot, we know that they have seen it, so we can check how they see outside. What else we have? The fusional amplitude. We also check how well people are capable of putting the images together. In my case, my left eye sees an image, my right eye sees an image. And my brain guides the eyes in such a way that both images perfectly overlap. So that's an active mechanism of my brain, bringing these images to overlap. And there are diseases where this function does not work properly. Or there is even disease where this functions better than normal. So people, for example, with a vertical strabismus can bring the images together, they are some times much much better than a normal person to be able to adjust for this. So that's another function we measure.
Alex X-Health.show:Okay, so you just mentioned eight examinations that it can do in 10 minutes. The huge benefit for any ophthalmologist or neurologist is basically the speed and there's no necessity for them to be there for the examination. Why would they pull neos out of the drawer? What could be the reason for them to use it, basically?
Dr. Mathias Abegg, machineMD:These two reasons you just mentioned, they don't have to do the examination by themselves and it's faster. But maybe what is much more important than that is that anybody can do it. It's not certain that the clinician at that moment at that place knows how to measure strabismus deviation in all directions of gaze. It's quite uncertain, I would say. So they have a skill they might not have available at that time. And even more important, for me anyways, and that's why I use it in my practice, too, its quantitative. You can look how much of whatever you find there. And most of the things we today measure is qualitative. I look at the eyes and say, They wiggle. And then I write in my chart, wiggly eyes – in medical terms, of course. But there is no number that allows me to say how fast or how big is the wiggling and this device makes all that quantitative. So I can pull up the recording of the last time and see how it has evolved over time. And for some things that is very important because that tells me whether this diseas is getting worse or whether my therapy works okay.
Alex X-Health.show:I also read on your website, Dr. Tatiana Brémova-Ertl mentioning that actually, this device can help differentiate between a stroke and an inner ear impairment. Like, you can use this device to see if a patient that arrives at the emergency room has a stroke.
Dr. Mathias Abegg, machineMD:Well, this is a class 1 medical device, so it's just not allowed to do such a thing because that would be what we call a diagnosis. But if a doctor wants to find out is it now a stroke or is it just a simple peripheral impairment of the inner ear, then he does clinical tests that at one point could or that can be done by eye tracking, too. So yes, we hope that at one point in the future, we'll be able to make this judgment but that's a different device, which has higher demands on. Class 1 medical product is not the same as class 2 and class 3. So that's the future she was speaking about. Yes, absolutely. Because when you make it wrong and a life is at stake, the things you need to fulfill are really different. And we are not there yet.
Alex X-Health.show:But again, congratulations, because actually neos has just been launched. And I know that because I met Phil Norris, who's actually here with us. I met Phil for the first time when I bumped into machineMD booth at Future Health Basel 2023. And then we spoke about the device and about, like, in the future, you want to launch it and have it certified. And last week, I bumped into him again at Basel Area event and he said, Well, we've just launched. Congratulations. Could you tell me, where is it available now? Where doctors can order it?
Dr. Mathias Abegg, machineMD:I need to peek over to Phil, our marketing person who knows all about this. You can order it here in Switzerland and in the UK.
Alex X-Health.show:So I also noticed that you your company's registered not only here in Bern, Switzerland, but also in Cambridge, Massachusetts. I can understand that there is US markets in the future for machineMD and for neos.
Dr. Mathias Abegg, machineMD:Absolutely. US market, obviously, is very important for any medical device company. And we need to start that market somewhere – that's in the Boston area.
Alex X-Health.show:How do you think, just for the closing, I'm very curious about your opinion, how do you think the work of an ophthalmologist or a neuro-ophthalmologist will develop in the future?
Dr. Mathias Abegg, machineMD:Even during my time, when I'm in practice, a lot has changed. I told you initially, nothing has changed, because the diseases are still the same but in terms of how we see patients, a lot has changed. And a lot has become more democratic. Almost any eye doctor here in Switzerland is fully equipped to do examinations that were very exclusive in the past. And I think that development will go even more in this direction, that accessibility for highly important diagnostic workups becomes easier in the future.
Alex X-Health.show:What's just in the immediate future for machineMD or what are the needs of the company that you want to fulfill just just now?
Dr. Mathias Abegg, machineMD:We really want to finish this product. We have a good, or we believe, we have a good first version, which...
Alex X-Health.show:Well, it certified. I mean, guys, you need to know that Mathias is pretty humble when speaking about stuff. So I mean, it's a certified device.
Dr. Mathias Abegg, machineMD:There are certified devices that are useless. I hope not our device.
Alex X-Health.show:And here is the scientist speaking, doubting everything.
Dr. Mathias Abegg, machineMD:Yes, indeed. And truly, I doubt anything, everything, first and foremost myself and what we do, and we need to really show we have done for some things, but we really need to show how useful is it and many things still need to evolve. So for now, I showed you your recording, and I'm a bit used toknow what things mean and with interpretation of this data, but other clinicians, they would just like to have an answer on the sheet of paper saying, okay, this is microstrabismus. And for that, to make it possible, we will first be a different class of device, we will need a lot of normative values, so we will need to learn from our users and from our clients, and from the patients that are being worked up with neos. We need to learn still a lot to make it better and more reliable.
Alex X-Health.show:I smell AI in there.
Dr. Mathias Abegg, machineMD:Yeah, you smell right. But, just to make it clear, this here has no AI, really in it.
Alex X-Health.show:It's automation.
Dr. Mathias Abegg, machineMD:Indeed. We have dreams, what is possible in the future with a device like this. This far we just showed you more or less what it can do now and the immediate next steps. But ultimately, we see ourselves as the company that measures brain function, full stop. And brain function can be measured as we do now by discussing, asking questions and you learn, maybe, whether my mind works more or less okay, certainly whether my speech motor centers work okay. But it's difficult to assess a brain function by language or by motor skills, how it is often done today. Our way to learn about brain function overall is by looking in the eyes. And there we are not only interested in the couple of diseases we just mentioned but more or less any disease affecting the human brain has some or another impact on eye movements. People with Alzheimer's disease, for example, they look at the world differently than people who are healthy. And this looking at the world differently can be seen in the eyes. We can see what are they interested in when they look at the scenery. You are looking at the UFO but maybe some people are just interested in the edges and the lines. Maybe the autistic people, for example, they have different interests than healthy people. All psychiatric diseases, or many of them, have particular features that can be assessed by different ways but also by looking at the eyes. And we dream that we can create a device that comprehensively assesses such brain functions quantitatively. So that not the psychiatrist or a neuropsychologist gives a verbal qualitative interpretation of his thoughts but it is measurable and reproducible. For this, we believe it is required that on top of eye movements, we want to add a few measures. One very obvious is the blinking. So how you close your eyes. That's already there, kind of, we only need to use it diagnostically. Our goal is not to find out how good the person is, but to find the disease in the brain. We are still a medical company. And that's our focus.
Alex X-Health.show:And we go back to my first question,
actually, to:What can you see when you look into people's eyes? And this actually can expand with new technology. And with, probably, with the help of AI, right?
Dr. Mathias Abegg, machineMD:Yes. Anything manifests in the eye that happens in the brain. As of now I can see a few things and certainly not all of them at the level of the eye. But with a good technology and a bit of clever combination of different modalities, yes, we believe that we can see much, much more than we do today.
Alex X-Health.show:I want to see that feature and I wish you that future, I wish you that research going into that direction. And well, it'd be great to have a product like that, I can I can imagine. So thank you very much, Mathias, for a very interesting conversation, I've learned a tone. And you guys, if you want to learn more about machineMD, like see, what are the news or at what stage is this research that we've just mentioned, go to machinemd.com. Thank you again.
Dr. Mathias Abegg, machineMD:Thank you very much for having me.[]
Alex X-Health.show:[POST-ROLL] I'm totally impressed by the audacity of researchers turned startup founders, doctors turned entrepreneurs or ordinary parents turned healthcare innovators. People battling the battles that no one fought before. For the eXtra health of the future. So if you see a startup posting on LinkedIn, show them some love, hit Like, comment, That's fabulous. If you have a couple drops more of that altruism, follow the X-Health.show, leave a review here. I'll be able to bring more of these visionaries to you. So a big thank you. You're awesome. See you next week.
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