CAKE POST (APACRS 2022 Edition) - Issue 2

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ISSUE

06 | 13 | 22

cataract • anterior segment • kudos • enlightenment

HIGHLIGHTS vs depth-of04 Quality focus: Experts are looking for the perfect balance as they weigh in on the best IOLs in town. surgeons share 05 Cataract pearls in managing complications ... find out more. Surgical presents 06 Teleon the next innovative level IOLs.

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C A K E M A G A ZIN E ’ S D A ILY CO N GR E S S N E W S O N T H E A N T E R IO R S E G M E N T

Triumph over Tragedy and Post-Pandemic Perseverance at

APACRS

2022 by Matt Herman

Matt Young

CEO & Publisher

Hannah Nguyen COO & CFO

Robert Anderson Media Director

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Hazlin Hassan Matt Herman Maricel Salvador Graphic Designer

Media MICE Pte. Ltd.

6001 Beach Road, #19-06 Golden Mile Tower, Singapore 199589 Tel. No.: +65 8186 7677 Email: enquiry@mediamice.com mediaMICE.com

piemagazine.org cakemagazine.org cookiemagazine.org Please note that this is an independent publication of Media MICE Pte Ltd (“Media MICE”) in our role as independent media and is not affiliated with APACRS. Media MICE is in no way affiliated to or with any person, organization, or entity mentioned in this publication, nor is this publication published in any way intended to convey any such affiliation.

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n air of camaraderie and cooperation prevailed at the 34th Annual Meeting of the Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS 2022) at events like the Film Festival and Opening Ceremony, and that’s a good thing – for both the professionals in attendance and their patients. There’s an image everyone forms in their minds about professional ophthalmology conferences – neverending symposia, workshops and poster sessions. This is exactly what your correspondent was buckled in for upon landing in Seoul for APACRS 2022, but the conference never ceased to turn these expectations blissfully onto their heads. Maybe it was the fact that this was one of the first in-person conferences since COVID-19 shut everyone into their respective countries; maybe this is just the way they roll in the AsiaPacific ophthalmology community. Whatever it was, it was dazzling to see the sense of community on display. Doctors from all over

the region embraced in the halls and engaged in conversation about not only the innovations and research on display, but also about family, about friends, and about emerging from the long winter-that-was of COVID-19. This undeniable ambience of community, of perseverance through adversity, of that shared burden of doctors moving medicine forward without precondition – this is the vibe at APACRS, and it is on display everywhere.

Tales of triumph at APACRS film festival symposium If the packed hall was any indication, the APACRS Film Festival Symposium and Awards Ceremony, chaired by the charming Aussie Dr. Graham Barrett was one of the most hyped events of the weekend. In a moving and wideranging speech, Chintan Desai, VP of Surgical

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CAKE Magazine’s Daily Congress News on the Anterior Segment

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for Asia Pacific at Alcon, reflected on the power of film. “There’s a saying that a picture is worth a thousand words,” he mused. “But there is a video that is worth a million.” The film festival, whose Chief Judge was Dr. Hungwon Tchah, featured over 50 contestant videos from around the region across four categories: Cataract/ Implant Surgery, Cataract Complications/ Challenging Cases, Refractive/Corneal Surgery, and General Interest. An overall winner was crowned with the Grand Prize at the end. The first category presented was Cataract Complications/Challenging Cases, and the winner was Dr. Karl Brasse from the Netherlands for his video YAG Posterior Capsulotomy: The Final Hurdle to Premium-IOL Outcomes. With its dramatic production and gripping soundtrack, it was no surprise that this outstanding piece of filmmaking featuring a performance of the cutting edge YAG laser T-membranotomy won the prize. For his film Dark Side of the Lens, Dr. Ronald Yeoh of Singapore took home the prize for the General Interest category. The film explored the technique of intraoperative OCT and why it is gaining traction in education, research and improving surgical outcomes for patients. After many attempts, this was Dr. Yeoh’s first film festival win, and he was beaming as he described his journey with intraoperative OCT in the post-video discussion. The winner of the Cataract/Implant Surgery category was Dr. Vaishali Vasavada of India for her production Looking into the Shadows: Airflow Dynamics in Ophthalmic Practice. Her video was as poignant as it was timely, as she deftly discussed airflow in the clinic and the surgery theater and how Schlieren imaging can help manage the transmission of airborne pathogens. In Refractive/Corneal Surgery category, Dr. Sheetal Brar won for her educational video Help Me I am Stuck! Techniques and Tips for Managing Retained Lenticules in SMILE. The video aimed to give pearls to beginners and advanced surgeons alike in SMILE surgery. Finally, the Grand Prize of the festival

was awarded to Dr. Viraj Vasavada of India for her inspirational A Whole New World, an entrant into the General Interest category. The entire audience was transfixed in a trance of awe and wonderment as Dr. Vasavada described how a stroke turned her world upside down at the peak of her professional and personal life, and her arduous battle to reforge her world. The lessons she wanted to share with the world after this journey of tragedy and triumph? “Never lose hope … open mindedness is key … and don’t forget to have fun,” said Dr. Vasavada.

Day 2 off to a strong start with opening ceremony and APACRS Lim Lecture The Opening Ceremony on Day 2 was the event that everything at APACRS 2022 led up to – the stars came out to receive the most prestigious awards of the ceremony and to watch the prestigious Lim Lecture. Kicking things off were enlightening remarks by Korean Society of Cataract and Refractive Surgery (KSCRS) President Dr. Joon Young Hyon about the challenges to the profession presented by the pandemic and thanking delegates, sponsors, and presenters. APACRS President Dr. Abhay Vasavada then echoed Dr. Hyon’s remarks and described a “new dawn” for cataract and refractive surgery in the region as the world emerges from the era of contagion. APACRS awards were then presented. The A.C.E. (APACRS Certified Educator) certification was given to three recipients: Prof. Dr. Tae-Young Chung of South Korea, Dr. Yeo Tun Kuan of Singapore, and Dr. Con Moshegov of Australia, who was the first posthumous recipient in the award’s history. The APACRS Gold Medal is the highest honor of the association, and was awarded to Prof. Dr. Hungwon Tchah of South Korea for his outstanding and significant contributions to cataract and refractive surgery. One of now just four South Korean recipients of the award, the affable Dr. Tchah humbly thanked his colleagues and mentors in his acceptance speech. Last up was the keynote lecture of the weekend, the Lim Lecture delivered by the avuncular Dr. Yao Ke of China.

Named after APACRS predecessor organization APIIA founder, the late Prof. Dr. Arthur Lim Siew Ming of Singapore, the lecture was given by Dr. Yao Ke, a multiple award-winning surgeon and the rising President of the APACRS. He was honored with the named lecture for his contributions to cataract surgery, including the founding of mobile cataract surgery centers that service the most remote and rural areas of China. “He really has spent a large part of his life focused on providing outreach care, eliminating blindness, and cataract surgery,” said Dr. Graham Barrett in his laudatory introduction to the lecture. The lecture itself began with China and the history of cataract surgery, beginning with couching in 206 B.C.E. and continuing to the extracapsular cataract extraction (ECCE) technique in use today. He touched on his pioneering mobile cataract surgery program, which has now branched out into establishing 15 eye centers in some of the most underserved areas of his homeland. The journey he took the packed-to-thegills lecture hall on culminated in a discussion of femtosecond laser-assisted cataract surgery (FLACS), where he discussed a battery of publications he and his team have published since 2014 on this groundbreaking technique, including one published in The Lancet. He highlighted its advantages for tricky cases like white cataracts and hard nuclear cataracts, analyzed the different fragmentation patterns used, and then dove into a comparison of FLACS vs. conventional phacoemulsification surgery (CPS). In summary, his team discovered that FLACS is now superior to CPS and other techniques due to its improved patient outcomes, higher safety profile, and better and faster visual rehabilitation. Commenting on his long-running and tireless efforts in advancing cataract surgical outcomes in China and around the world, Dr. Yao made reference to Chinese legend. “Just like the ancient Chinese myth [of] Kuafu running after the sun, our pursuit of light has never stopped.” And for the millions worldwide who suffer from the blinding scourge of cataracts, we look forward to see what this mythical titan of Chinese ophthalmology does next.

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Battle of the IOLs Achieving The Perfect Balance of Quality and Depth of Focus by Hazlin Hassan

versus multifocal technology. Johnson & Johnson Vision’s TECNIS Symfony IOL distributes light across a range of distances, creating an extended depthof-focus. EDoF suits patients seeking a high-quality continuous range of vision. “With EDoF, light is not split between two focal points,” he noted. EDoF technology does not result in a secondary focal point or peak in defocus as is the case for a multifocal with a fixed add power. Ninety-two percent (92%) of light is transmitted across the range of vision compared to a multifocal which splits approximately 82% of light between two focal points. Postoperative expectations include a normal foveal contour and healthy nerve, while Prof. Dr. Findl advises to avoid previous LASIK for hyperopia. “Surgeons should hit the target refraction, aim for plano — even hyperopic if closest to plano,” he said. Patients need to be advised about possible readers for small, close, and/or dim light, and to be prepared for glare and halos which are tolerable.

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ith the ever-increasing visual demands of patients today, intraocular lenses (IOLs) that offer more vision than monofocals and fewer image quality concerns than multifocals are gaining ground. These are the new extended depth-offocus (EDoF), monofocal plus, and other designs. In a session on Day 2 of the 34th Annual Meeting of the Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS 2022) titled ZEN: A Balance of Quality and Depth of Focus, experts discussed if the new range of IOLs can effectively bridge the gap between monofocal and multifocal IOLs. Johnson & Johnson Vision’s TECNIS Eyhance IOL allows for better spectacle independence for intermediate distance,

The TECNIS Symfony IOL showed minimal night vision symptoms, he added. The TECNIS Symfony lens expands the scope of patients who might be candidates for expanded range of vision. The TECNIS Symfony lens makes it easier for surgeons to achieve good results with an enhanced range of vision. “Continued research to improve quality vision like the Symfony is extremely exciting,” he said. said Professor Dr. Oliver Findl from the Vienna Institute for Research in Ocular Surgery, Hanusch Hospital (Austria). “Unmet needs of today’s standard monofocal IOLs include a higher demand in intermediate distance activities and subjective visual disturbances like glare and halo,” he said. The TECNIS Eyhance IOL uses a proven lens design based on continuous higher order aspheric surface, visually indistinguishable from the TECNIS 1-Piece IOL. The basic geometry is identical to all other TECNIS 1-Piece IOLs and it reduces spherical aberration to almost zero. The TECNIS Eyhance, added Prof. Dr. Findl, has been his standard IOL for more than two years. During his presentation, Dr. Francis S. Mah, MD, director of cornea and external disease at Scripps Health (La Jolla, California, USA) compared EDoF

Furthermore, Dr. Terry Kim, MD, professor of ophthalmology at Duke University School of Medicine (Durham, North Carolina, USA) shared his clinical experience with Alcon’s AcrySof IQ Vivity IOL. The Vivity lens is an EDoF IOL meeting all four American National Standards Institute (ANSI) effectiveness requirements, he said. It is at least 0.5 D greater than a monofocal control at 0.2 logMAR, superior to a monofocal, achieves 0.2 logMAR or better in 50% of eyes, and is non-inferior to a monofocal. According to Dr. Kim, he has seen outstanding reception and results with patients with the Vivity lens. “It has a more forgiving platform,” he emphasized, when it comes to biometry and visual disturbances, and demonstrates a visual disturbance profile similar to an aspheric monofocal IOL.


CAKE Magazine’s Daily Congress News on the Anterior Segment

Cushioning

A Crash Landing Safely

I

by Hazlin Hassan

n the hit K-drama series Crash Landing On You, a paragliding mishap lands a South Korean heiress into North Korea, a complication that also sees her entering the life of a military officer who tries to help her escape.

severe cases, systemic steroids may be required.

During Day 2 of the 34th Annual Meeting of the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2022) in Seoul, Korea, a session titled Crash Landing (On You) Cataract Complications saw a panel of experts present videos of their cataract surgery complications, in order to share lessons learned in minimizing the negative consequences and ensuring safer outcomes.

Dr. Yong-Soo Byun from Seoul St. Mary’s Hospital, Catholic University of Korea, presented on What Happens Behind The Iris? Posterior Iris Chafing Syndrome. Pseudophakic posterior iris chafing syndrome is a spectrum of iris-ciliary body irritation syndromes related to posterior chamber IOLs.

Dr. Young Joo Shin from Hallym University, South Korea, talked about Corneal Complications after Cataract Surgery. “Careful attention during cataract surgery and in the postoperative period should be paid to prevent serious corneal complications,” she told delegates. Corneal complications include wound problems, toxic anterior segment syndrome (TASS), corneal edema, epithelial ingrowth and astigmatism. The treatment for corneal edema involves eliminating the cause, treating the pain, enhancing surface dehydration, and restoring the anatomy. The mainstay treatment of TASS is the suppression of the secondary inflammatory response, with topical prednisolone acetate 1% drops every one to two hours and in

Intraocular pressure should be closely monitored and controlled, she concluded.

“An unstable PC-IOL causes mechanical irritation and trauma to the posterior iris and uveal tissue,” she said. The liberated pigments occlude the trabecular meshwork and raise the IOP. A breakdown of uveal blood-aqueous barrier leads to signs of uveitis. It manifests through iris transillumination defect, pigment dispersion, elevation of IOP, uveitis, IOL tilt or subluxation or pseudophacodonesis. Conditions prone to iris chafing include single-piece IOL in sulcus. Its management is through IOL repositioning or IOL exchange, while its prevention is through the use of 3-piece IOL in sulcus, IOL with capsular tension ring (CTR)/ capsular tension segment (CTS) in the bag and anterior vitrectomy. In cases of persistent epi-defect after cataract surgery, Professor Dr. Joe Woong Koh from Chosun University

College of Medicine, South Korea, said it is best to treat the condition before it worsens. Persistent epi-defect (PED) is a complication after surgical trauma or toxicity of medications and antiseptics. The multi-layered corneal epithelium acts as a protective barrier to infectious agents via tight junctions between neighboring cells and maintains its smooth optical surface by constantly regenerating cells in the basal cell layer. “Disruptions in this protective layer can render the eye susceptible to infection, stromal ulceration, perforation, scarring and decreased visual acuity,” he said. The condition is uncommon and management of patients with PEDs can be quite challenging and may require an extended follow-up period. Patients at risk may benefit from preoperative use of lubricants. PEDs should be treated within 7 to 10 days to avoid secondary complications, cautioned Prof. Dr. Byun. The goal of treatment is to provide protection and favorable conditions for the differentiated epithelial cells to migrate, proliferate and regenerate the normal epithelial layer. Treatment options include transplantation of corneal epithelial stem cells, phototherapeutic keratectomy, amniotic membrane grafting to decrease inflammation, vascularization, and scarring of the cornea while promoting the re-epithelialization of the cornea. Treatment should be carried out in advance before the symptoms caused by PED worsen.

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Bringing on the New Breed of IOLs by Matt Herman

In a conference depopulated by difficulties with visas and entry into the country in these early post-lockdown days here in South Korea, how could it come to pass that people were actually STANDING while eating their lunch to catch the action? As speaker after speaker passed off the mic, the answer became clear: the innovative next level of IOLs led by Teleon’s rhexis fixated FEMTIS IOL Family is upon us, and everyone wants in.

The writing is on the wall for manual capsulotomy In the opening presentation, Dr. Sheetal Brar (India) all but sounded the death knell for manual capsulotomy in her talk High Precision Cataract Surgery – Options and Advantages. Manual capsulotomy vs. femtosecond laserassisted cataract surgery (FLACS) is a topic well-known to have ruffled more than a few ophthalmic feathers in the past, but those days are over, argued Dr. Brar, and it’s time to get with the program.

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n a lunch symposium hosted by Teleon Surgical BV (Spankeren, the Netherlands) on Day 2 of the 34th Annual Meeting of the Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS 2022), experts delved into the next innovations in intraocular lenses (IOLs) and why this seismic shift needs to happen now.

Another day of APACRS 2022 in Seoul, South Korea ... another lunch symposium, right? Not exactly. Something immediately seemed amiss – in a good way – as almost every single seat in the house filled up in Grand Ballroom 105 for the Teleon-hosted symposium Next Level Visual Outcomes: Technologies & Techniques to Meet Patients’ Growing Expectations.

The debate over whether FLACS has better outcomes is still unsettled, with even Dr. Brar admitting there not being a preponderance of evidence supporting FLACS. But what has tipped the scales towards automated capsulotomies are the incredible outcomes of rhexis fixated IOLs. Led by Teleon’s FEMTIS IOL Family, cutting-edge IOLs are far more sensitive to alignment, position and centration. And without the consistency and precision offered by FLACS platforms, the new wave of IOLs like diffractive multifocal and extended depth-of-focus (EDoF) lenses and their strides in intermediate vision — and spectacle independence — would be just another case of putting the cart before the horse.


CAKE Magazine’s Daily Congress News on the Anterior Segment

In the end, regardless of misgivings about things like radial tears and incomplete capsulotomies, Dr. Brar thinks there are enough reasons now to get on the FLACS wagon due to the superiority of IOLs like FEMTIS. But what exactly makes these IOLs so good?

FEMTIS and its staying power IOL explantation, that age-old foe of cataract surgeons around the world, is still kicking around. It needs to be minimized no more than ever as IOL technology comes of age and patient expenses mount with the adoption of new technology. In his presentation Fixation of IOL-OPTIC in FS-Laser Capsulotomy: Is this the future of modern IOL-fixation? Prof. Dr. Gerd Auffarth (Germany) discussed the new generation of IOLs and how clever new design innovations in the Teleon FEMTIS IOL Family can help. IOL decentration is one of the main causes of IOL explantation and thereby many unnecessary stints on the surgeon’s table. The future is here, though, and Prof. Dr. Auffarth knows that the solution lies with FLACS and the advanced IOL platform of Teleon FEMTIS. According to a study performed by Prof. Dr. Auffarth, FEMTIS is unrivaled in its ability to stay put after implantation, meaning less chances of explantations. “Everything we measured [like rotation, decentration, and tilt] was like 3x less with the FEMTIS IOL,” he said. “There’s absolutely no movement at all. It is completely stable over time … there’s no lens available that has better rotational stability,” he continued, and then cited additional literature that showed the same. Before concluding his talk, Prof. Dr. Auffarth pointed to a key additional advantage. There were no dysphotopsias with FEMTIS, an incredible result that he attributes to the capsulotomy rim and FEMTIS IOLs forming an ideal unit.

Asymmetric refractive optics technology, king of the IOL hill So the Teleon FEMTIS IOL Family stays in place. That’s all well and good, but does it actually perform when it comes to visual outcomes? According to Dr.

Patrick Versace’s (Australia) presentation — Asymmetric refractive optics give better visual quality than diffractive lens designs for EDoF and MF IOLs. How do they work? — that answer is a resounding “yes.”

patients receiving the EDoF 1.5 diopter addition.

Dr. Versace went into detail about different types of lens designs. Though many existing lens types give good vision, they all have their drawbacks in the game of checks and balances that is IOL design.

In the final talk of the symposium, and with the scrape of empty plates being cleared away, Dr. Jung Wan Kim (South Korea) presented data on 300 FEMTIS IOL implantations. “There are many kinds of multifocal IOLs, and in my opinion, long-term stability of the IOL position and visual acuity are the keys of a successful outcome,” he said.

Diffractive lens designs give great vision but there are major issues with halos, and there are a variety of other types of lenses that seem to cheat the game of checks and balances, but don’t. Multifocal lenses that use clever “tricks” like spherical aberration or chromatic aberration to make gains in some areas end up falling short in others, sometimes even sacrificing the visual range, quality, and acuity that patients flock to premium lenses for in the first place. Enter Teleon FEMTIS IOL’s asymmetric, segmental, pure refractive multifocal lenses with 1.5, 2.0 or 3.0 diopters near addition that seems to have shattered the paradigm. “Being pure refractive lenses, we have better quality of vision,” Dr. Versace explained. “The benefit of this lens is that even though it looks like a bifocal, there are two refractive elements there,” he continued. The results of this platform, which is quickly gaining traction in the IOL world, speak for themselves. The FEMTIS offers superb distance visual acuity (DVA), with minimal dysphotopsias, and incredible quality of vision while maintaining a highly functional range of vision. And ultimately, it offers much sought after spectacle independence: 60% of FEMTIS wearers Dr. Versace studied never wear spectacles, with the other 40% sometimes wearing spectacles for reading in the group with

More data crowns FEMTIS next-level IOL royalty

We already know that FEMTIS is unrivaled in stability because of its four additional haptics (which Prof. Dr. Auffarth discussed), but what about visual acuity? In the first study, Dr. Kim compared FEMTIS MF 30 with the RayOne trifocal IOL (Rayner, West Sussex, United Kingdom). Results indicate that the FEMTIS far outperformed the RayOne at near vision, with only a slight dip in intermediate vision for both monocular and binocular defocus curves. FEMTIS also showed less glare and halo than RayOne in a questionnaire, with significant advantages over RayOne in patient indications of satisfaction with starburst phenomena.

Summary In the end, the four speakers and their illuminating presentations confirmed with a host of data what a packed house at APACRS 2022 already suspected. Next-level IOLs are here, and Teleon’s FEMTIS IOL Family stands at the front of the pack with its unrivaled in situ stability, its innovative asymmetric optic technology, and its ability to deliver multifocal visual acuity with none of the drawbacks in visual quality.

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