CAKE Post (APACRS 2023 Edition) - Issue 2

At the Nexus of Global Ophthalmology

Ophthalmologists

from across the globe descend on Singapore for APACRS 2023’s long weekend of camaraderiefilled cataract and refractive action

by Matt Herman

One of the world’s great cultural melting pots has provided the perfect backdrop for the 35th iteration of the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2023) annual meeting. Here at the crossroads of Asia, the stage was set for a three-day-long melding of ophthalmic innovation, research, and collaboration in the cataract and refractive space.

June is here again, and for ophthalmic conference-goers in the Asia-Pacific region and beyond, that means it’s time for the APACRS annual meeting. And while last year’s meeting in Seoul had the tenor of a post-pandemic sigh of relief, this year’s 35th version of the Meeting has the celebratory air of a festival.

Did you know that Dry Eye Disease (DED) affects 20% of the population of Asia?

Topcon’s MYAH and Espansione’s eye-light® are here to help! By combining forces, they provide comprehensive dry eye management from diagnosis to treatment.

So be sure to come by the Topcon booth #A34 at APACRS 2023 June 8—10 to discover how Topcon and Espansione are joining forces to combat DED!

Cont. from Page 1 >>

Though the meeting’s theme of “NEXUS – Connecting Everyone and Everything” may seem ambitious, the ambience on the floor showed that it is anything but. From the steady, dull roar emanating from the Exhibition Hall throughout Day 1 to the impressive slate of well-attended sessions and wet labs, everything at APACRS 2023 feels hot. It feels alive — and there’s far more to it than the sticky equatorial heat of the Singaporean summer.

Welcome reception sets the bar

After APACRS 2022’s triumphant return to in-person meetings was dampened by hiccups and travel disruptions due to South Korea’s postpandemic visa rollout, APACRS 2023 feels like the true coming out party for Asia-Pacific cataract and refractive surgery.

This was no more apparent than during the welcome reception in the exhibition hall, where the conversation flowed as freely as the drinks. A little too freely, to your correspondent’s dismay — after one beer and a brief round of photo-snapping, a mangled bundle of disconnected tubes at the bar signaled that there would not be a second.

But this unexpectedly rapid consumption of the venue’s alcohol only reinforced the feeling that APACRS is back in a big way. A vibrant array of saris and sarongs mingled with suits and skirts. Hands and arms gesticulated wildly as attendees engaged in animated and often feverish conversation in scenes reminiscent of the city’s famed hawker stalls and alleyway eateries. Your correspondent was nearly trampled underfoot by a group of three-metertall performers clad in stilts and traditional Chinese opera costumes working the crowd for photo ops. And this was just the beginning.

Day 1 scientific highlights

It wasn’t all party, though. Day 1 was also chock full of superb sessions on all things anterior segment. The day

started off strong with a variety of masterclasses and scientific programs featuring research and updates in all of the latest in the cataract and refractive space. Among these were rapid-fire symposia on angle closure surgery, infectious keratitis and glaucoma vs. myopia-associated optic neuropathy, which are covered later in this issue.

Masterclasses on Day 1 covered all of the classics and more. Traditional cataract topics like phacoemulsification and IOLs were well-represented, but the next generation of ophthalmology also made an appearance.

The ever-charming Dr. Ronald Yeoh hosted a particularly interesting series of presentations entitled “What They Don’t Teach You in Residency” on a variety of trending topics, like worklife balance and innovation. And, of course, it wouldn’t be an ophthalmic conference in the 2020s without MIGS.

World-renowned expert Prof. Chelvin Sng moderated a packed masterclass called “Mastering MIGS Complications,” a reflection of the ubiquitous nature of these tiny devices in the modern glaucoma landscape.

Looking to Day 2

Day 1 was just the beginning, and Day 2 promises to pack just as much heat

into its offerings. The beating heart of any APACRS annual meeting is the official Opening Ceremony and prestigious Lim Lecture, delivered this year by the unparalleled Prof. Gerd Aufarth of Germany, which is going down at 9:00 am.

There are also plenty of symposia to watch out for, including the Prof. Johan Hutauruk-chaired “The New Black in Presbyopia Correction.” With presbyopia rates in Asia on the rise, this is sure to be a Day 2 highlight for doctors seeing these patients daily.

And, of course, no APACRS annual meeting would be complete without the perennial favorite Film Festival Symposium and Awards Ceremony. Last year’s in Seoul was a raucous affair that played out in front of a full house, and there’s no reason to believe that the 2023 version won’t be even rowdier.

These highlight sessions will be reported on extensively in Day 2’s CAKE Post by your Media MICE reporters in the field, so be sure to keep a lookout.

It’s been quite the opening day here in Singapore for APACRS 2023 — and while the stage has been set for an epic three days of cataract and refractive goodness, the best is surely still yet to come.

Field Notes from APACRS 2023

Day 1 kicks off with a rapid-fire session on angle closure surgery

by Matt Herman

From phacoemulsification to MIGS and LPI… Day 1 at the 35th Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2023) annual meeting in Singapore kicked off with a jam-packed, informationloaded session entitled “Angle Closure Surgery – New Insights.”

The infamous Day 1, Session 1 is the ophthalmic conference’s version of the graveyard shift, with jet-lagged, traveled-out delegates either in bed or shuffling listlessly around the conference venue.

But at the “Angle Closure Surgery –New Insights” session, the tenor was different. Seats were full of inquiring eyes — and we were there to get the lowdown on the latest in open-angle glaucoma surgery.

At the top of the order was Dr. Baskaran Mani (India), who got it cooking in Hall A of Singapore’s Suntec Convention Centre with his talk, “Phaco is the Best Angle Closure Treatment We Have.” Though the main argument of his talk was that phaco is the best weapon against angle closure, he cautioned against blanket statements. Most important for deploying this powerful tool for Dr. Mani were the magnitude of angle closure, the cause of the closure (i.e., caused primarily by the lens), and making sure the cataract grade and resulting visual improvement are high enough to justify such an invasive procedure.

Up next, Prof. Jimmy Lai (Hong Kong) wanted people to know that goniosynechialysis (GSL) is back from the dead in his lecture, “Goniosynechialysis – A Resurgent

Technique.”

After an overview of the technique, Prof. Lai argued that goniosynechialysis has a place in primary angle closure glaucoma treatment — if medication and laser peripheral iridotomy (LPI) have failed, peripheral anterior synechiae are extensive, and the glaucoma is not advanced.

The venerable Prof. Prin Rojanapongpun (Thailand) picked it up from there by revisiting a thorny topic in angle closure treatment with his talk, “Phaco – MIGS in Angle Closure. Is it as Controversial as it Seems?” Though Prof. Rojanapongpun suggested the contentiousness of this topic is subsiding, especially with MIGS’ advantages to postrefractive stability, he cited a lack of published literature, study standardization, and patient selection as hurdles to overcome to settle the debate for good.

Prof. Graham Lee (Australia) continued on with surgical technique in his demonstration, “Incisional Surgery in Angle Closure. Tips and Tricks.” And

though there were pearls aplenty, one in particular got both the panel and audience arguing in the Q+A session due to its exotic nature — using a oneport vitrectomy (he used a 25-gauge port) to remove vitreous for a slight softening of the eye in patients with very narrow (in his example case, <2 mm) anterior chamber depths.

Unlike Prof. Lee, Prof. Hon Tym Wong (Singapore) was in the business of quashing controversy in his talk, “ALPI and SLT in Angle Closure.” In the end, Prof. Wong concluded that iridoplasty while argon laser peripheral iridoplasty (ALPI) might be great for acute cases, for chronic cases its use is best limited to patients with plateaued irises. Selective laser trabeculoplasty (SLT)’s uses are also similarly limited to iridotomy patients who don’t respond to or are unable to use eye drops.

Optical coherence tomography (OCT) is coming to the masses, and Dr. Joseph Anthony Tumbocon (Philippines) explained in his talk, “Risk Factors for Progression in PACD – How Can Imaging Help Determine Risk”, that anterior segment OCT (AS-OCT) has a significant role to play in primary angle closure disease (PACD). His talk laid out the case for AS-OCT as a tool to stratify risk and identify patients likely to progress from PACS, as well as provide quantitative data critical in monitoring.

Dr. David Lubeck rounded things out with his illuminating discussion, “Current MIGS Treatment Strategies for Cataract and Refractive Surgeons.” The talk functioned as an overview of MIGS available to cataract surgeons, including a well-received recommendation that patients with uncontrolled IOP or ocular surface disease and narrow angle glaucoma make excellent candidates for GSL and canaloplasty.

Experts opened Day 1 of APACRS with an information-loaded session on angle closure surgery.

Beat the Bug and Inflammation!

Updates on the latest diagnosis and treatment options of infectious keratitis in Asia

by Tan Sher Lynn

Experts from the Asia-Pacific region shared the latest findings from the ACSIKS study, as well as provided updates on the treatment of various forms of infectious keratitis.

Established by the Asia Cornea Society (ACS) in August 2010, the Asia Cornea Society Infectious Keratitis Study (ACSIKS) is a multicenter, prospective, observational study of infectious keratitis in each participating center, conducted over 12 months. “All together we recruited more than 7,300 patients between 2012 and 2019,” said Dr. Khor Wei Boon (Singapore).

“Pseudomonas aeruginosa (P. aeruginosa) was the most common bacterial pathogen isolated in ACSIKS. Multi-drug resistance (MDR) was found in 14% of P. aeruginosa isolates, largely from the centers of India. Some of the fluoroquinolone (moxifloxacin and besifloxacin) had the highest cumulative resistance rates,” shared

Dr. Khor. “This is a concern as topical fluoroquinolone is the antibiotic of choice for the treatment of infectious keratitis. However, fortunately, this data is largely contributed by the high resistance rates in Indian isolates. Outside of India, most of the centers are seeing a much lower rate of drug resistance,” he continued.

Nevertheless, there are limitations to the study. “ACSIKS is conducted in major tertiary eye centers, so infections may be more serious and more likely to be resistant. Nonetheless, we hope that this information will help Asian ophthalmologists in making informed and prudent antibiotic choices in the management of infectious keratitis,” Dr. Khor said.

Novel diagnosis methods

Meanwhile, Dr. Venkatesh Prajna (India) shared about new methods that will help to diagnose fungal keratitis more accurately, including deep learning, fluorescent smart probes, and the lateral flow device.

According to him, clinicians are only able to correctly distinguish bacterial from fungal ethology 66% of the time. On the other hand, computer vision models were able to achieve superhuman performance in identifying the underlying infectious cause of microbiologically positive corneal ulcers, with the bestperforming convolutional neural network (CNN) being the Mobile Net, which attained an AUC of 0.86 on the single center test set.

Dr. Vilavun Puangsrich Arern, Thailand (at right)

The fluorescent smart probe offers a comparative method to gram stain for delineating gram-positive or gram-negative bacteria or fungi within corneal scrapes, demonstrating equivalent or higher sensitivity, specificity positive predictive value (PPV), and negative predictive value (NPV) and accuracy than culture to gram stain. “Our approach has scope for point-of-care clinical application to aid in the diagnosis of microbial keratitis,” Dr. Prajna said.

In addition, the lateral flow device can be used to rapidly diagnose Aspergillus keratitis in just 20 minutes.

“There are innovative diagnostic modalities in the anvil, which may reduce the need for an expensive microbiology setup,” he said.

Managing atypical keratitis

Atypical keratitis is caused by an uncommon organism, such as Phythium insidiousum, that is difficult to identify, leading to delayed diagnosis and treatment as well as

poor visual outcomes, noted Dr. Vilavun Puangsrich Arern (Thailand).

She described three types of atypical keratitis — Phythium keratitis, Microsporidial keratitis, and Acanthamoeba keratitis

“Atypical keratitis should be suspected in cases with indefinite diagnosis which failed to respond to conventional treatment. Several unique clinical courses and presentations would be clues to suspicion of each causative organism. When in doubt, perform special staining techniques and cultures together with in vivo confocal microscopy (IVCM), polymerase chain reaction (PCR), and corneal biopsy for histopathological examination, which will guide you to the diagnosis and treatment,” she shared.

Updates on microbial keratitis treatment

Keratitis is sight-threatening with one in 10 elderly patients losing an eye and 40% losing vision, noted Dr. Stephanie Watson (Australia). “It is the fifth

Ophthalmologists Discuss Extended Range of Vision with the RayOne EMV IOL

At a packed breakfast symposium today at APACRS 2023, a highprofile panel of ophthalmologists, led by APACRS Past President Prof. Graham Barrett, delved into how the RayOne EMV IOL from Rayner provides patients with an extended range of vision — especially when used with a monovision approach.

In-coming ESCRS President Prof. Filomena Ribiero showed defocus curves from her study comparing Rayner’s EMV IOL with EDOF and monofocal IOLs. The RayOne EMV demonstrated excellent visual outcomes for distance and intermediate vision, and good visual acuity for near vision.

Out-going ESCRS President Prof. Oliver Findl then presented the first multicenter clinical data on the EMV Toric. Results showed significant cylinder reduction, UDVA similar to a

standard monofocal IOL, a range of vision extension with excellent UIVA values, and very good functional UNVA outcomes.

Lastly, Dr. Tun Kuan Yeo, senior consultant for the Department of Ophthalmology at Tan Tock Seng Hospital in Singapore, presented his findings comparing clinical outcomes of the EMV with emmetropia and modest monovision. He found good distance and intermediate VA with bilateral emmetropia, as well as good distance, intermediate and near VA with modest monovision. Further, the EMV lens showed similar performance in photopic and mesopic conditions and was pupil size independent.

Prof. Barrett said: “For many years I have worked on optimizing a lens for monovision, given that it accounts for nearly 30% of all surgeries. I collaborated

leading cause of blindness worldwide with most of the burden in lowerincome countries. People in those countries where they lose one eye are more likely to lose vision in the other eye,” she added.

According to Dr. Watson, more cost-effective community-driven eye care models, effective and safe pharmacological interventions, and educational interventions to enable rapid diagnosis and treatment, as well as preventive eyewear, are needed to tackle the problem.

“To improve outcomes, we need to be able to identify the microbe and choose antimicrobial therapy. Global surveillance will have a key role in this, along with improved regimes and newer antimicrobial agents. Importantly, we need the resources for more research and technology to really advance the field. And while we do this, the public and patients need to be educated that if they get an abrasion, they need to seek help and treatment. Finally, we need to improve our patient experience,” she concluded.

with Rayner on bringing this lens to market as RayOne EMV, an exciting new product for all surgeons looking to treat presbyopia reliably.”

Dealing with a Double Whammy

that excluding deep retinal layer S-F associations may help to increase the diagnostic accuracy of high myopiaglaucoma.

Optic neuropathy in high myopia

by Tan Sher Lynn

Experts share insights into the diagnosis and treatment of myopia-associated glaucoma

Glaucoma can cause vision loss by damaging the optic nerve. According to Dr. Jost Jonas (Germany), risk factors for glaucomatous or glaucoma-like optic nerve damage in highly myopic eyes include a larger parapapillary delta zone, larger optic disc, and older age. However, the potential role of intraocular pressure (IOP) is still unclear.

On the other hand, he noted that nonglaucomatous optic nerve damage is perhaps due to the elongation of axons, longer axial length, and wider parapapillary gamma zone. He suggested that all highly myopic eyes should be considered to have optic nerve damage until the contrary has been proven in individual patients.

Accurate diagnosis and appropriate management of glaucoma in highly myopic eyes remain a challenge. On Day 1 of the 35th Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2023) annual meeting, experts shared their thoughts on tackling the high myopia-glaucoma issue

First up was Dr. Wong Chee Wai (Singapore), who talked about imaging the highly myopic eye. According to Dr. Wong, both functional and anatomical assessment can be confounded in highly myopic eyes. As such, careful and detailed evaluation with multimodal imaging is necessary to properly assess these eyes.

He noted that visual field abnormalities can arise from myopic traction maculopathy (MTM) and various lesions in myopic macular degeneration (MMD), while thinning or thickening of the inner retinal layers can arise from MTM or previous macula-off retinal detachment. In addition, the use of microperimetry may improve structure-function (S-F) correlation.

“As always, longitudinal analysis is key for assessing both glaucoma and myopic maculopathy. By comparing the same eye over time, the impact of

ambiguous anatomy on diagnosis and monitoring will be reduced,” he said.

Structure-function associations in diagnosis

Next, Dr. Rachel Chong (Singapore) explored the question of how to improve high myopia-glaucoma diagnosis using the S-F relationship.

According to Dr. Chong, myopia alters chorioretinal layer thickness and retinal topography, and is associated with visual field defects. In her study, she found that in high myopia-glaucoma patients, the superficial retinal ganglion cell (RCG) layers show the strongest S-F associations with visual field sensitivity.

Meanwhile, in high myopia-glaucoma suspects, both superficial and deep retinal layer thickness measurements are associated with visual field sensitivity. Therefore, she concluded

Surgical management of glaucoma in myopic eyes

Meanwhile, Dr. Ho Ching Lin (Singapore) noted that since there are no clear surgical algorithms for glaucoma in high myopia currently, there is a need to treat each patient differently, as each has a different cause and progression risk.

“We need to monitor closely for the location of defect, progression rate, and relation to IOP changes. Document definite progression — not just indepth defects but also new areas before escalating treatment,” she said. “Also, exercise caution in performing glaucoma surgery in myopic eyes. Always lean towards safety in very elongated eyes with staphyloma and significant retina-choroidal changes.”

Dr. Ho also suggested avoiding augmented filtration surgery. “Noninvasive options such as medicines, laser trabeculoplasty, and safer surgical options should be considered first before opting for conventional filtration surgery whenever possible,” she concluded.