CAKE Issue 07: The ebook version (The 'Back to the Future' Issue, ESCRS 2020 Virtual Edition) by Media MICE

THE WORLD’S SECOND FUNKY OPHTHALMOLOGY MAGAZINE

THE “BACK TO THE FUTURE” ISSUE

Sept/Oct 2020

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IN THIS ISSUE...

Cataract Matt Young CEO & Publisher

Robert Anderson Media Director

Hannah Nguyen Production & Circulation Manager

Gloria D. Gamat Chief Editor

Brooke Herron Editor

Mark Hillen Editor-At-Large International Business Development

Ruchi Mahajan Ranga Brandon Winkeler

06 06 08

Anterior Segment

New Treatment Alternative Can CEaP Work as a Complete Treatment for Neovascular Glaucoma?

The Rising Infection Rates of Ocular Syphilis in Tandem with HIV

Transparency at Risk Neovascularization of the Lens Why Canâ&#x20AC;&#x2122;t This Child See? Addressing Issues of Poor Vision in Children

Cover Story

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Andrew Sweeney April Ingram Chow Ee-Tan Joanna Lee Hazlin Hassan Konstantin Yakimchuk Khor Hui-Min Olawale Salami Sam McCommon Tan Sher Lynn Maricel Salvador Graphic Designer

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Enlightenment

Amid the Pandemic Safety Precautions Before and During Cataract Surgery

The New Normal Refractive Surgery Returns After COVID-19 Lockdowns

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Conference Highlights

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Asia-Pacific Academy of Ophthalmology

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WOC 2020 Is COMET a Herald of New Ocular Surface Treatments? Interesting e-Posters from ASCRS 2020 Highlights from WOC 2020 The Latest in Cataract Surgery

Alternative Medicine Homeopathic and Nonsurgical Cataract Treatments

Keeping Up with the Times Integrating Telehealth in Ophthalmology

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LETTER TO READERS

If I fancied a trifocal IOL, might I come to Europe in 2010 and get the first, Damien Gatinel-designed one implanted? In fact, the last decade has been about launch after launch after launch of better lasers, phaco machines, optimized biometry, lens calculations, IOL materials and optical designs.

nlike cars (even DeLoreans), doesn’t time fly? When I read a few years ago that phacoemulsification was 50 years old, that doesn’t even bring you, ahem, “Back in Time” to the 1950s — rather, to the 1970s! This got me thinking about time travel. If I was in the improbable situation of having to escape from some Libyans (from whom my old crazy friend had swindled some plutonium) and I accidentally went back in time (and needed cataract surgery) — just how comfortable would I be having cataract surgery when I arrived? Readers, I’m sure it’s a thought that, at some point, has crossed your minds. I mean, couching? With a thorn? First described in detail by Maharshi Sushruta in 800 BCE, that’s not going to fly like a 2015-spec DMC. I mean, I want good outcomes, right? The first intracapsular cataract extraction (ICCE) was described by the British surgeon Samuel Sharp, in 1753. A few snips, then pressing his thumb down on the eye until the lens is expressed out of the eye? No thanks. I think want to have “modern” extracapsular cataract extraction (ECCE). Ecce bonum vision, right? I might need to end up a few years earlier in France in 1747 to have ECCE surgery performed by good old Jaques Daviel. But then, his surgery involved a large (1cm!) corneal incision. The surgically induced astigmatism must have been spectacular. Okay, let’s move 112 years back (in) to the future to have the 19th century’s finest German ophthalmologist, Albrecht von Graefe, perform an ECCE with a much smaller scleral incision. But again, can you imagine the complications, let alone the outcomes? Was povidoneiodine even a thing back then? ECCE eventually waned in popularity and so ICCE became the standard-of-care for many years.

But frankly, I don’t want to be aphakic and have to wear huge Mr. Magoo-style glasses (once the wounds recover after weeks of being bandaged in bed) to see anything at all. So maybe I’d want to end up in the same era as Marty McFly in the first Back to the Future film and fly across the Atlantic to get me some recently (1949) invented Harold Ridley plexiglass intraocular lenses (IOLs). Still ICCE, still phenomenal complication rates — compared with today’s surgery. At least I’d enjoy the birth of rock ‘n’ roll, and the invention of the skateboard? Maybe I should hope to end up in the 1970s, when Charlie Kelman invented phaco — the “flux capacitor” of modern cataract surgery. But early phaco delivered a lot of ultrasound energy to the eye, and again, the technology would have needed to be refined further before I would have felt comfortable having that put in my eye. Perhaps the late 1980s then? Howard Gimbel and Thomas Neuhann had by then both described the continual curvilinear capsulorhexis (CCC). We also had foldable silicone IOLs available by then (with the first three-part foldable silicone IOLs coming to the market in 1989). At this point, we’ve arrived at bona fide ECCE surgery. But what about the advent of better IOL calculation formulae? Biometers that gave better and better readings of corneal and lens thickness and position? If I started in 1985, in the Hill Valley Twin Pines/Lone Pine mall parking lot, where in the future would I be comfortable ending up? A year later to have the first bifocal IOL implanted by John Pearce? Perhaps 1991 for Gimbal’s divide and conquer? What about 1995 to receive a square-edged IOL to combat posterior capsular opacification? Or 2008, should I have visited Budapest for Zoltán Nagy to perform femtosecond laser-assisted cataract surgery? I mean, if you are going to have cataract surgery, why not do it in style?

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Today, the plethora of options available to me is incredible. I can truly have something almost completely customized to my anatomy and visual requirements. In the film, Doc Brown goes to the distant future, 2015, and comes back from the rejuvenation clinic having had an “all-natural overhaul”, with all-new blood, colon and spleen. Perhaps I could go forward and have something like a solar-powered accommodative IOL implanted with some augmented reality displays added to it. Or even better, a freshly-grown lens gel that could be injected into the bag once the old one was removed. Who knows? I mean, I’d go for the all-new blood, colon and spleen too, naturally. I guess the point of the journey is, throughout history, people have had cataract surgery because they absolutely needed to. What was previously a major operation requiring weeks of recovery is now a “15-minutes-and-you’re-done” outpatient procedure that routinely achieves great outcomes. As the Blue Mountains Study showed a few years back, cataract surgery improves your life — and lengthens it, too. We are lucky to live in this era. Why waste time waiting for a slightly better lens on the horizon? Really. If you need cataract surgery, the right time to have it is now.

Dr. Mark Hillen

Director of Communications ELZA Institute, Zurich, Switzerland Editor-At-Large | CAKE

ADVISORY BOARD MEMBERS

Dr. Jodhbir S. Mehta

Dr. William B. Trattler

Dr. Chelvin Sng

Dr. Harvey S. Uy

Dr. Mehta is head of Cornea External Disease and senior consultant in the Refractive Service at Singapore National Eye Centre (SNEC), deputy executive director at Singapore Eye Research Institute (SERI), as well as a professor at DukeNational University of Singapore. With a main interest in corneal transplantation, he completed a corneal external disease and refractive fellowship at Moorfields Eye Hospital in London and at SNEC. He has co-authored nearly 20 textbooks and 333 citations, and holds 16 patents, six of which have been licensed. A seasoned committee organizer, Dr. Mehta

will be part of the World Corneal Organizing Committee in 2020, as well as the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS), Singapore, in the same year. He has won several awards from the American Academy of Ophthalmology (AAO) and the Association for Research in Vision and Ophthalmology (ARVO), among others, the latest of which was from the American Society of Cataract and Refractive Surgeon (ASCRS) in 2018. Dr. Mehta is also a favorite keynote speaker and presenter in several international conferences. jodmehta@gmail.com

Dr. Trattler is a refractive, corneal and cataract eye surgeon at the Center For Excellence In Eye Care in Miami, Florida, USA. He performs a wide variety of cataract and refractive surgeries, including PRK; all laser LASIK; no injection, suture-less cataract surgery; as well as laser cataract surgery. He has been an investigator for next generation technologies (like the Tetraflex accommodating intraocular lens) and procedures like corneal collagen crosslinking (CXL). His involvement in the FDA-approval study for CXL led to its approval in 2016. In addition to his private practice, Dr. Trattler is on the Volunteer

Faculty at the Florida International University Wertheim College of Medicine, as well as the University of Miami’s Bascom Palmer Eye Institute. He is board certified by the American Board of Ophthalmology and has been an author of several articles and abstracts. In 2016, Dr. Trattler received the Catalyst Award in Advancing Diversity in Leadership from the Ophthalmic World Leaders (OWL), an association of interdisciplinary ophthalmic professionals dedicated to driving innovation and patient care by advancing diversity in leadership. wtrattler@gmail.com

Dr. Sng is a consultant at the National University Hospital (NUH) and assistant professor at National University of Singapore (NUS). She is also an honorary consultant at Moorfields Eye Hospital, London, and adjunct clinic investigator at SERI. A pioneer of minimally invasive glaucoma surgery (MIGS), Dr. Sng was the first surgeon in Asia to perform XEN, InnFocus Microshunt and iStent Inject implantation. A co-author of “The Ophthalmology Examinations Review”, Dr. Sng has also written several book chapters and publications in various international journals. She has received international grants and awards for her research accomplishments

from the American Academy of Ophthalmology and the Australian and New Zealand Glaucoma Interest Group. Proficient in conventional glaucoma surgery and trained in complex cataract surgery, Dr. Sng co-invented a new glaucoma drainage device, which was patented in 2015. She has been invited as a reviewer for several international ophthalmic publications, and as a speaker in various international lectures and conventions. When not working, Dr. Sng can be found volunteering in medical missions in India and across Southeast Asia. chelvin@gmail.com

Dr. Uy currently serves as associate clinical professor at the University of the PhilippinesPhilippine General Hospital, consultant for Retina and Uveitis Services at St. Luke’s Medical Center, as well as medical director at Peregrine Eye and Laser Institute in the Philippines. Previously, he was a clinical fellow in Medical and Surgical Retina at St. Luke’s Medical Center, Philippines, and in Ocular Immunology and Uveitis at the Massachusetts Eye and Ear Infirmary at Harvard Medical School. In 2015, he co-invented the Modular Intraocular Lens Designs, Tools and Methods,

which was patented with the United States Patent Office. Dr. Uy is a recipient of numerous awards and honors, including the Immunology Award, presented by the Ocular Immunology Service from the Massachusetts Eye and Ear Infirmary, Harvard Medical School (1998), and the Senior Achievement Award from the AsiaPacific Academy of Ophthalmology (2017). He has also published more than 32 international peer-reviewed journals and 30 book chapters, and is a prominent speaker, presenting in various national and international conferences. harveyuy@yahoo.com

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ATARACT PHPV

Transparency at Risk Neovascularization of the Lens by Olawale Salami

Family history can be an important diagnostic tool.

he human lens and cornea are transparent tissues. In intrauterine life, the lens is nourished by a generous network of fetal capillaries which regress completely by the late fetal period, before birth. The avascular nature of the human lens is an important anatomical feature needed to maintain its optimal transparency. The invasion of the lens by abnormal or leaky vessels — or neovascularization — may occur in response to several types of insult and is a significant cause of opacity and/or blindness.

Blood vessels that just won’t go away Persistent hyperplastic primary vitreous (PHPV) is a failure of the regression of a component of fetal blood vessels within the eye. It remains an important cause of amblyopia and visual disabilities in children1 and should be suspected in any child with leukocoria. Affected eyes may develop complications including glaucoma, cataracts, intraocular hemorrhages, retinal detachments and/or phthisis, that will further affect the child’s vision.2

Although the majority of cases are both unilateral and non-hereditary, the occurrence of some familial clinical patterns points to genetic factors and can be inherited as an autosomal dominant or recessive trait.3 Neovascularization of cornea, iris, optic disc and retina is well-documented. However, the adult human lens and its capsule are avascular and resistant to neovascularization. Latest research findings in the field suggest that the underlying mechanisms that drive neovascularization in the intraocular lens after cataract extraction may be related to diabetes and ischemic central retinal vein occlusion (CRVO), leading to chronic hypoxia and high levels of vascular endothelial growth factors (VEGF) in anterior chamber.4 Furthermore, anatomical proximity of the intraocular lens (IOL) with pupillary margin and loss of vitreous and its antiangiogenic factors, like opticin have been implicated.5

A family-centered approach to diagnosis According to Dr. Manoharan Shunmugam, director of clinical

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services at the flagship branch of OasisEye Specialists in Kuala Lumpur, during the diagnostic work-up of a patient, it would be helpful to examine parents and siblings, as many genetic conditions — though they may have variable penetrance and expressivity — may have some detectable clinical manifestations. “For patients with hereditary conditions, it is imperative that the parents receive genetic counseling so that they are aware of the possibilities of these conditions affecting any other children,” Dr. Shunmugam emphasized. “It would also be prudent to ensure that siblings or extended family have a routine eye examination.” In addition, he advised that “a thorough social and dietary history is necessary, as some modern dietary restrictions have been shown to have an impact on even normal individuals, let alone those with an underlying genetic condition.”

Look out for leukocoria Early PHPV typically presents with leukocoria in the smaller eye of an infant within one to two weeks of birth.

The classical presentation is that of leukocoria, micro-ophthalmia and a cataract. However, it’s important to rule out other differential diagnoses of leukocoria, such as retinoblastoma, congenital cataract, Coats’ disease, astrocytic hamartomas (related to tuberous sclerosis), uveitis, toxocariasis, retinopathy of prematurity, Norrie’s disease, Trisomy 13, and WalkerWarburg syndrome.

Spanning from anterior to posterior segment Anterior PHPV has milder features compared to the posterior phenotype and results in better surgical outcomes and visual results. The anterior subtype has been defined as the presence of a retrolental opacity, elongated ciliary process, or cataract. But it can also include a membranous transformation of the anterior vitreous face causing traction on the peripheral retina, a shallow anterior chamber, poor pupil dilation and microphthalmos. The posterior subtype has been defined by a stalk of tissue extending from the optic nerve to the retrolental area, causing an elevation of the vitreous membrane from the optic nerve, retinal folds, dysplasia or detachment.

Diagnosing PHPV By careful clinical examination, PHPV is readily diagnosed by direct visualization of any component of the persistent fetal vasculature. In patients with poor visualization of the fundus, ultrasonography is preferred. In general, ultrasound, computed tomography scanning, magnetic resonance imaging, and fluorescence angiography are all reasonable options for establishing a diagnosis. Fluorescein angiography, with either a slit-lamp camera or fundus camera, can detect abnormal vasculature in various locations and can be used to visualize the brittle-star configuration. However, peripheral retinal capillary nonperfusion in PHPV should not be confused with those seen patients with retinopathy of prematurity, familial exudative

vitreoretinopathy, Norrie disease and incontinentia pigmenti.

Is this a pediatric cataract? Surgical treatment remains central to the management of PHPV. According to Dr. Shunmugam: “It is essential to double-check that this isn’t a pediatric cataract as there have been reported cases of patients being taken in for cataract surgery then finding a retinal detachment due to the PHPV. There should be a very low threshold for performing B-mode ultrasound in these patients as it is non-invasive, requires no sedation, and reveals much more than can be discerned via ophthalmoscopy in a moving or crying child.” In cases in which cataract is associated with PHPV, intraoperative bleeding is a potential complication during cataract surgery.6 The pars plana approach along with endocoagulation has been used successfully by some surgeons, while others have also described an alternative approach using a Fugo plasma blade via an anterior route, which provides better control over the posterior capsulotomy along with minimal traction over the retina and, most important, hemostasis during surgery.7 In a recent paper8, Zhao et al. described a surgical strategy in which anterior PHPV was treated using phacoemulsification with underwater electric coagulation on posterior capsule neovascularization, posterior capsulotomy, anterior vitrectomy, and IOL implantation; while posterior PHPV

was treated with lensectomy, posterior vitrectomy, retinal photocoagulation, and IOL implantation or silicone oil tamponade. Postoperatively, visual acuity significantly improved in 25 of 33 eyes (75%) following operations and 3 to 48 months of amblyopia treatment. These encouraging results demonstrate that early surgical intervention and amblyopia therapy can result in positive treatment outcomes.

Contributing Doctor Dr. Manoharan Shunmugam is a consultant ophthalmologist, adult and pediatric vitreoretinal surgeon who trained in the United Kingdom. Based in Malaysia since 2013, Dr. Shunmugam has a keen interest in research with publications in a wide range of high-impact journals and has been invited to many international conferences as a speaker. He is also a contributing author of two book chapters in vitreoretinal reference textbooks. He graduated in Scotland and subsequently undertook his ophthalmic specialist training and VR Fellowship in London. En route, he further honed his skills with a pediatric VR fellowship at the prestigious L.V. Prasad Eye Institute, Hyderabad, India – making him one of the few pediatric VR surgeons serving in the Asia-Pacific region. He is currently the director of clinical services at the flagship branch of OasisEye Specialists in Kuala Lumpur, a multi-subspeciality ambulatory eye centre in Malaysia. He continues to serve probono at Hospital Kuala Lumpur and is the honorary secretary of the Malaysian Society of Ophthalmology and is a member of the Asia-Pacific Vitreoretinal Society. mano.shun@oasiseye.my

REFERENCES: 1

Buerk BM, Sharma MC, Shapiro MJ. Persistent hyperplastic primary vitreous (PHPV). Pediatric Retina. 2011. doi:10.1007/978-3-642-12041-1_8

Pollard ZF. Persistent hyperplastic primary vitreous: Diagnosis, treatment and results. Trans Am Ophthalmol Soc. 1997;95:487-549.

Shastry BS. Persistent hyperplastic primary vitreous: Congenital malformation of the eye. Clin Exp Ophthalmol. 2009;37(9):884-990.

Kuzmin A, Lipatov D, Chistyakov T, et al. Vascular Endothelial Growth Factor in Anterior Chamber Liquid Patients with Diabetic Retinopathy, Cataract and Neovascular Glaucoma. Ophthalmol Ther. 2013;2(1):41-51.

Le Goff MM, Lu H, Ugarte M, et al. The vitreous glycoprotein opticin inhibits preretinal neovascularization. Invest Ophthalmol Vis Sci. 2012;25;53(1):228-34.

Dass AB, Trese MT. Surgical results of persistent hyperplastic primary vitreous. Ophthalmology. 1999;106(2):280-284.

Khokhar S, Tejwani LK, Kumar G, Kushmesh R. Approach to cataract with persistent hyperplastic primary vitreous. J Cataract Refract Surg. 2011;37(8):1382-1385.

Li L, Fan DB, Zhao YT, Li Y, Cai FF, Zheng GY. Surgical treatment and visual outcomes of cataract with persistent hyperplastic primary vitreous. Int J Ophthalmol. 2017;8;10(3):391-399.

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ATARACT PEDIATRIC CATARACT

Why Can’t this Child See? Addressing Issues of Poor Vision in Children

part from trauma, among the broad reasons for poor vision in children include developmental causes and genetic or hereditary diseases. These are some of the topics that pediatric vitreoretinal surgeon Dr. Manoharan Shunmugam shared and discussed with ophthalmologists, opticians and optometrists in a recent webinar organized by OasisEye Specialists Centre in Kuala Lumpur, Malaysia.

by Joanna Lee

of which are warning signs and must be taken seriously. “If a child has any exotropia, check that their reflection on the cornea is normal,” he said.

“If a child has any exotropia, check that their reflection on the cornea is normal.”

Raise the red flags early For preverbal children, several tests can be done to determine the cause of poor vision. “If the tests are not accessible, you should check for leukocoria — abnormal white reflection from the retina — to make sure the pupils are normal. If you find any reduced red reflex, then you have to refer them up,” shared Dr. Shunmugam, cautioning to check for asymmetrical pupils or relative afferent pupillary defects, all

There are also intraocular malignancies such as retinoblastoma, a rare cancer most commonly found in children, that physicians should look for. “Should you see any lens subluxation, there’s a high likelihood they’ve had trauma or a significant syndrome that needs to be investigated further,” added Dr. Shunmugam. “If there is a lot of excoriation of

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the eyelids or erythema around the periocular area, then you can suspect the child has been rubbing his eye a lot. Not only can it cause keratoconus but it can also lead to lens subluxation,” he warned.

Watch out for pediatric cataract Pediatric cataract causes 10% of vision loss in children worldwide. It is important to treat it urgently — and if left untreated, visual deprivation can cause permanent amblyopia. About one in 250 children has this autosomal dominant (AD) condition. “Thus, it’s important to check family members to find out more information, especially if you refract the child and can’t get it down to 6/6 or 6/9,” he said. “You might know this already, but unilateral cataracts tend to be more amblyogenic, and the posteriorly located cataracts are worse and it’s best

to treat them if the children are under two months old,” Dr. Shunmugam added. Rarely would ophthalmologists need to look at non-accidental trauma like shaken baby syndrome. But if children have been involved in motor vehicle accidents, they can develop cataracts, as well as retinal detachments or hemorrhages.

The importance of pediatric eye screening The incidence of hearing problems in babies is about 1 in 300; while the incidence of eye problems needing immediate attention is about 1 in 70 for children at birth. “You hear about hearing tests for babies, but hardly do we hear of children having eye tests at birth. So, it’s far more worthwhile to screen their eyes,” said Dr. Shunmugam. Screenings are vital to detect several abnormalities in infants’ eyes. During the webinar, Dr. Shunmugam also shared about BabySight, which helps provide pediatric digital examinations — from birth through the first year — which involves non-invasive RetCam Digital Imaging for retinal screening at birth to detect potential eye issues.

has been no pathology found,” Dr. Shunmugam added. “Well, it could be traced back to childhood. That’s why we need to do screenings and follow-up until adulthood to see if they develop any visual deprivation.”

“If a young adult comes in with myopia, ask them if they’d been born prematurely. Chances are the answer would be positive.”

Retinopathy of prematurity When a child is born prematurely and the oxygen levels are not maintained, vasculogenesis stops. “That’s where the trouble starts,” Dr. Shunmugam said. Retinopathy of prematurity (ROP) is found in babies born before 30 or 40 weeks of gestation, weighing less than 1,500 grams. “If a young adult comes in with myopia, ask them if they’d been born prematurely. Chances are the answer

would be positive,” Dr. Shunmugam said, adding that as younger and younger children survive premature births, the incidences of ROP are increasing as well. “If a child is born early and his vasculature hasn’t fully developed, he is put into a room where there is more oxygen than in utero, so there’s a stimulus for vessels to grow. If you give them enough oxygen, the vessels stop growing,” Dr. Shunmugam explained. He added: “But what happens is, the retina starts developing and the oxygen requirements of the retinal cells increases. So, as the retina is developing, there isn’t enough blood supply as the blood vessels never grew there. Then, the body tries to grow new blood vessels, which aren’t good because they grow on a sheet of fibrovascular tissue.” At this stage, he said it can be stopped by using a laser on the ischemic retina or giving them a neonatal anti-VEGF dose. This sometimes allows the vessels to grow normally again. If that doesn’t work, there might be a risk of retinal detachment.

The dangers of retinal hemorrhages “Childbirth is a highly traumatic event; when going through the birth canal, the baby goes through intracerebral pressure which increases pressure on vessels and nerves, sometimes causing bleeding,” said Dr. Shunmugam. Even in Caesarean-section births, there will be manipulations on the baby’s skull, which could also affect pressure. Nine out of 10 times, these retinal hemorrhages are innocuous. But, if they continue to block the child’s vision, then they should be removed via vitrectomy. “It’s interesting as we’re doing more studies, we’re coming to find out why some people are amblyopic where there

The increased use of digital devices has been correlated to increased incidences of myopia in East Asian children.

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ATARACT PEDIATRIC CATARACT

Screening and treatments of ROP These children are not born with any abnormality of the retina, but rather an abnormality of the vasculature in the retina. “The retina still has a 100% potential to work normally. So, what we’re doing is to try to ensure normal vascularization,” explained Dr. Shunmugam.

Eye strains, headaches, blurred vision and dry eye are common symptoms of computer vision syndrome or with the overuse of digital devices. Other characteristics include reduced attention span, poor behavior, and irritability in children aged below 10.

Retinitis pigmentosa and more ailments

Even with a 50% chance of success at stage 5 of ROP, it’s worth a try because if the child ends up being able to see some light or hand movements, it would help them with their diurnal rhythm. “If it is detected at stage 3 or 4, there’s an even better chance of helping them to see,” said Dr. Shunmugam.

“If you have a child who comes in with 6/9, yet he can’t see as he often bumps into things, you’ve got to think about retinitis pigmentosa. It’s the most common retinal dystrophy and it’s a chronic, progressive, inherited disease with a broad spectrum of severity,” Dr. Shunmugam added.

“What’s more important after the surgery is visual rehabilitation. For children who have had any eye surgery, it’s important to ensure their refraction is checked more frequently. For babies, they need to be shown light. If they’re at stage 5, they’re usually left aphakic, so they’ll need adequate aphakic glasses,” he added

“Its onset could be from childhood right into adulthood, depending on the expression of genes involved. It’s usually in both eyes, and if you find it in only one eye, you have to think of possibilities like drusen or diffused unilateral subacute neuroretinitis (DUSN),” he said.

Digital eye strain in children Myopia is a common and increasing condition among children today, with a high (73%) prevalence rate in East Asia.1 This has been associated with the use of digital devices and lack of time spent outdoors.2 Not surprisingly, children in Africa and South America have a low prevalence (under 10%) of myopia.

said. Confirming his hunch, the boy’s older brother had a bilateral scleral buckle two years earlier. Upon further investigation, his 6-month-old brother also has the same condition. It turned out, they all have X-linked retinoschisis (XLRS), which is only seen in boys. It occurs in one out of 15,000 or 30,000, and it’s usually inherited from the mother, a carrier. “If there’s only one message you can take home from this talk, it’s that it is important to do genetic counselling,” concluded Dr. Shunmugam. “Ensure that the other siblings are checked along with the family and extended family members, as they may be harboring similar conditions. These would be clues that could help detect eye conditions in the family’s future children.”

For treatment, they need to avoid the sunlight and be given orangetinted glasses to help with contrast. This might not always help their vision, but improving their contrast might help significantly.

As prevalent as FEVR Familial exudative vitreoretinopathy (FEVR) is more prevalent than we thought it was. The signs are very subtle and it has a wide range of severity. Dr. Shunmugam pointed at its fundus fluorescein angiography (FFA), which would look normal but it may be seen at the temporal periphery — similar to ROP. “For juvenile retinal detachment or in young adults who may not be myopic or have other trauma or syndromes, you should have a high suspicion for FEVR,” he said. Apart from choroidal hemangioma, one of the interesting cases he mentioned was of a two-year-old boy who came in with bilateral detachment. “Now, this is where it’s important to check on the other family members,” Dr. Shunmugam

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mano.shun@oasiseye.my

REFERENCES: 1

Grzybowski A, Kanclerz P, Tsubota K, et al. A review on the epidemiology of myopia in school children worldwide. BMC Ophthalmol. 2020;20(1):27.

Zadnik K, Mutti DO. Outdoor Activity Protects Against Childhood Myopia-Let the Sun Shine In. JAMA Pediatr. 2019;173(5):415-416.

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INDUSTRY UPDATE

New Myopia Progression Findings Presented at ARVO

s part of its comprehensive myopia research collaboration with Singapore Eye Research Institute (SERI) and the Singapore National Eye Centre (SNEC), Johnson & Johnson Vision recently presented new myopia progression findings from one of the largest studies with children in AsiaPacific at the recent virtual Association for Research in Vision and Ophthalmology (ARVO) Annual Meeting. Data from five studies were presented, which focused on new techniques and practices to better predict myopia progression and vision impairment. On progression, the team reported that in a study of 674 myopic children (aged 7-10) over two years, they found that the child’s prior year myopia progression

correlates with the immediate, subsequent year’s progression. For example, children with slow progression in the first year, generally had slow progression in the second year. Meanwhile, those with faster progression in year one, also experienced faster progression in year two. However, these findings were presented with the caveat that year-over-year progression does not fully predict longterm myopic progression, and that the child’s age and parental myopia are also important variables to consider in choosing whether to treat a child’s progression. “Globally, for parents of children with myopia, and eye care professionals, an important takeaway is the need

for myopic patients to receive regular annual check-ups,” said Study Lead Author Noel Brennan, Ph.D., global lead, Myopia Control, Johnson & Johnson Vision. “While myopia progression rates will naturally be followed from year-toyear, it is also important that eye care professionals consider the age of myopia onset and parental myopia.” Xiao-Yu Song, M.D., Ph.D., global head of research and development, Johnson & Johnson Vision Care, added: “Through close collaborations with SERI, SNEC, and other aligned public health groups, we are helping to address this crisis by building a better understanding of the science and biology behind myopia and developing comprehensive programs to address and treat the disease.”

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NTERIOR SEGMENT GLAUCOMA TREATMENT

New Treatment Alternative

Can CEaP Work as a Complete Treatment for Neovascular Glaucoma? by Olawale Salami

or decades, ophthalmologists have been working on finding the best treatments for neovascular glaucoma (NVG). A refractory form of glaucoma, NVG is characterized by vessel proliferation involving the iris and the anterior chamber angle, with eventual angle closure and intractable elevation of intraocular pressure (IOP). It is commonly associated with ischemic retinal conditions, such as proliferative diabetic retinopathy (PDR), branch retinal vein occlusion (BRVO), central retinal vein occlusion (CRVO), central retinal artery occlusion (CRAO), and carotid artery occlusion. Sustained IOP reduction and elimination of neovascular proliferation are critical treatment goals. However, few available treatments can meet both targets simultaneously. Current treatment options for NVG include pan-retinal photocoagulation (PRP), filtering surgery, anterior retinal cryotherapy (ARC), anti-vascular endothelial growth factor (VEGF) injections, cyclocryotherapy (CCT) and transscleral cyclophotocoagulation (TSCPC). Some procedures such as CCT and TSCPC can produce sustained

IOP reduction in NVG by reducing aqueous humor formation. However, their associated complications, such as marked inflammation, hypotony and phthisis, limit their clinical utility in many patient populations.

A patient-friendly treatment alternative for NVG Endoscopic cyclophotocoagulation (ECP) utilizes a high precision laser beam, which can be delivered to the target tissue under direct visualization at appropriate energy levels. The high accuracy of this technique helps avoid damage and inflammation in surrounding tissue.1 Therefore, combining endoscopic cyclophotocoagulation and pars plana ablation as one single procedure (ECPplus) could be an effective and safe treatment toward the relief of refractory glaucoma. So, does this work in patients with NVG? To answer this question, Dr. Chia-Jen Chang and colleagues at the Taichung Veterans General Hospital in Taiwan, developed a combination therapy, known as

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Combined Endoscope assisted Procedures (CEaP), which involves endoscopic cyclophotocoagulation and pars plana ablation (ECP-plus), combined with endoscopic pan-retinal photocoagulation. Their findings — summarized in a paper titled Combined Endoscope assisted Procedures (CEaP) as a Complete Treatment for Neovascular Glaucoma — were published recently.2 In a retrospective and noncomparative interventional case series, the team analyzed data from patients who were diagnosed with NVG, and whose treatment had failed with previous anti-glaucoma drugs, PRP and anti-VEGF treatment. Diagnosis of NVG was confirmed if the patient had vessel growth at the iris and an anterior chamber angle with an IOP > 21 mmHg. Failure following previous treatment was defined as the presentation of neovascularization at the iris and the anterior chamber angle, along with an IOP > 21 mmHg after treatment of more than 3 months. Overall, 25 eyes from 23 patients were included over a 24-month period.

The exclusion criteria included eyes with visual acuity worse than hand movement, along with those patients who had received an intravitreal injection of anti-VEGF within 6 weeks prior to CEaP. Patients who had not received a lens extraction, together with those patients who had received glaucoma filtering surgery, glaucoma implants, ARC, CCT or TSCPC were also excluded.

“In my opinion, the greatest advantage of this technique is its success rate in IOP control.”

Who would benefit more from CEaP? Dr. Chang provided insights into the group of patients who could derive the greatest benefit from CeaP. “Generally speaking, patients who have intractable high IOP are candidates to receive ECP,” he shared. “For those who have ischemic retinal diseases such as diabetes mellitus (DM) retinopathy or CRVO, ECP and endoscopic plateletrich plasma (PRP) are one of the treatment options.” Furthermore, he explained: “The patients who have NVG and who are unsuitable for multiple intravitreal injections of anti-VEGF — for example, patients who have recent cerebrovascular accident history — get the greatest benefit from this combined procedure. Patients of NVG, who have not had an ideal response to previous treatments, can also receive this procedure as the next option,” Dr. Chang added. Postoperatively, Dr. Chang and colleagues reported that all patients had a lower IOP value than their preoperative value. The mean IOP was 38.2 ± 7.1 mmHg preoperatively, and 10.2 ± 4.7 mmHg (1 day), 13.8 ± 4.6 mmHg (1 week), 15.0 ± 5.3 mmHg (2 weeks), 17.4 ± 4.7 mmHg (1 month), 16.6 ± 4.1 mmHg (3 months), 16.0 ± 5.0 mmHg (6 months), and 15.7 ± 5.5 mmHg (12 months) postoperatively. At the 6th and 12th months, the IOP

stabilized rate was 84% and 75%, respectively. “The 3-month postoperative complications were minimal, and included uveitis and hyphema in 24% and 16% of eyes, respectively, which resolved in the early postoperative period,” Dr. Chang further explained. “Beyond the 6-month postoperative period, two patients experienced hypotony and phthisis bulbi.” In addition, he said no postoperative cases of retinal detachment, endophthalmitis or any other severe complications were reported.

Practical benefits for patients and surgeons According to Dr. Chang, there are several important advantages of this technique over existing treatment modalities of NVG. “Firstly, it is safe, and the complication rate is low, according to literature. It lasts long, and long-lasting means patients do not have to receive multiple treatments,” he said. “The economic burden is low for patients because they do not have to spend a lot on antiVEGF treatments. The ECP-plus and endoscopic PRP procedure takes less than one hour, and the procedure can be done without general anesthesia in most situations. Also, the wound is small, which is 23 to 19 gauge in size. But in my opinion, the greatest advantage of this technique is its success rate in IOP control,” Dr. Chang explained. According to the results shared by Dr. Chang and his colleagues, CEaP is both safe and effective. However, there are important limitations to its widespread use, including its cost and technical feasibility. “Another concern is that proficiency in endoscopy requires skills which have a relatively steep learning curve for operators,” Dr. Chang noted. Therefore, he provided practical advice to retinal surgeons who want to learn and integrate this into their practice. “It is not easy to get a good orientation when a surgeon shifts from microscope

view to endoscope view. In order to avoid iatrogenic injuries, surgeons really should practice getting used to the view of the endoscope before applying it to their patients,” he explained. The retrospective nature, the relatively small sample size, and the lack of a control group were identified as limitations of the study. Therefore, Dr. Chang and colleagues advocated for further research with a larger sample size and longer follow-up periods to buttress the findings from this study.

A complete treatment for NVG Taken together, the promising results of the study provide convincing evidence that CEaP can result in IOP lowering and NV regression. CEaP is a complete treatment for NVG in controlling IOP and NV growth. The IOP lowering effects can be sustained upon completion of the treatment.

REFERENCES: 1

Lin S. Endoscopic cyclophotocoagulation. Br Journal Ophthalmol. 2002;86(12):1434-1438.

Cheng YS, Lin SH, Chang CJ. Combined Endoscope assisted Procedures (CEaP) as a complete treatment for neovascular glaucoma. PLoS One. 2020;15(6):e0234798. doi: 10.1371/journal.pone.0234798. eCollection 2020.

Contributing Doctor Dr. Chia-Jen Chang, MD, PhD., is a vitreoretinal surgeon who specializes in applying endoscope into intraocular surgery, especially vitreoretinal surgery. He is a graduate of National Cheng Kung University in Taiwan and finished his Ph.D. at Chaoyang University of Technology in Taiwan. He has completed his vitreoretinal fellowship at Taichung Veterans General Hospital. He is currently the chief of the Division of General Ophthalmology of the Department of Ophthalmology at Taichung Veterans General Hospital in Taiwan. His clinical interests include endoscopeassisted intraocular surgery, vitreoretinal surgery, diabetic retinopathy, and macular diseases. His research focus is on retinal diagnostic imaging and retinal image analysis. capmchangcj@gmail.com

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NTERIOR SEGMENT OCULAR SYPHILIS This nightmarish stage is called neurosyphilis, and it can literally rot away the bone in a person’s skull. Neurosyphilis is relatively rare, occurring in around 7% of patients who reach the tertiary stage.

Ocular syphilis: The great imitator The ocular syphilis subtype frequently presents during the tertiary stage of the disease. Ocular syphilis can involve almost any eye structure. However, posterior uveitis and panuveitis are the most common. Additional manifestations may include anterior uveitis, optic neuropathy, retinal vasculitis and interstitial keratitis. It’s many presentations have given it the nickname of the ‘Great Imitator’.

The Rising Infection Rates of Ocular Syphilis in Tandem with HIV by Andrew Sweeney

yphilis is one of those conditions that many of us know of, but prefer not to think about. It’s the ultimate old-school disease, a sexually transmitted infection most commonly associated with Victorian novels and tales of yesteryear. Indeed, as it is easily treatable with antibiotics if caught early, it’s almost disappeared from public consciousness. But alas, syphilis remains with us to varying degrees. In the Western world, syphilis infection rates have been rising steadily over the last decade. Meanwhile, in the developing world, and particularly in Africa, syphilis remains a common disease that is frequently left untreated until the damage is severe.

accompanied by swollen glands. This stage usually lasts between two and eight weeks. If untreated, syphilis develops into the secondary stage. A blotchy red rash will develop somewhere on the body, skin growths will appear around the genitals, white patches develop in the mouth, and flu-like symptoms appear, accompanied by swollen glands and hair loss. Uveitis also sometimes presents during this state. If treated, these symptoms will usually disappear after a few weeks. However, the patient will remain infectious.

Syphilis comes in three stages, and the first is the most well known. In the primary stage, one — but sometimes more — painless sore or ulcer will develop on the genitals, sometimes

The latent stage of the disease can last years, sometimes even decades. Usually, though, it doesn’t always result in tertiary stage syphilis. This final stage of the condition is far more serious and can cause meningitis, stroke, blindness, cardiovascular issues, and soft tumors in the head. Dementia is also common. And these symptoms are usually the harbinger of syphilis’ worst outcome.

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Symptoms and stages of syphilis

As syphilis is commonly encountered in patients who are human immunodeficiency virus (HIV) positive, due to the body’s weakened immune system being more susceptible to infection, ocular syphilis is frequently encountered in tandem with HIV. In Africa, which continues to be the epicenter of the HIV pandemic, infection rates of both syphilis and its ocular subtype have exploded in number. Small surprise, therefore, that ocular syphilis was a topic of note at the recent 37th World Ophthalmology Congress (WOC2020 Virtual®). Several e-posters showcased at the conference were dedicated to the subject of ocular syphilis and the research occured in a variety of locations — from Africa to East Asia.

Raising awareness on ocular syphilis Given the global growth in syphilis, both in HIV-positive and negative individuals, detection is a crucially important issue. To learn more, a group of researchers from the University of Stellenbosch in South Africa examined detection issues in a poster titled, Clinical Laboratory Characteristics of Ocular Syphilis and Neurosyphilis Amongst Individuals with and Without HIV.1 All in all, 215 eyes of 146 patients were examined, with 68% HIV-positive.

The researchers discovered that HIV co-infection was present in 52.1% of patients, with 23.7% of these patients newly diagnosed on presentation. This led them to conclude that HIV status must be determined in all patients with ocular syphilis, since almost 25% of patients were newly diagnosed with HIV infection by doing so. Creating a cross-testing system between ophthalmology and other medical sectors could present a lucrative business opportunity. This is because cross-infection with syphilis and HIV is prevalent in all regions, not just in Africa. The University Hospital in Wroclaw and the Wroclaw Medical Hospital in Poland, recently published “The Resurgence of Syphilis – Ocular Manifestations of the Disease”2 to highlight ocular syphilis and raise awareness of it as one of the causes of uveitis and optic neuritis. Three patients (one was HIV-positive) participated, with two reporting improved visual acuity afterwards.

CASIA2 A3 ëpîΩ_Resized-02-29-20.pdf

The conclusion was that a longer period over which the disease develops is connected with poor prognosis and recurrence of syphilis with no ocular symptoms.

The treatment options were as follows:

Mathew D, Smit D. Clinical and Laboratory Characteristics of Ocular Syphilis and Neurosyphilis Amongst Individuals with and without HIV Infection.

Szydełko U, Pytrus W, Bulek M, Juszkiewicz S. The Resurgence of Syphilis – Ocular Manifestations of the Disease. University Hospital in Wroclaw & Wroclaw Medical University.

• Ceftriaxone: 1 g twice a day for 7 days and 1 g once a day for the next 7 days • Topical: dexamethasone (5 times a day); tropicamide (3 times a day) • Systemic: prednisone (65 mg/day); doxycycline (100 mg twice a day for 7 days); and ceftriaxone (1 g i.v. for 14 days)

2/29/20

REFERENCES:

What makes syphilis so exasperating is that it is completely treatable if caught early on. The growth in the global prevalence of syphilis and its subtypes, like ocular syphilis, will continue to represent an excellent opportunity for research and business alike.

Editor’s Note: Information for this article was provided by two e-posters published during the World Ophthalmology Congress 2020 (WOC2020) virtual conference. Reporting for this article also took place during WOC2020, and a version of this article was first published on www.cakemagazine. org on August 3, 2020.

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COVER STORY

by Brooke Herron

dvances in cataract surgery over the past two decades — even over the past two years — have been nothing short of revolutionary. Today, procedures are faster, using innovative devices and surgical maneuvers to restore sight.

Mannheim, University of Heidelberg, Germany, and Dr. Daniel Badoza, medical director of Instituto de la Visión de Buenos Aires, agree that the introduction of multifocal IOLs has been the biggest innovation in cataract surgery over the past two decades.

We’ve already come this far. So… what’s next?

“Multifocal IOLs allowed this technique to reach its potential as a tool for refractive surgery,” said Dr. Bardoza. This spurred innovations in power calculations like optical biometry (OB) — which was launched in 2000.

To answer, we travel through time — in the cinematic style of Back to the Future — to assess the past, present and future of cataract surgery.

IOLs Changed Cataract Surgery… Forever To travel through time, the Back to the Future DeLorean used a flux capacitor, requiring 1.21 gigawatts of power and a speed of 88 miles per hour. Without these three factors, time travel was not possible. Modern cataract surgery also requires certain elements to achieve the best possible patient outcomes. One key factor? Intraocular lenses (IOLs). Without them, the procedure would not be what it is today — a sight-restoring surgery of refractive proportions.

“Until the 1990s, IOL power calculations were based on ultrasound biometry, which obtained postoperative refractive results that were less accurate than those required by refractive lens surgery,” he said. “The improvement in IOL power calculation using OB paved the way for the introduction of the multifocal IOLs, which, in fact, were ideas from the mid-1980s.”

Both Dr. Michael Knorz, professor of ophthalmology at the Medical Faculty

Indeed, correct IOL power calculations are critical to predictable refractive outcomes. Dr. Matt Oliva is a private practice corneal specialist and associate clinical professor at Oregon Health Sciences in Medford, Oregon, USA. He said that modern IOL formulas — such as the Barrett Universal II, Hill-RBF and Kane — have been a complete game-changer

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in terms of dramatically improving the predictability of refractive outcomes with cataract surgery. “When coupled with innovations in IOL design and options, the answer to patients’ refractive needs is increasingly a lens-based approach,” explained Dr. Oliva. “Modern IOL formulas allow surgeons to deliver the results patients expect — and have also allowed us to effectively treat post-refractive surgery patients comfortably and predictably with cataract surgery.” In addition, Dr. Dee Stephenson, founder and director of Stephenson Eye Associates in Venice, Florida, USA, values the Optiwave Refractive Analysis (ORA) system (WaveTec, Dubai, UAE) for intraoperative aberrometry. No other instrument can provide realtime reading of total corneal power, she said. “It takes a phakic reading and tells the magnitude and axis of astigmatism, then helps you align the toric IOL or shows you where to make the appropriate axis.”

Bridging the gap: Vision at all distances New designs in multifocal and trifocal IOLs address the problem of the

or Mini Well (Sifi Medtech, Catania, Italy) have so little in the way of visual disturbances that they can be offered to patients with minimal risk of nonacceptance,” said Dr. Packard. Dr. Bardoza mentioned another EDoF technology to consider: small-aperture optics, like the IC-8 (AcuFocus, Irvine, California). These IOLs are based on the pinhole effect, which extends the range of focus and thus, allows for some spectacle freedom — at least in the intermediate range, without compromising vision or inducing halos. Dr. Bardoza said that this makes them suitable for patients who normally aren’t good candidates, like dry eye or glaucoma patients, or for those who require good quality of vision for certain activities.

“gap” between near and intermediate vision, which is typically present in trifocal IOLs, said Dr. Knorz. For this important reason, he uses the TECNIS Synergy (Johnson & Johnson Vision, Jacksonville, Florida, USA), which was introduced in 2019. “With this IOL, fewer patients complain about difficulties at intermediate distances. It’s only an incremental innovation, but a step in the right direction,” said Dr. Knorz. “Trifocal IOLs present one of the most rewarding and fast-growing options in ophthalmology today — and that’s because patients are happy.” Dr. Stephenson also uses trifocal IOLs like the AcrySof IQ PanOptix (Alcon, Geneva, Switzerland), which gives the advantage of great distance and near visual acuity, while decreasing dependence on glasses. In his practice, Dr. Florian Kretz, founder and CEO of PVK Precise Vision in Germany, utilizes a variety of IOLs, including monofocal presbyopiacorrecting IOLs like the Santen MonoEDoF IOL (ME4; Osaka, Japan), the TECNIS Eyhance (ICB00; Johnson & Johnson Vision), as well as the Oculentis LENTIS Comfort EDoF IOL (Berlin, Germany), which, according to him, all offer patients a wide range of spectacle independence.

“These provide slight monovision, even full range of vision, and side effects are comparable to monofocals,” said Dr. Kretz. For patients with astigmatism, Dr. Stephenson recommends the recently launched enVista MX60ET aspheric monofocal toric IOL (Bausch & Lomb, Laval, Quebec, Canada). “This lens gives greatly increased depth of field, which allows a large proportion of patients (84%) to have intermediate visual acuity of 20/40 or better. This is a huge advantage compared to other monofocal toric IOLs.” “The new enVista trifocal has great potential to be a great lens due to its asphericity and decrease in HOA and dysphotopsias, as does the new Vivity EDoF (Alcon),” added Dr. Stephenson. On the other hand, Dr. Richard Packard, senior consultant at Arnott Eye Associates in London, United Kingdom, said that with the current stage of development of EDoF lenses, monofocal lenses should become obsolete. “Unaided distance vision of 6/5, with a well-centered aspheric monofocal lens may seem like surgical success to the surgeon, but not to the patient when they can’t see the food on their plate without glasses.” “Modern EDoF IOLs like Eyhance, Vivity

The final IOL mentioned was the Light Adjustable Lens (LAL; RxSight, California). “This allows you to customize to the patients’ needs and then lock it in with a laser treatment,” shared Dr. Stephenson. She shared that she currently uses all of the newer IOL technology, except for the LAL IOLs. “I’m waiting to see where it may fit into my practice, as far as cost versus what patients are willing to pay, as well as its logistical implementation.”

IOLs of the future “A truly accommodating IOL is what we really need,” said Dr. Knorz. “A large percentage of my patients are RLE patients who hate glasses and the disability introduced by needing them. Trifocal IOLs are a good way to treat them, but there are some side effects, which need to be addressed,” he said. Dr. Knorz is watching companies that are working on accommodating IOLs, like Juvene (LensGen, Irvine, California). Dr. Bardoza is also following the development of newer and more effective accommodative lenses: “An IOL capable of accommodating 3-5 D would restore full range of vision, without the adverse effects of multifocal optics.” Meanwhile, Dr. Matthew Ward, a cornea, external disease and refractive surgeon at Riverwoods Eye Center in Provo, Utah, USA, said IOL power

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COVER STORY

adjustments using femtosecond lasers are an important consideration. “We all have refractive misses, no matter how careful we are with our preoperative and/or intraoperative measurements. Moreover, we all have unhappy patients who would have preferred a different refractive target,” he said. He added: “This technology is exciting because it seems to provide a means by which the power of nearly any IOL can be adjusted after cataract surgery by changing its hydrophilicity. Though it’s not ready for prime time, how cool would it be to stop all the handwringing in the exam lane with these disappointed patients and simply fix their problem?”

Advances in Devices, Tools and Surgical Techniques IOLs are great (okay, way more than great)… but without the proper tools for visualization and to remove the opacified lens, it wouldn’t be cataract surgery (as we know it today, anyhow).

Phaco steps up Advances in existing phaco technology, especially improvements in fluidics, have made cataract surgery an even safer procedure by reducing complications, said Dr. Packard. “The biggest advancement here is undoubtedly on the Alcon Centurion phaco machine — initially Active Fluidics, and now with Active Sentry, which provides enhanced stability of the anterior chamber with much lowered intraocular pressure, compared with previous machines.” According to Dr. Bardoza, to embrace combined systems like femto-phaco (or other robotic technology), significantly better results, like a lower complication rate, are needed to replace the current paradigm. “Also, the technology should have a lower cost of use and maintenance to be finally embraced by cataract surgeons as the standard of care.”

not be as practical as other methods. On the pro side is Dr. Knorz, who notes femtosecond laser in cataract surgery as his second biggest innovation in the past two decades. “I became involved as early as 2009 using the first available laser, the LenSx laser, later acquired by Alcon. I still use this laser in 90% of my lens surgeries and are very happy with the results,” he shared. “FLACS with the LENSAR laser system, with iris registration cyclotorsion control and the intelliaxis marks on the anterior capsule, make toric alignment efficient and easy, as well as [treating] small amounts of astigmatism, using accurate nomograms for accurate incisions,” shared Dr. Stephenson. “The new Gen2 LENSAR (Orlando, Florida) will be integrated with a phaco machine — this technology is exciting for better efficiency.” Dr. Packard agrees that femtosecond laser is an extraordinary technology. However, he said it has not fulfilled its attached promise, and therefore, has not been universally adopted. “This was due to a combination of high capital and running costs and minimal, if any improvement, in outcomes of surgery over conventional phaco,” he explained. The adoption of femtosecond lasers has been a big change for Dr. Kretz, and he said it remains underdeveloped — but that there is hope: “I believe combined machines with smaller lasers will really bring change to the adoption especially in premium centers.”

Innovative surgical techniques IOLs and devices aside… sometimes it’s all about the technique. Both Dr. Oliva and Dr. Ward agree that manual small incision cataract surgery (MSICS) has been the biggest development over the past two decades.

Femtosecond laser in cataract

“The biggest event over the last 20 years has been the development of MSICS techniques and their role in making high quality, low-cost cataract surgery available to the masses around the world,” said Dr. Oliva.

For its part, the use of femtosecond laser-assisted cataract surgery (FLACS), while seen as a great innovation, might

“MSICS is the single most influential development in cataract surgery in the last 20 years,” agreed Dr. Ward.

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“It shows how creative and committed surgeons used their minds to bring safe, low-cost and reliable cataract surgery to millions in need,” he shared. Dr. Oliva continued: “MSICS, when combined with affordable consumables, has allowed cataract surgery to become accessible for millions of blind patients in the world. I never imagined that blind patients can have their sight restored with MSICS in under 10 minutes for less than $20 in material costs!”

Devices add to visual outcomes Recent advances in devices have also improved patient outcomes, like the Zepto (Mynosys Cellular Devices, Fremont, California) capsulotomy device, which aligns and automates the anterior capsulotomy on the visual axis of the eye, using patient fixation during surgery. “For me, Zepto has been a great help in difficult cases. There’s no more trypan blue in white cataracts and a lower risk for Argentinian flag syndrome in those cases,” said Dr. Kretz. “It works in smaller pupils, too — and in young patients and children. I believe it is an added preventive method for phimosis.” Capsulotomy devices were also highlighted by Dr. Packard, who notes involvement with CAPSULaser (EXCELLENS, Livermore, California), which creates accurately sized, centered and strong capsulotomies in 0.25 seconds. Therefore, he said it will find its place as a standard tool for cataract surgery in the future. “The low cost relative to femto, and the ease of incorporating this device into standard surgical flow should lead to increased adoption,” he explained. Computer-assisted cataract surgery systems can also help facilitate better outcomes. “The use of digital axis positioning systems such as VERION (Alcon) or the CALLISTO ophthalmic microscope (Carl Zeiss Meditec, Jena, Germany) takes the guessing out of toric IOL implantation,” said Dr. Knorz. Another ZEISS device, the miLOOP for manual nuclear disassembly, is a great adjunct for successful phacoemulsification in cases of dense

cataracts or zonular instability, shared Dr. Oliva. “I find it helpful in a handful of cases each month, where otherwise I would be doing MSICS.” Dr. Oliva said he’s watching the development of the XPort microfragmentation lens device, also under development by ZEISS. “It just recently received FDA approval and offers the potential to remove cataracts through a small incision, without the need for phacoemulsification,” he said. “I think we are on the cusp of exciting technological advances for lens extraction, where small pen-like devices will be able to remove cataracts safely and efficiently, without a bulky or expensive machine.” Lastly, Dr. Ward shared there is one instrument that he considers vital: the Malyugin Ring pupil expander (Beye, Pennsylvania, USA). “I think the hallmark of a great innovation is not being able to imagine life without it,” he said. “Thanks to this device, complex cases with small pupils or floppy irises become routine…. not having to fiddle with iris hooks and having a stable pupil every time provides a great boost in confidence going into surgery, and preserves efficiency in a packed day of surgery.”

Advances in medical While surgical advances in cataract get a lot of fanfare, advances in medical are important too, like the use of Omidria (Omeros Corporation, Seattle, Washington, USA), a combination drug product containing a mydriatic agent (phenylephrine) and an NSAID (ketorolac), shared Dr. Stephenson. “This helps promote and maintain pupil dilation and decrease pain during cataract surgery. Its advantage is that you do not need to use pupil dilators, rings or hooks, which can cause damage to the iris and are time consuming to use.” Dr. Stephenson also shared that she would like to see Dextenza (dexamethasone 0.4% intracanalicular

implant; Ocular Therapeutix, Massachusetts, USA) used more widely following cataract surgery. “It lasts for 28 days and eliminates the need for postoperative topical steroids. Further improvement of diagnostic devices and medications to improve the ocular surface will help to continually improve outcomes in cataract surgery,” she concluded.

Final Thoughts on the Future Although there are complexities in the machines, IOLs and the surgical skill required for cataract surgery —- for the

patient, it is only a short, simple and painless procedure, said Dr. Knorz, who hopes for further advances in accommodating IOLs. This sentiment was echoed by Dr. Kretz: “The biggest change is the change in mindset. [Previously,] cataract surgery was the treatment of an opacified lens to restore visual potential, without really caring for refraction or patient comfort,” he explained. “It’s changed and has become much more refractive cataract surgery, where the patient’s outcome is the most important part — not just removing the opacified lens.” This point was also raised by Dr. Bardoza: “From the beginning of my career, I’ve seen the transformation of cataract surgery from a method to restore visual acuity lost by opacity, to a lens-based refractive surgery,” he explained. Dr. Ward agrees with this point of patient expectations: “It’s clear that patients are expecting more from their cataract surgery than ever before. More than ever, a higher percentage

want to be independent of optical correction after surgery.” For the future, Dr. Bardoza expects better technologies for automation of surgical technique with reproducible outcomes, and a significant reduction on the (already) low rate of complications related to phacoemulsification. Further, he said: “I hope we will find the biomaterial able to fill the capsular bag completely — which should have adhesive properties to the capsule in order to prevent PCO, and the viscoelasticity needed for the IOL to be modified in its shape by the mechanism of accommodation. Then, the term ‘cataract surgery’ will be replaced by ‘lens surgery’.” “This is an incredible subspecialty, with the fastest growing and everchanging technology, like artificial intelligence, new IOLs, diagnostics and pharmaceuticals,” concluded Dr. Stephenson. “COVID-19 has reinforced how precious our eyes, and our lives, are — and I’m ready for a new day, in a new normal world, to continue providing the best care to my patients possible.” For the sake of cataract patients — and their expectations — we hope that all of these promising technologies will see the light of day (in the near future).

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COVER STORY

Contributing Doctors Dr. Richard Packard is senior consultant at Arnott Eye Associates in London. He started using phacoemulsification in 1979 and in that year, inserted the world’s first folded soft IOL during a rabbit study. In 1990, he implanted the very first Acrysof IOL. He has lectured and operated in 61 countries on all aspects of cataract surgery and written many peer-reviewed papers and book chapters. He has recently published, with Lucio Buratto, “The history and evolution of modern cataract surgery.” mail@eyequack.vossnet.co.uk

Florian Kretz (FEBO), MD, is an internationally established ophthalmologist, surgeon, speaker and researcher, with research around cataract, refractive surgery, glaucoma and macular degeneration. As founder and CEO of PVK Precise Vision GmbH, he works at the following locations: Rheine , Greven and Erlangen, Germany. Dr. Kretz has published more than 100 scientific articles in specialized ophthalmological press and is a frequent consultant for ophthalmic news magazines. f.kretz@precisevision.de

Dr. Michael Knorz earned his medical degree from the University of Heidelberg in 1983. Since 2001, he has served as professor of ophthalmology at the Medical Faculty Mannheim of the University of Heidelberg in Mannheim, Germany. Dr. Knorz introduced LASIK in Germany in 1993 and founded the FreeVis LASIK Center at the University Medical Center Mannheim in 1999, where he is currently its CEO and medical director. Dr. Knorz is senior associate editor of

the Journal of Refractive Surgery. He has published numerous original articles in peer-reviewed journals as well as book chapters, and a comprehensive textbook on phacoemulsification. knorz@eyes.de

Dr. Daniel Badoza has served as medical director at the Instituto de la Visión de Buenos Aires, Argentina, since 1999, and as chairman of the Conexión Alaccsa-R (Latin American Society of Cataract and Refractive Surgery) since 2020. He is past president of the Argentine de Córnea, Refractiva y Catarata (2015-2017) and past treasurer of the Consejo Argentino de Oftalmología (2016-2019). He is also assistant professor of ophthalmology at the School of Medicine, University of Buenos Aires. He obtained his MD in 1992 from the Facultad de Ciencias Médicas, Universidad de Buenos Aires. Dr. Badoza is also a reviewer of the Journal of Cataract and Refractive Surgery. abadoza@gmail.com

Dr. Matthew S. Ward currently practices ophthalmology at Riverwoods Eye Center in Provo, Utah. He completed a research fellowship in Boston at the Schepens Eye Research Institute, Harvard Medical School. Dr. Ward completed training in ophthalmology at the University of Iowa, with additional fellowship training in cornea, external disease, and refractive surgery. As a cornea fellow, he helped design a novel injector system and method to simplify DMEK cornea transplant surgery. Dr. Ward enjoys working with doctors and patients throughout the world and has contributed to international medical programs in Nepal, Peru, Romania, Moldova, Ghana and esWatini. mattsward@gmail.com

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Dr. Matt Oliva is an associate clinical professor at Oregon Health Sciences and a private practice corneal specialist in Medford, Oregon. He serves on the board of the Himalayan Cataract Project (HCP) and as medical director of SightLife. He plays a crucial role in setting the clinical and programmatic direction of HCP’s efforts in Ethiopia and travels multiple times a year to the Himalayas and Sub- Saharan Africa to perform surgeries and teach physicians. He completed his ophthalmology residency at the University of Washington and a fellowship in corneal surgery in Melbourne, Australia, at the Royal Victorian Eye and Ear Hospital. moliva@cureblindness.org

Dr. P. Dee Stephenson, MD, FACS, is the founder and director of Stephenson Eye Associates in Venice, Florida. Dr. Stephenson has been recognized by numerous institutions and journals for her expertise and contributions to cataract surgery and premium IOLs. She was listed as one of the 250 in Premier Surgeons of Leading Innovators, and more recently was named in the Ocular Surgery News Premier Surgeon 300 and Who’s Who in Ophthalmology. Dr. Stephenson shares her knowledge with ophthalmologists worldwide, and to ophthalmology residents, as an associate professor at the Morsani College of Medicine Department of Ophthalmology at the University of South Florida in Tampa. She is on the editorial board of CRST, editor of the cataract section for AAO Focal Points, a founding member of AECOS, and CEDARS/ASPENS. eyedrdee@aol.com

The Remarkable Past and Bright Future of Cataract The first IOL was implanted by

Dr. Harold Ridley

1949 1967

Manual small incision cataract surgery (MSICS) was developed

The first commercially available three-piece silicone IOL for use after clear corneal small incision phacoemulsification was introduced

The FDA approves femtosecond laserassisted cataract surgery (FLACS)

Phacoemulsification was introduced by Dr. Charles

Kelman

1970 1978

The first foldable silicone IOL was implanted by Dr. Kai-yi Zhou

1989 1997

The FDA approves its first multifocal IOL

2010 2016

The FDA approved the first EDOF IOL

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UDOS WOMEN IN OPHTHALMOLOGY

I Am Ophthalmologist, Hear Me Roar by Sam McCommon

t CAKE, we keep in touch with all aspects of the ophthalmic world — and this interest, of course, includes keeping up with our beloved female ophthalmologists. We reached out to three lovely practitioners — Dr. Sanushka Moodley from South Africa, Dr. Laura Periman from Seattle, USA, and Dr. Sana Sayadi from Tunisia — to get their take on what it’s like being a woman in ophthalmology.

need to be available at any time. The surgical aspect of ophthalmology also may be time-consuming. Now for a woman, you may have many other responsibilities interfering with work responsibilities. I can add an important detail — patients are more confident if the doctor is a man particularly when it comes to surgery. Fortunately, this isn’t always true.

Without further ado, and to give them full reign of the floor, here are three of our favorite doctors presenting their views. CAKE: What challenges do female ophthalmologists usually face? Dr. Moodley: I think the most common challenge for females in a surgical field is to convince some of the patients to take us seriously as a surgeon. I usually get taken for the optometrist in our practice, and our patients assume that my male partner will be doing their surgery. It’s just an old fashioned way of thinking I guess based on the old-maledoctor stereotype. Most of them have no problem at the end of the day when I explain to them that I have the same qualifications as my male partner. Some patients will opt to change over to the male surgeon, but very few. Dr. Periman: I’ve been in medicine for a long time, I have seen and experienced overt instances of gender-based discrimination. The good news is — I do a lot of teaching and mentoring of the next generation — and I gotta say, I love this generation. They’re equityminded, and they have this mindset of parity and equity that’s going to continue to create an opportunity for everyone, so that everyone can reach their fullest potential.

CAKE: What are the upsides to being a woman in ophthalmology? Dr. Sayadi: I think that there aren’t any direct advantages of being a woman in this industry. It depends on the doctor herself. I cannot ignore that a woman doctor may be more reassuring for some patients. Some of us have a superpower when it comes to dealing with children. Dr. Periman: I’m busier as a solo practitioner and have the flexibility and the power to make decisions. It’s reinvigorating as well! Ophthalmology has lots of room for independence and for women to be founders. I’ve found incredible support from all colleagues — men and women.

Dr. Sayadi: There are some challenges common to many medical specialties like emergencies and night shifts. You

Dr. Moodley: There are many. So firstly, on the contrary to my first answer, some patients prefer a female doctor. They have expressed that we have a more compassionate bedside manner and a gentle feminine touch when it comes to our surgery. Secondly, I think being a woman in ophthalmology right now has opened many doors for me. We live in a time where we have been lucky enough to have a platform to project our voices

| Sept/Oct 2020

from as natural leaders. In South Africa, we currently have our first female President of our national ophthalmology society and the president-elect is also female. I am the current chair of Young Ophthalmology in South Africa. CAKE: Has your experience in ophthalmology been significantly colored by gender differences? Dr. Sayadi: I haven’t felt any gender differences in my practice. I can only talk about personal challenges. Life is just easier for men than women regarding personal, non-professional responsibilities. Dr. Moodley: I definitely came across that in my training. Once again, the much older generation just assumes that our male colleagues are more capable than us. Once they see you perform surgically and clinically, this perception easily changes, though. So it wasn’t something that tainted my training experience — we just have to put in more effort to prove our worth.

CAKE: What’s it like being a female doctor in your country? [Editor’s Note: This question was addressed differently to Dr. Moodley and Dr. Sayadi. Dr. Sayadi was asked about her experience in the context of living in a Muslim country.] Dr. Moodley: I think it’s a great time to be a female doctor in South Africa. There has never been a time like now where we are being taken more seriously by our male counterparts and peers. We have huge voices that echo in the mountains. We have amazing female doctors that are doing amazing work in academics, research, and clinical medicine, and we have proved that we are a force to be reckoned with. I think females make up the majority of most, if not all, undergrad medical classes in South Africa right now. Dr. Sayadi: I guess I cannot describe women’s situations in all Muslim countries. In Tunisia, women got their place and role in society decades ago. Being Muslim in itself doesn’t harm the professional career of an ophthalmologist. CAKE: Is work-life balance more of a challenge for a woman than for a man? How is it resolved? Dr. Moodley: For sure. I personally have been in an interview where I was asked if I plan on getting married and having children during my residency training. It’s definitely frowned upon to go on maternity leave during your residency training. The management sees it as a hindrance to the workflow in your clinic even though there are enough hands to do the work and you have to ‘pay back’ your maternity leave by working an extra four months once your residency contract has come to an end. I work in private practice now with a male colleague who is my friend and is super supportive. So starting a family for me now is no longer an issue. I can finally do it, but it means not earning an income for a few months. This is a sacrifice all private female doctors going into motherhood make. But at least I have someone whom I trust, who will be looking after my patients while I am away.

Dr. Sayadi: Finding balance is a challenge for all women in all fields, not only in ophthalmology. But we have some additional challenges such as night shifts, research work, preparing for meetings and conferences. I think that this balance issue differs from one doctor to another. Some women sacrifice a part of their career. For example, they are satisfied by day work without any research or other engagements. Others sacrifice their personal life such as not getting married, or not having children. I think that they may succeed. But what about regrets? The last choice is doing both. It’s not easy at all to find the perfect balance, but it’s possible. The key is to be organized and to have a helping and understanding family and husband. CAKE: How does ophthalmology compare to other medical fields for women? Is there a notable difference? Dr. Moodley: It’s definitely less demanding in terms of after-hours duties when compared to fields like general surgery and internal medicine — which is definitely appealing to women. I also think it’s a nice, clean field to work in and it’s a combination of both medical and surgical work. Our patients are also not sick or ill, they just can’t see. So it’s not as emotionally taxing as having to save someone in heart failure or someone with a gunshot to their chest. And the reward of giving a patient their sight back is just indescribable. It is probably also less male-dominated these days than other surgical disciplines. Dr. Sayadi: Compared to other medical fields, ophthalmology stands right in the middle. Obviously, it’s easier than working in emergencies, cardiology or intensive care. But the work still demands more availability compared to dermatology or some other medical specialties. CAKE: What advice would you give to young women looking to enter the field? Dr. Moodley: It’s an incredible field to work in. Once your training is done, I think it’s easier to find a good worklife balance than most other surgical disciplines. Ophthalmology is a great

field for females to specialize in if they are meticulous and surgically inclined. Dr. Periman: With ophthalmology, there is a real potential to be an independent practitioner. With that comes the ability to make the decisions, and that’s empowering. Dr. Sayadi: My advice for other women is to define their priorities and be organized. We have all the right to have a successful medical career, as well as a happy family life. We should do the right thing at the right time.

Contributing Doctors Dr. Laura M. Periman is a boardcertified ophthalmologist, fellowshiptrained cornea and refractive surgeon and ocular surface disease (OSD) expert. Dr. Periman completed her ophthalmology residency and cornea/refractive fellowship at the University of Washington in Seattle. She has 11 peer-reviewed publications and has written extensively on the topic of OSD. As founder and director of Dry Eye Services and Clinical Research at Periman Eye Center in Seattle, Washington, USA, she combines her clinical care passion, scientific drive, and innovative creativity to provide first-class OSD management. dryeyemaster@gmail.com Dr. Sanushka Moodley, MBChB (Stell), DipOphth(SA), FCOphth(SA), Mmed(Wits), is an ophthalmologist doing full-time private practice at the Pretoria Eye Institute in Pretoria, South Africa. She is also Chair of the Ophthalmological Society of South Africa Young Ophthalmologists. Dr. Moodley’s subspecialty interests include cataract surgery, glaucoma, and medical and surgical retina. drsanushkam@gmail.com Dr. Sana Sayadi is a medical doctor who graduated from the Medical University of Monastir, Tunisia. She is also an ophthalmology resident at the Hospital Mohamed Taher Maamouri Nabeul under the leadership of Pr Walid Zbiba. sanasayadi271991@gmail.com

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NLIGHTENMENT CATARACT SURGERY

Amid the Pandemic Safety Precautions Before and During Cataract Surgery

by April Ingram

or more than six months, most regions around the world have been implementing social distancing measures, and the term “new normal” seems to be something we are settling into. Maintaining a two-meter distance between people and avoiding crowded and congested areas are now the norm. Our hands require a minimum of 20 seconds of cleaning with a 70% alcohol-based solution or with soap and water. Proper use of a mask and other personal protective equipment (PPE) is essential. It seems as though the COVID-19 virus is going to be with us for some time and has already demonstrated its strong potential to re-emerge, even if once effectively contained.

Eye care and pandemic measures Despite the importance of pandemic measures, however, our patients continue to require regular eye care. And the need for cataract surgery has certainly not diminished. In order to meet the need, healthcare systems and surgeons have had to be strategic and thoughtful about how to implement important changes in patient management and surgical practice to address the COVID-19 new normal. The good news is that surgeons — especially ocular surgeons — are, and have always been, masters of infection control. In fact, one of the safest places that someone could be over the next few months would be in an operating theatre. The challenge is getting to that stage.

Overcoming challenges in patient management Two cataract surgeons from very different parts of the world share their expertise and management strategies from the last few months and how they see cataract surgery moving forward from here. Dr. Keith Yap is an ophthalmologist and surgeon in Kelowna, British Columbia, Canada. He shared that cataract surgeries were stopped by their local health region from the middle of March until mid-June this year. Although surgeons and all medical professionals looked to government and national societies, such as the Canadian Ophthalmological Society (COS), for recommendations and protocols, as Dr. Yap explained, some of the best information came from colleagues. “The COS and provincial health authority did provide some guidance for ‘minimum standards’, which were fairly standard things. But one place that myself and fellow British Columbia ophthalmologists found really helpful was the BC ophthalmologists chat groups, where we could discuss what was happening, and bounce ideas off one another about how to best manage things,” shared Dr. Yap.

are masked, and temperatures are checked when they enter the hospital. Their drivers or caregivers are asked to wait outside until we call them back after the surgery is complete,” explained Dr. Yap. “The waiting room has only one-third of the chairs, and cleaning of the area is done more frequently. We are all gowned and gloved and the patient enters the OR with their surgical mask. Once we are ready to proceed, I remove the patient’s mask and replace it with the plastic drape, because I think the mask and the drape might be claustrophobic for the patient. Once the surgery is done, I remove the drape and replace the patient’s mask,” concluded Dr. Yap.

“Symptomatic persons will not be allowed entry, and those who were once COVID-19 positive must be recovered and certified negative.” – Dr. Boateng Wiafe

Measures to control the airborne transmission of the virus Dr. Boateng Wiafe, an ophthalmologist and surgeon at Watborg Eye Services in Awutu Bereku, Ghana, agrees that the key to managing COVID-19 infections is to take serious measures to control the airborne transmission of the virus.

When cataract surgeries began again in June, very little has changed within the operating room, which has always been under strict protocols directed by the Kelowna General Hospital infection control committee. But those changes were more about how patient flow was managed.

Similar to the practices in Canada, temperature and symptom checks are performed before the patient may enter the hospital. “Symptomatic persons will not be allowed entry, and those who were once COVID-19 positive must be recovered and certified negative,” Dr. Wiafe said. “We need to be vigilant because every person entering the hospital premises is a potential asymptomatic COVID-19 carrier.”

“In general, cataract surgery has a low aerosolization risk, so we perform the procedure in much the same way. The big differences are that patients

Patients in Ghana also wear masks inside the operating room, and they do one more additional step. “Just before coming into the operating theatre,

| Sept/Oct 2020

patients are asked to gargle with hydrogen peroxide,” shared Dr. Wiafe. The Ministry of Health in Ghana instituted a total lockdown of surgeries in the region for more than a month. Since reopening, Dr. Wiafe said one of the biggest COVID-19-related changes in the operating room has been reducing the number of operating tables in each operating theatre to just one. “Especially in low- and middle-income countries, in an effort to keep up with the demand for cataract surgeries and increase productivity, there had been more than one table per theatre, which has now been limited to one. The surgical procedure remains the same because infection prevention and control have always been one of the basic principles of eye surgery,” explained Dr. Wiafe. He added: “Things are much slower with all of the new protocols in place. We used to perform three to four cataract surgeries per hour, and now it is one to two per hour. The backlog is currently about eight weeks and the cost per cataract has now doubled, which I worry will have a significant impact on the burden of blindness globally.”

Developing individual protocols Surgeons agree that there is so much information available about practice management during COVID-19, but it can be difficult and time-consuming to sift through it all and figure out what can be most applicable to each individual situation. With that said, some regions are carefully developing protocols. But the process takes so long, and the situation is so fluid that it seems that “developing your own” is the popular choice. Although in some places, people are not happy about being required to wear masks and all the extra safety measures. It’s not the case with most eye care patients. “The vast majority of patients are very happy to comply, and that seeing all the extra measures makes them feel safe,” shared Dr. Yap. Dr. Wiafe noted: “Although many in the

public are getting used to using masks and other safety measures, there are still problems with people who keep removing them, and keep touching their face, nose and mouth. So educating people is still so important.” Both of our surgeons acknowledge that the challenge now is to address the mountain of backlogged cases. Part of this could be adding more funding to staff additional operating rooms and everything else needed to perform the surgery. Furthermore, there are additional budgetary implications of PPE for patients and staff and additional cleaning and disinfecting measures. In Africa, surgeons and the health ministry are looking at planning surgical outreach centers, in addition to the usual fixed surgery days, in an effort to limit patient travel and reduce the number of patients assembling in one place.

The important role of telemedicine in today’s practice A pleasant surprise has been how beneficial telemedicine can be in ophthalmology. “One of the biggest challenges during the pandemic is keeping people distanced, which is often a challenge in waiting rooms no matter how carefully you monitor the schedule,” shared Dr. Yap. “The wait is rarely due to back-up with the ophthalmic technicians, and almost always is with the physicians. We have found it to be really beneficial for patients to come in and have their assessments like intraocular pressure (IOP), vision and imaging done by the technicians. Usually there’s no waiting time, just in and out. Then I review everything and have a telephone consultation with the patient later that day. It works well and the patients really like it. We are even able to conduct our post-op visits virtually as well,” he added. Dr. Wiafe has also adopted telehealth, and teleconsultations are encouraged by his facility, particularly for followups. Not unexpectedly, both surgeons

agree that what is now happening, as far as the new normal goes, is really what is supposed to be normal. “There can be no shortcuts. What we are doing now to manage infection control is what it ought to be. COVID-19 has come to stay, and we all have to make the necessary adjustments to become COVID-19-compliant in all we do,” surmised Dr. Wiafe. “With the new protocols at our surgical facilities, we are addressing all the elements of quality to make sure that the surgery is safe for the surgeon and the patient. This ensures the best outcomes and reduces infections to zero,” he concluded.

Contributing Doctors Dr. Keith Yap, BMSC, MD, FRCSC is an ophthalmologist and surgeon in Kelowna, British Columbia, Canada. He performs cataract surgery at Kelowna General Hospital and his private surgical center, also in Kelowna. Dr. Yap completed his ophthalmology residency at the University of Alberta and a fellowship at the University of Iowa. He is board-certified in Canada with the Royal College of Surgeons of Canada. Dr. Yap and his wife, Dr. Mandy Wong, also a physician in Kelowna, are very active in the community and support numerous charitable causes. When not in the office or operating room, Dr. Yap enjoys many of the sports and recreation activities available in Kelowna and the Okanagan region, including tennis in the summer and hockey in the winter. He starts each day by waterskiing before heading to work. editor@mediamice.com Dr. Boateng Wiafe, MD, MSc (Community Eye Health), FGCP, is an ophthalmologist and surgeon at Watborg Eye Services in Awutu Bereku, Ghana. He currently serves as technical advisor for Operation Eyesight Universal and spent several years in other roles as their director of quality and advocacy and regional director for Africa. Dr. Wiafe is also the WHO master trainer for primary eye care, chair of the Ghana Eye Health Advocacy Steering Group, and chair of the International Agency for the Prevention of Blindness. Dr. Wiafe shares his operating theatre with his wife Ruth, a nurse at the hospital. editor@mediamice.com

| Sept/Oct 2020

NLIGHTENMENT OPHTHALMIC BUSINESS

The New Normal Refractive Surgery Returns After COVID-19 Lockdowns by Brooke Herron

efractive procedures were among the first to go when the COVID-19 pandemic pushed the “pause button” on non-emergent surgeries. Now, as social distancing measures begin to relax around the world, clinics are reopening for elective procedures. But are patients returning? To find out, we reached out to four refractive specialists from three different continents to gauge the new normal in patient volume and demographics in these areas.

India’s procedures resume at lower volume In India, things are slowly getting back to normal. “Refractive surgery has resumed, but it’s at a lesser volume. However, for many patients that are coming now, it’s because they have time to recover from surgery. They are not working full-time or are working from home, and so they have more time and flexibility,” shared Dr. Soosan Jacob, director at Dr. Agarwal’s Refractive and Cornea Foundation and senior

consultant of Cataract and Glaucoma Services at Dr. Agarwal’s Group of Eye Hospitals in Chennai. “Plus, postoperative follow-up is not as intensive for refractive surgeries compared with some other procedures, which makes them easy to undergo at this time,” she added. At her hospital, they offer all types of refractive procedures, but the majority of corrections are done with small incision lenticule extraction (SMILE). “SMILE has a lot of advantages. However, we do all the procedures, including laser-assisted in-situ keratomileusis (LASIK), femto-LASIK, photorefractive keratectomy (PRK), Contoura Vision, etc. We give them all the options — but many patients prefer SMILE if they can afford it,” continued Dr. Jacob. For the most part, patient demographics have remained similar to pre-pandemic conditions. “It’s remained steady, there’s not much change. However, we have seen more students coming in lately, those doing their graduate or

| Sept/Oct 2020

postgraduate studies. They have time now that colleges have closed down,” she said. “We are also seeing patients pre-marriage. They want to get rid of their glasses before marrying. All of these patients are still coming.” Safety measures have also increased. Dr. Jacob says her hospital has implemented safety protocols from the government, as well as associations like All India Ophthalmological Society (AIOS), plus guidelines from her own hospital group, which has 90 locations. “We were involved with AIOS in forming their COVID-19 safety guidelines — and we put safety guidelines into place at our locations before the first lockdown was ever announced in India,” she said. “When we first heard about Wuhan, we knew this would be an issue, so we immediately prepared and implemented safety measures at a very high level.” This is not just for the safety of physicians and staff, but also for patients. “Each surgical patient gets personal protective equipment (PPE) and an N95 mask. This is important for

both patient trust and peace of mind.” As noted by Dr. Jacob, patients now have time off to recover from refractive procedures. However, this “vacation” from work, could put some people in a precarious financial position. This has not gone unnoticed by her hospital. “We understand that people may have some economic issues or problems with their work. We take that into consideration when we advise them, and we do have special offers for students and people with certain needs. We are trying to help them,” explained Dr. Jacob.

The US sees increased demand “Year-to-date, we are up 50% — despite being off for six weeks. The demand is incredible,” shared Dr. John F. Doane, a refractive surgeon in Kansas City, Missouri, USA. His practice reopened on May 4. He shared that patient demographics cover ages 17 to 80, with requested procedures like SMILE, LASIK, PRK, as well as premium intraocular lenses (IOLs), toric IOLS, and standard IOLs. In addition, Dr. Doane said that the demand for cataract surgery also appears to be inelastic. “We are busier now than pre-COVID. It’s not at all explained by being off and playing catch up,” he continued. At his clinic, Dr. Doane’s patients and staff wear masks at all times for increased safety. Prior to entering, patients must fill out a health questionnaire and have their temperature taken. Staff must also have their temperature taken twice daily. “If their temperature is high, or if they have a positive response to the questionnaire, they are sent home and they must see a physician,” Dr. Doane said.

Refractive correction in Ireland skews younger According to Dr. Arthur Cummings, consultant ophthalmologist and medical

director at Wellington Eye Clinic in Dublin, Ireland resumed laser vision procedures in mid-May, and intraocular surgeries on July 1. He shared that procedures like LASIK, PRK, implantable contact lens (ICL) and custom lens replacement or refractive lens exchange (CLR or RLE) are available. And interestingly, the patient demographics are now skewing younger. “LASIK patients are younger than before the lockdown — the average age is below 30-years-old,” said Dr. Cummings. “Presbyopes are in their early 50s on average, which is, again, younger than before lockdown.” According to Dr. Cummings, conversions are up significantly since the lockdown. “Patients are not shopping around. If they are suitable, they simply go ahead as soon as they can get an appointment for surgery,” he shared. “Uptake of presbyopia-correcting IOLs has gone up significantly in my practice, from around 10% to around 50%.” And, of course, this is all done under enhanced safety measures. In his clinic, social distancing is in place, with both parties wearing masks. In addition, they are using telemedicine for part of the consultation process, which cuts down in-person meeting time.

Hong Kong avoids lockdown and stays steady In Hong Kong, they fortunately never had to lock down. “This is because of our painful experience with SARS in 2013, everyone immediately practiced mask-wearing and social distancing. So everything is quite under control,” shared Dr. John Chang, director of GHC Refractive Surgery Center at Hong Kong Sanatorium & Hospital and clinical associate professor in the Department of Ophthalmology at the University of Hong Kong. “Although we are presently having a third wave of a community outbreak, the death toll is still relatively low, so elective surgeries were never stopped,” he continued. In Dr. Chang’s refractive surgery

consults, 70% of patients request SMILE, and the remaining 30% don’t have a preference. In the end, 50% of his patients undergo SMILE and the other half have LASIK. According to Dr. Chang, patient demographics have changed a bit, although demand has remained steady. “In our cataract center, the number of older patients has dropped by 70%. Most of the patients now are around 60 years old or younger,” he explained, adding that the older patients have stayed away because their mortality rate for COVID-19 is quite high. “Surprisingly, our refractive volume never went down — we are as busy as ever,” shared Dr. Chang. He shared that during the worst period of the outbreak, the patient volume dropped by about 90% at the cataract center, but only by 40% at the refractive surgery center. “However, patient volume returned rapidly after the second outbreak, and our volume did not drop at all during the present third outbreak.” Dr. Chang noted that in Korea, some refractive centers have reported a 120% increase in surgical volume. This can be attributed to several reasons: First, younger patients are not as concerned about the virus as their mortality rates are very low. Another reason, also mentioned by Dr. Jacob, is that most people are working from home right now, so they can have surgery without needing to take time off work. “Younger patients also have more time at home now to communicate with their friends, thus sharing refractive surgery experiences,” continued Dr. Chang. And the final reason: “Because of the mask-wearing, spectacles fog up, and also there is a higher possibility of contact lens-related eye infection,” he explained. At his hospital, there are also some new safety regulations at the hospital. This includes providing and wearing surgical masks, and safe disposal of all masks and post-op surgical coverings. “They are folded patient-side-in and discarded in closed bins,” concluded Dr. Chang. He said a COVID-19 test is not required for refractive patients (as the center is not within the hospital), but other safety regulations still apply.

| Sept/Oct 2020

NLIGHTENMENT OPHTHALMIC BUSINESS

Contributing Doctors Dr. Soosan Jacob, MS, FRCS, DNB, MNAMS, is the director and chief at Dr. Agarwal’s Refractive and Cornea Foundation (DARCF) and senior consultant of Cataract and Glaucoma Services at Dr. Agarwal’s Group of Eye Hospitals in Chennai, India. She has been the recipient of the following prestigious International awards: JRS (Journal of Refractive Surgery) Waring medal for editorial excellence; ISRS Kritzinger Memorial award (the first Indian and the first woman internationally to receive this award); Innovator’s award (Connecticut Society of Eye Physicians); ESCRS John Henahan award for Young Ophthalmologist; AAO International Ophthalmologist Education Award; AAO International Scholar award; AAO Achievement award; ASCRS Top-Gun Instructor Award; Bruce Jackson oration (Canadian Ophthalmological Society); Harold Stein Innovator lecture (Canadian Ophthalmological Society); and is also a two time recipient of ASCRS Golden Apple award and also the prestigious Indian awards: IIRSI (Intraocular Implant and Refractive Society of India) Special Gold medal; UKSOS Gold medal (Uttarakhand); AM Gokhale award and oration (Pune Ophthalmic Society); Dr. TN Gopinathan Menon Memorial Oration award & gold medal and the Dr. P R Mondal Memorial Oration Award. In addition, she has won more than 50 prestigious international awards for her surgical videos as well as Best Paper of Session awards on her innovations and challenging cases at prestigious international conferences in the USA and Europe.

Dr. John F. Doane, MD, FACS, has practiced as a corneal and refractive surgeon with Discover Vision Centers in Kansas City for the past 23 years. He is a clinical associate professor at Kansas University Medical Center Department of Ophthalmology in Kansas City, Kansas. Dr. Doane has written over 80 peer-reviewed articles and book chapters and has edited textbooks on refractive surgery. He has been an investigator with numerous FDA clinical trials for corneal refractive surgery, intraocular lens implants, and laser surgical techniques, as well as international studies of LASIK outcomes, prototype laser systems, and software applications. He is the founding editor of Cataract and Refractive Surgery Today which is a collaborative effort of ophthalmic surgeons, ophthalmic industry leaders, and ophthalmic research groups to address better treatment options for patients worldwide. He is the current Board Chairman of the American European Congress of Ophthalmic Surgery. He is an active speaker to audiences in the U.S. and internationally. jdoane@discovervision.com

Dr. Arthur Cummings, MD, is a cataract and refractive surgeon in Dublin, Ireland. He works closely with industry and colleagues in an attempt to grow refractive surgery and bring the benefits of refractive surgery to more people.

Dr. John Chang, MD, is presently the director of the Guy Hugh Chan Refractive Surgery Centre of Hong Kong Sanatorium & Hospital. Dr. Chang was trained in ophthalmology at Jules Stein Eye Institute, UCLA. He then went to UCSF and did a fellowship there. He is presently the president of International Society of Refractive Surgery. Dr. Chang is a past president of the Hong Kong Association of Private Eye Surgeons. He is an honorary associate professor of the University of Hong Kong and the Chinese University of Hong Kong. He is on the executive committee of the APACRS. He is on the editorial board of CRST, APJO, EyeWorld (Asia Edition), Ocular Surgery News (APAO Edition), the Open Ophthalmology Journal, Chinese Journal of Ophthalmology (CJO), and EyeNet (AAO), and is the chief editor of EuroTimes (China Edition). He has also been awarded the “Certified Educator Award” by the APACRS, “Gold Medal” by IIRSI- India, “Distinguished Service Award” and “Achievement Award” by APAO, “Casebeer Award” and “Founders’ Award” by the International Society of Refractive Society (ISRS), the American Academy of Ophthalmology’s “Secretariat Award” and “Senior Achievement Award” by the AAO. Dr. Chang is also active in research, publishing and traveling abroad to give lectures as an invited speaker. John.SM.Chang@hksh.com

abc@wellingtoneyeclinic.com

dr_soosanj@hotmail.com

INDUSTRY UPDATE

DE-128 (MicroShunt) from Santen Continues on Path to FDA Approval

n early July 2020, Santen Pharmaceutical Co. Ltd. announced that the United States Food and Drug Administration (FDA) has accepted the Premarket Approval (PMA) application for review for the DE-128 (MicroShunt). Now, DE-128 will undergo an in-depth review, following which the FDA will make a decision as to whether the PMA is approved. This process usually takes 180 days from receipt of application.

Designed to reduce intraocular pressure (IOP) in patients with primary open angle glaucoma (POAG), DE-128 is an investigational, ab-externo, minimally invasive, surgical implant. The implant helps drain eye fluid and reduce IOP in patients with POAG whose IOP is not controlled when using maximum tolerated glaucoma medications.

styrene)], the implant is a flexible, 8.5mm-long tube with planar fins to help fixate the device in the tissue and prevent leakage and migration.

DE-128 is made with a proprietary, biocompatible material called “SIBS” [poly(styrene-block-isobutylene-block-

For more information, visit www.santen. com.

| Sept/Oct 2020

If approved, this could expand treatment options for the estimated 3.7 million Americans living with POAG, a leading cause of blindness.

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INDUSTRY UPDATE

Schwind ATOS and SmartSight Receive CE Approval extraction, performed entirely with the ATOS. The system features eye tracking with pupil recognition and cyclotorsion compensation to provide precise centering of the patient’s eye along the visual access, and to ensure maximum safety and predictable treatment outcomes.

he latest CE approval for Schwind’s ATOS femtosecond laser and SmartSight broadens options for lenticule extraction as a treatment option for refractive correction. Developed by Schwind, SmartSight is the latest generation of lenticule

SmartSight is suitable for the treatment of myopia and astigmatism up to 5D. In addition, ATOS offers high-precision flaps for femto-LASIK. Managing Director Rolf Schwind said: “Schwind is continuously working on the goal of providing the eye surgeons and their patients with state-of-the-art, particularly safe and high-precision

treatment options based on our latest technologies. With the CE approval for our femtosecond laser, we have reached another milestone.” According to the company, the ATOS expands Schwind’s comprehensive range of applications — and with the combination of SmartSquare (with ATOS and the AMARIS excimer laser), it covers the most up-to-date all-laser procedures in refractive surgery. In addition to the ATOS SmartSight lenticule extraction, and flap cutting for femtoLASIK, the AMARIS can be used for intrastromal LASIK treatment and touchfree TransPRK/SmartSurfACE surface treatment.

| Sept/Oct 2020

NLIGHTENMENT HOMEOPATHY

Alternative Medicine

raw garlic per day. However, medical advice suggests that honey and garlic should be left in the kitchen.

Homeopathic and Nonsurgical Cataract Treatments by April Ingram

ataracts are considered part of the natural aging process. So, if we live long enough, we will likely eventually develop a cataract. Or two, if we’re unlucky. In fact, it isn’t uncommon to hear chatter among older folks, comparing their surgeons and what type of lens they have.

is a medical philosophy and practice based on the idea that the body has the ability to heal itself. It believes in the concept that “like cures like”, meaning that if a substance causes a symptom in a healthy person, giving the person a very small amount of the same substance may cure the illness.

But what if surgery isn’t the only treatment for cataract?

Dr. Lian and Dr. Afshari noted that there are many alternative and homeopathic products available which claim to prevent and treat cataracts. The remedies are extremely varied and include different herbs, natural products, honey, vitamins and antioxidants, and have undergone clinical studies to varying extents. They narrow in on examples of substances that have actually been studied as a potential alternative or homeopathic nonsurgical cataract treatments.

Dr. Rebecca R. Lian and Dr. Natalie A. Afshari of the Shiley Eye Institute at the University of California San Diego in La Jolla, California, USA, recently explored the available evidence related to several homeopathic remedies purported to treat age-related cataract. Their review1 was recently published in the journal Current Opinion in Ophthalmology, and we were intrigued.

Homeopathy, or homeopathic medicine,

The Internet is full of “medical information” touting remedies for cataract — such as drops of unprocessed honey in the eyes, or slowly chewing two to three cloves of

| Sept/Oct 2020

Homeopathy and ophthalmology

The question is, why is this alternative treatment being explored when there is an easy and effective surgical treatment for cataract? Dr. Lian and Dr. Afshari shared: “Developing a pharmacologic treatment to reverse cataract would likely reduce the need for surgery and increase access to treatment in resource-poor areas.”

Homeopathic remedies that show efficacy After sifting through all the evidence and reports and follow-up studies, Dr. Lian and Dr. Afshari reported that there are a number of types of substances, including homeopathic remedies that have shown some efficacy in preventing cataract formation in cell cultures and animal models. They shared two key findings of their review. “Recently, it was discovered that compounds such as lanosterol, 25-hydroxycholesterol and rosmarinic acid are able to restore transparency to lens proteins by reversing protein aggregation and increasing crystallin solubility,” they noted. “Although more research is needed, these compounds have shown exciting potential for the development of a pharmacologic treatment option for age-related cataract.”

acid restored full transparency to human lens fragments gathered during routine cataract surgery.” Also work in vivo was done in a rat model, wherein “rosmarinic acid was found to delay opacification and reduce the severity of selenite induced cataract”. The authors were careful to caution that although there are some interesting and positive findings, “several challenges remain,” and, “not all studies have yielded positive results”.

A safe and natural mode of cataract treatment

Let’s better understand what it is about lanosterol, 25-hydroxycholesterol and rosmarinic acid — a naturally occurring polyphenol that can be found in several plants and herbs including rosemary, sage, basil and oregano — that help in the treatment of cataract. Through different mechanisms, both lanosterol and 25-hydroxycholesterol have been shown to restore lens transparency by reversing protein aggregation and increasing the solubility of lens proteins. Studies were conducted using cataract material from previous phacoemulsification incubated with lanosterol or 25-hydroxycholesterol for two weeks, which demonstrated that lanosterol released a-crystallin — molecular chaperones that help to prevent cataract by maintaining the solubility of other lens proteins from aggregates — as well as b- and g-crystallins from protein aggregates. Meanwhile, 25-hydroxycholesterol only released a-crystallin, but did so better than lanosterol. Dr. Lian and Dr. Afshari also highlighted experimental work done with rosmarinic acid and its ability to reverse cataract opacity. They described the compound’s ability to destabilize amyloid, as well as its antioxidative, anticholinergic, antiinflammatory, and anti-amyloidogenic properties. The authors noted a 2018 study in which, “incubation with rosmarinic

Vikas Sharma, an MD of homeopathy practicing in Chandigarh, India, for more than two decades, shares his knowledge of homeopathy in cataract treatment on his website.2 “Homeopathy is the safest and natural mode of treatment for cataract. In the early stage, when the cataract starts to develop, these medicines are known to retard clouding of the lens. They are equally helpful in restoring blurred vision. Homeopathic medicines for cataract are, therefore, beneficial for the opacity of the lens and stop further progression of the disease,” Dr. Sharma said in his article. “Top medicines for cataract are Calcarea Fluorica, Cineraria Maritima, Conium, Silicea and Natrum Muriaticum,” he shared. However, there is an absence of published literature supporting the clinical benefit of cataract treatment with therapies like Cineraria.

The need for more tests and scientific studies A previous article by Tewari et al., published in 2019, similarly reviewed 44 medicinal plants and natural products used in cataract management.3 Of the 120 papers analyzed, most of the ethnobotanical survey studies were from developing countries like Bangladesh, Chile, India, Nepal and Tanzania. They found that combinations of plants were also used, such as KIOM-79, which is a mixture of ethanol extract

(80%) of parched Puerariae Radix, gingered Magnoliae Cortex, Glycyrrhizae Radix and Euphorbiae Radix. Another such important combination formulation is Triphala, which is a widely used Ayurvedic formulation in India containing fruits of Emblica officinalis Gaertn., Terminalia chebula Retz., and Terminalia belerica (Gaertn.) Roxb. There is no scarcity of chat groups full of people in various stages of cataract development, hoping to learn about anything natural that may prevent their need for cataract surgery. There is also a great deal of “experts” willing to solve any of their ailments for a cost. Before all of us aged over 40 run to the natural health market, Dr. Tewari and co-authors were careful to note: “Many of the plants used in traditional medicines have not been evaluated for their efficacy using rigorous scientific studies and that evaluation of possible toxicity of these natural products is also important, as these medicines are directly applied in the eyes and can have not just potential benefits, but also harmful effects.” On the other hand, Dr. Lian and Dr. Afshari added: “Some medicinal plants have shown efficacy in preventing protein damage in preclinical trials. However, no homeopathic or alternative treatment available is able to effectively reverse cataract.” “Lanosterol, 25-hydroxycholesterol and rosmarinic acid have been reported to increase the solubility of previously aggregated lens crystallin proteins both in vitro and in animal models, thereby restoring transparency to the lens. More research is needed to determine the efficacy, safety and potential pharmacologic benefits,” they concluded.

REFERENCES: 1

Lian RR, Afshari NA. The quest for homeopathic and nonsurgical cataract treatment. Curr Opin Ophthalmol. 2020;31(1):61-66.

https://www.drhomeo.com/homeopathictreatment/homeopathic-medicines-for-cataract/

Tewari D, Samoila˘O, Gocan D, et al. Medicinal plants and natural products used in cataract management. Front Pharmacol. 2019;10:466.

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NLIGHTENMENT TELEHEALTH

Keeping Up with the Times

Integrating Telehealth in Ophthalmology by Chow Ee-Tan

elehealth — the use of digital information and communication technologies to remotely access healthcare services — is taking center stage amid the current COVID-19 pandemic. Worldwide, there has been a drop of around 60% to 80% of visits in most private clinics and hospitals. Factors for this include patients’ fear of infection; movement restrictions (e.g., within 10km of their homes); and the cancelation of routine, non-emergency surgery, which was restricted during the first couple months of lockdown.

Perfect timing: The rise of telemedicine Specialists such as dentists, ENT and ophthalmologists are at more risk of contracting the coronavirus because of their close proximity to patients. However, digitalization and advanced technology have allowed doctors and patients to be connected without meeting face-to-face during times of mandated social distancing and selfisolation. Telehealth protects patients by keeping them out of the hospital and clinic environment and at the same time, protects doctors by reducing the time they spend in close proximity with patients. “This is a time for digitalization. Telehealth comes about at the right time,” said Dr. Hoh Hon Bing, an ophthalmologist from Pantai Hospital in Kuala Lumpur, Malaysia, who is a proponent of telehealth consultation. Dr. Hoh is the co-founder of the mobile app Teleme, a healthcare platform that links patients with doctors and

specialists for virtual healthcare consultations online. Through the app, patients can speak to doctors, collect prescriptions and get reminders for appointments — all without leaving the comfort of home. Dr. Hoh — who has been actively using Teleme since 2017 — said there are currently between 600 and 700 healthcare practitioners on the platform. Ophthalmologists are the third-largest group of specialists on the platform, after skin and aesthetic doctors.

Of apps and digitalization Teleme has a complete ecosystem of

| Sept/Oct 2020

doctors, pharmacies and health labs. It helps patients by allowing them access to a team of healthcare practitioners. “We must admit that healthcare delivery, not only in ophthalmology, is at times inefficient,” shared Dr. Hoh. “Teleme can reduce the long wait times in clinics and hospitals, and in the long run, help doctors focus their resources on patients needing urgent care.” He added that very often, patients forget most of the instructions from doctors during a consultation. Now, doctors can give their patients clear instructions over the app, which they can refer to at any time. It also allows doctors to write a summary report of the consultation.

In Teleme, Dr. Hoh has written many articles for ophthalmologists to use as instructions. There are also some multimedia health articles with attached videos. Additionally, there is a free “Find Me a Doctor” feature, which allows users to post healthrelated questions, to which they’ll get a professional’s reply within 24-hours.

The power of “forward triage” Perhaps one of the biggest benefits of telehealth is that it incorporates the power of “forward triage,” which is a recognized strategy for managing healthcare surges by sorting patients for medical treatment based on need, emergency and severity of illness. Reduction in face-to-face consultations during a pandemic allows patients and medical practitioners to comply with social distancing and self-isolation. In ophthalmology, the implementation of forward triage includes elements of clinical history, objective measurements such as visual acuity, intraocular pressure and imaging (including photographs, OCT and visual field, among others). “Similarly, Teleme allows patients to ask their doctors whether they can postpone their visits, or if they have new symptoms, whether they need to come immediately. The ability to ask such questions saves the patient from going out of the house during the height of the pandemic,” shared Dr. Hoh. “This helps in the effectiveness of the quarantine so that only the patients who really need to see a doctor urgently do so,” he added. Patients who do not need to go to the clinic can get their e-prescription via the app and they can purchase from the local pharmacy, or have them delivered to their homes. Another benefit of Teleme is that it records the date and time of the patient’s next appointment and sends a reminder a day prior. Dr. Hoh uses Teleme on all his patients and currently, he provides telehealth consultations to about 10 patients per day.

Telemedicine: Here to stay Dr. Hoh noted that during the last six months, the volume of telehealth users has doubled. “COVID-19 has introduced video calls to everyone as we work from home, do school from home and order food from home. We can also have healthcare from home,” enthused Dr. Hoh. While Teleme doesn’t encourage ophthalmologists to do diagnosis and treatment online, Dr. Hoh said a lot of information can be obtained from a teleconsultation, such as a history and description of symptoms, photos of the eye (if necessary), and even self-vision checks using electronic vision or an Amsler chart for macular degeneration testing. “Patients can take a photo of their eye to share with the doctor. In addition, the patient can video-call his ophthalmologist to describe the symptoms and ask for health advice,” added Dr. Hoh. Teleme also has a “Health Tips” section that allows patients to access a library of eye health articles so that they can self-monitor their conditions. If there is any sudden deterioration, the patient can contact the doctor to arrange for a physical clinic appointment for a more thorough eye check. “For ophthalmologists, we use video calls not to diagnose or do treatment, but to consult with patients to determine whether they need to come to the clinic, or if we can give the medication prescription online,” he explained. Teleme gives patients the choice of three options to communicate with their ophthalmologists: text messages, voice call and video call. During any crisis, the patient is never out of touch from their health practitioner.

Keeping up with the times Undoubtedly, there is still resistance from doctors about using telehealth, as some are wary that their privacy may be intruded.

“Telehealth does not reveal personal contacts of the doctor, and each doctor should get a team, including the head nurse, to assist in communicating with the patients,” Dr. Hoh explained. Indeed, this can be an especially stressful time for patients with macular degeneration, glaucoma and other vision-threatening conditions. Ophthalmology practices can rise to the occasion with new ways of serving and connecting patients. “It is about connection and communication. Patients would appreciate the extra services rendered to them by doctors,” he said, adding that the new normal after the COVID-19 pandemic will be hybrid, whereby the ophthalmology clinic will have both online and offline options for patients to make their practice more efficient and seamless. “Now is a good opportunity, not just for eye care specialists, but all industries to get their businesses online. In whatever specialty you are in, you can use telehealth and apply it to your practice,” Dr. Hoh concluded.

Contributing Doctor Dr. Hoh Hon Bing, BM (UK), MRCOphth (Lon), FRCOphth (Lon), FRCS (Edin), DMed (Bristol), is an ophthalmologist trained in London and Bristol, England. In his previous life, he was an academician, having served as the chairman of Malaysian Ophthalmology Society (1999-2001) and associate professor at the University Malaya, with over 40 research publications and an ophthalmology textbook. Since October 2016, he became chief medical officer of the Teleme healthcare mobile app, which was designed to provide a platform for healthcare professionals, such as ophthalmologists, with an online presence and be connected and accessible to their regular patients as well as new patients. Features on the platform include e-prescriptions, e-lab tests and remote teleconsultation. drhoh@teleme.co

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CONFERENCE HIGHLIGHTS WOC2020 COVERAGE

Is COMET a Herald of New Ocular Surface Treatments? by Sam McCommon

he effectiveness of cultivated oral mucosal epithelial transplant (COMET) in repairing conjunctival tissue was a noteworthy point mentioned at the 37th World Ophthalmology Congress (WOC2020 Virtual®), held on June 26 to 29, 2020.

sheet then becomes the graft that can later be applied as a transplant.

valuable in repairing a damaged ocular surface in different circumstances, including burns and injuries. So how does the treatment work?

A study presented by Dr. Tsutomu Inatomi delved into the topic in the context of ocular surface squamous neoplasia (OSSN). COMET appears to be a viable technique to promote regrowth while reducing the incidence of scarring and maintaining ocular movement. Additionally, because the mucosal tissue comes from the patient themselves, there is no risk of rejection. Speaking of conjunctival reconstruction in very advanced cases of OSSN, Dr. Inatomi noted that COMET is more effective than amniotic membrane transplantation (AMT) treatment when treating a large area of the conjunctiva because it provides a new epithelial source. This can be especially important after removing a large tumor.

A short background The corneal epithelium is essential for proper vision and protection of the eye against pathogens. In healthy eyes, the corneal epithelium is replenished throughout a person’s life by stem cells located in the limbus. In damaged or diseased eyes, however, stem cells levels become lower and may not be enough to replace the corneal epithelium.

The treatment also appears to be

To correct this problem, different tissues can be used. One valuable tissue is oral mucosal tissue taken from the patient. A small biopsy is taken and is placed on a sterilized human amniotic membrane where the cells multiply in the form of a sheet. This

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Dr. Inatomi summed up the process succinctly: “We harvest a very small amount of the oral tissue and isolate it in a cell suspension and generate a sheet on the amniotic membrane. We can then transplant this sheet to reconstruct the conjunctival space.” In his WOC presentation, he noted great success in a few example operations.

COMET for persistent epithelial defect Medical literature also provides evidence supporting the efficacy of COMET treatment for other surface anomalies. Dr. Inatomi was involved in a study1 using COMET to treat patients with persistent epithelial defect (PED), including patients with StevensJohnson syndrome and others with a thermal or chemical injury. Though it was a small study (10 eyes, 9 patients), the results were very promising. PED had improved in all cases (except one, in which the patient couldn’t

return to the hospital) at 24 weeks. No PED was found in any eye at followup, and the treatment led to long-term ocular stability. The conclusion? COMET allowed for complete epithelialization of PED and stabilized the ocular surface, preventing long-term scarring and vision loss.

“We harvest a very small amount of the oral tissue and isolate it in a cell suspension and generate a sheet on the amniotic membrane. We can then transplant this sheet to reconstruct the conjunctival space.”

COMET for severe corneal burn Another study demonstrated COMET’s usefulness in treating severe corneal burns.2 This small study documented the effect of COMET on five eyes: two with an acute alkaline burn, one with a chronic alkaline burn, and two with a chronic thermal burn. COMET was used for re-epithelialization in the alkaline burn eyes, and to reconstruct

the ocular surface in the thermal burn eyes. After COMET, the study noted, the corneas of all patients became less inflamed. Furthermore, the ocular surface of all eyes was re-epithelialized within three to 10 days. Following additional surgeries, like conjunctolimbal autografting and penetrating keratoplasty, each patient experienced significantly improved vision. The study concluded that COMET is a potentially valuable alternative surgery for corneal burns and to reconstruct the corneal surface.

Substrate-free sheets vs. amniotic membrane substrate Using COMET with substrate-free sheets may be more effective than using an amniotic membrane (AM) substrate when treating similar conditions. So says a study3 that compared just that. At 12 months, the success rate of COMET was 62.5% in the substrate-free group compared to 43.5% in the AM group. The graft survival rate was also significantly higher in the COMET group than the AM group.

experienced greater best-corrected visual acuity (BCVA) at all points than the AM group, and neovascularization was also notably improved in the COMET group.

More than healing COMET appears to be a valuable treatment for a number of serious surface injuries, especially severe ones. In yet another example, there’s good news for patients with complete limbal stem cell deficiency (LCSD): COMET has been shown to significantly improve4 vision in these patients. If one were to describe this procedure to doctors a century ago, they may have imagined it to be the wild ramblings of a madman. To take tissue from a person, grow it in a laboratory, and transplant it somewhere else on their body — and to have the procedure be effective — sounds like something straight out of the future. And yet here it is. What other cool stuff will our medical industry come up with next?

REFERENCES: 1

Sotozono C, Inatomi T, Nakamura T, et al. Cultivated oral mucosal epithelial transplantation for persistent epithelial defect in severe ocular surface diseases with acute inflammatory activity. Acta Ophthalmol. 2014; 92(6): e447–e453.

Ma DHK, Kuo MT, Tsai YJ, et al. Transplantation of cultivated oral mucosal epithelial cells for severe corneal burn. Eye (Lond). 2009;23(6):1442-1450.

Hirayama M, Satake Y, Higa K, et al. Transplantation of cultivated oral mucosal epithelium prepared in fibrin-coated culture dishes. Invest Ophthalmol Vis Sci. 2012;53(3):1602-1609.

Sotozono C, Inatomi T, Nakamura T, et al. Visual improvement after cultivated oral mucosal epithelial transplantation. Ophthalmology. 2013;120(1):193-200.

Furthermore, the COMET group

Editor’s Note:

No, not that kind of comet, though it’s nearly just as fascinating.

WOC2020 Virtual® was held on June 26 to 29, 2020. Reporting for this article also took place during the virtual WOC 2020 conference.

| Sept/Oct 2020

CONFERENCE HIGHLIGHTS ASCRS 2020 COVERAGE

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Interesting e-Posters from ASCRS 2020 by Joanna Lee

surgeries done in a single calendar year — both phaco-surgeries and manual small incision cataract surgeries (MSICS).

CAKE magazine has selected some interesting highlights, which might pique your curiosity.

He measured the waste produced in association with the surgeries and converted them into CO2 equivalents to see their impact on our environment. Using an online calculator, the CO2 was calculated and compared with other similar studies.

he American Society of Cataract and Refractive Surgery (ASCRS) made history this year as the world’s first-ever fully virtual ophthalmic conference. As such, the submitted e-posters reflected this groundbreaking concept, with exciting ideas and advances of their own.

Sustainable ophthalmology Have we ever thought to measure the annual carbon footprint of cataract surgeries? The pandemic has had many questioning the human impact on the environment.

It was found that each time a phaco was performed, an average waste of 375 g was generated which is equivalent to 9 kg CO2 Eq. In contrast, each SICS produced 150 g in waste, which translates to 3.2 kg CO2 Eq.

One of them was Dr. Madhu Uddaraju, whose concern has led him to ponder: What are the implications that cataract surgeries have on environmental sustainability? To answer this question, he conducted a retrospective observational study of 10,342 cataract

Cumulatively, the effect of all these surgeries was equivalent to 2.2 tons of waste, resulting in 55.3 tons of CO2 Eq in a year. The poster indicated that 3,854 phaco-surgeries made 34.6 tons of CO2 Eq, while 6,488 SICS generated 20.7 tonnes of CO2. In summary, each phaco-surgery had a carbon footprint 2.5 times more than MSICS. He also

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did a separate analysis on energy use and travel. Dr. Uddaraju’s message was simple: “In order to leave a greener world for a better tomorrow, we need to adopt a balanced approach of reducing the use of disposables wherever feasible without compromising on sterility principles.”

3D-printed ocular drug delivery system This study saw the potentials of using hydrogel in the development of a new type of drug delivery system containing N-acetylcysteine through bio 3D printing technology in filamentous keratitis — a biodegradable drug release device. In the study, hydrogel was used to encapsulate N-acetylcysteine to create implantable and biodegradable devices. Dr. Jae Woong Koh authored this study, which investigated different models through modifying the size, thickness and porosity of the hydrogel types. The

structure is fabricated by inducing shear stress to a hydrogel-based conjunctiva derived extracellular matrix bio-ink based on a 3D cell printing technique. In vitro release of N-acetylcysteine was observed to be constant (zeroorder) through its four weeks of study. Release rates were tunable by altering hydrogel porosity and thickness. N-acetylcysteine concentration in the blood was below the lower limit of quantification, while the drug remaining in the device was chemically stable in vitro and in vivo. The study’s evaluation of the printed shape’s maintenance has also opened the possibility toward reliable in vitro combining 3D bio-printing and technology, and biodegradable processes.

Vitamin D3 effects on dry eyes In a prospective study of 40 patients (80 eyes) which had undergone femtosecond laser-assisted in situ keratomileusis (FS-LASIK) surgery in 2018, one group (experimental) received 1,000IU/d of oral vitamin supplements continuously for 12 weeks after surgery, while the control group did not take oral medication. The team of researchers looked at the ocular surface disease index (OSDI), tear break-up time (TBUT), and Schirmer’s Test I preoperatively and postoperatively. They also measured serum vitamin D level and tear cytokine levels. The results showed that the experimental group’s mean OSDI score (17.8 ± 3.5) was significantly lower than that of the control group (25.1 ± 4.6) (p<0.05). The TBUT and mean Schirmer’s Test I value were higher (12.6 ± 0.4 secs; 28.7 ± 2.4) in the experimental group than those in the control group (9.2 ± 0.7 secs; 19.6 ± 1.8) (p<0.05). An inverse correlation was seen between serum vitamin D level and OSDI score (r=-0.649; p=0.03). The control group had higher levels of interleukin (IL)-17, IL-2, IL-4 and IL-10 than the experimental group (p<0.05). The number of subjects

with UDVA≥20/20 and photopic contrast sensitivity in the experimental group was higher than those in the control group (p<0.05). The authors concluded that vitamin D3 has positive effects on post-LASIK dry eye symptoms, tear quality and ocular surface condition while also improving visual quality after FSLASIK.

Alzheimer’s disease: Seeing signs in the eyes Ophthalmologists may be vital assets in the early detection of Alzheimer’s disease (AD). Dr. John T. LiVecchi and Dr. Matin Khoshnevis highlighted this in their analyses of studies that have shown a significant link between AD and age-related macular degeneration (AMD), diabetic retinopathy, and primary open-angle glaucoma (POAG). There is epidemiologic evidence linking AD with POAG, which shown that AD patients have an increased risk of POAG, possibly because AD is a neurodegenerative process influenced by elevated intraocular pressure (IOP). Higher IOPs increase endogenous retinal tau proteins, which is a marker of AD. In turn, AD also leads to a loss of retinal ganglion cells, choroidal thinning, cataracts and optic nerve degeneration; while agnosia may also give way to visual deficits. Instances of retinal ganglion cell degeneration and extracellular fibrillar deposits in exfoliation syndrome were also observed in AD and POAG. In addition, optic nerve pallor may be linked with the severity of AD. The researchers deemed that ophthalmologists should have a lower threshold for glaucoma evaluation in patients with suspected dementia. In addition, ophthalmologists should be more aware of the risk of developing AD in patients with AMD and diabetic retinopathy.

Slam dunk on eye injuries in the NBA

in basketball at its highest level of play. It’s also a look at the economic and industry impacts that these injuries have in a regular professional basketball season. Dr. Jonathan Go and his team of researchers analyzed eye injuries in the 2018-2019 National Basketball Association (NBA) season in a prospective cohort study. They looked at 301 players from all 30 NBA teams across 1,230 regular season basketball games, gleaning information of the injuries from verified media sources, analysis of game footage, and interviews with teams’ eye care providers. The researchers also looked at variables, such as the playing team, position, diagnoses, laterality, games missed from injury, injury date, quarter of injury, mechanism of injury, player activity and location when injured, and treatment. The data were analyzed with Fisher exact goodness-of-fit tests. They discovered that 18 eye injuries caused a loss of $2,317,755 in productivity, 0.85 wins, and 18 missed games. Corneal abrasion (6), orbital contusion (3), and lid laceration (2) were the most common eye injuries. Injury was more likely in the fourth quarter (p=0.003), near the basket (p=0.003), and in guards and forwards (p=0.047). There was no correlation between player activity (rebound/shot/ block/other) and injury (p=0.484). Three injuries disclosed by team eye care providers were not reported by the media and a significant 82.4% of players did not wear eye protection when returning to play.

Editor’s Note: The ASCRS 2020 Virtual Annual Meeting — the world’s firstever successful virtual ophthalmic conference — was held on May 16 to 17, 2020. Reporting for this article also took place during the virtual ASCRS 2020 conference.

This study is a slam dunk on clinically characterizing the types of eye injuries

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CONFERENCE HIGHLIGHTS WOC 2020 COVERAGE

Highlights from WOC 2020 The Latest in Indian Cataract Surgery

by Tan Sher Lynn

uring the 37th World Ophthalmology Congress (WOC2020 Virtual®), held on June 26 to 29, eye specialists from India shared updates and technological advancements in cataract surgery. Below are our “Top 5” notable highlights.

The evolution of femto laserassisted cataract surgery

Dr. Mahipal Sachdev, president of the All India Ophthalmic Society (AIOS), noted that as the technology of femtosecond lasers evolves, it has found widespread use in complex cases.

example, in hard cataracts (that are not white), you can get a perfect capsulorhexis with the femto-laser,” said Dr. Sachdev, who urged physicians to take the leap of faith and incorporate the femto-laser into their practice.

Mark-less toric IOL alignment

For eyes with cataracts and regular corneal astigmatism, toric intraocular lens (IOL) implantation is the preferred modality during phacoemulsification, and precise toric IOL alignment is a prerequisite to achieve optimal visual and anatomical outcomes.

“The advantages of the femto-laser are that it enhances safety; it softens the nucleus to help tackle harder grades of cataracts; and it [allows for] the perfect continuous curvilinear capsulorhexis (CCC) for sulcus implantation. For

Dr. Namrata Sharma, from the All India Institute of Medical Sciences, noted that with the advent of imageguided surgeries, “mark-less” toric IOL alignment is being increasingly performed. Clinical trials have shown that it is possibly better than manual marking — which can be imprecise,

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faded or misaligned due to head tilt during the marking process, or due to an uncooperative patient. “Conventional manual marking has given way to image-guided systems and intraoperative aberrometry, which provides a mark-less IOL alignment. The surgical-guidance system provides pre-op planning of surgical incisions and CCC, correct placement of IOLs, accurate alignment of toric IOLs, and IOL positioning. Future technological advancements may further refine outcomes of toric IOL implantation, with more precise visual results and enhanced IOL stability,” explained Dr. Sharma.

iOCT for white cataracts

White cataracts pose a number of challenges during surgery, including the absence of red reflex and a raised intralenticular pressure (ILP).

“The use of microscope-integrated intraoperative optical coherence tomography (iOCT) helps to comprehensively classify white cataracts based on the morphological characteristics of ILP and intraoperative dynamics of the anterior capsule and lens cortex after the initial nick creation,” shared Prof. J.S. Titiyal.

Barrett Universal II formula

Phacoemulsification in extreme hyperopia may be a challenge to perform. Dr. Danapani Ramamurthy, from the Eye Foundation India, said that coexisting challenges in extreme hyperopia include associated lower endothelial counts, angle crowding/glaucoma,

increased risk of iris prolapse, uveal effusions, a requirement for high powered IOLs, and difficulty in predicting effective lens position (ELP).

no accommodative strain to his head and neck. “The option of viewing with binoculars at any time is hassle-free, and the device has a short learning curve,” shared Prof. Natarajan.

“The Barrett Universal II formula is the go-to formula, as it outperforms all other formulae and takes into account changes in principal planes. As for preoperative considerations, we use pre-op mannitol or glycerol and perform a gentle orbital massage which reduces IOP,” explained Dr. Ramamurthy.

As for the advantages experienced in surgeries, he noted that they include “a much notable depth of trench, posterior capsular tension and wrinkling, a clear distinction of membranes while dissecting, and better visualization of stained vitreous”. He added that he and his team of trainees and staff were very pleased and thrilled with the digital microscope.

First digital microscope for the eye

Prof. Dr. S. Natarajan from the Aditya Jyot Eye Hospital, on the other hand, shared his experience with the 3D ARTEVO800 — the first digital microscope for the eye. On the very first day of using it in surgery, he was pleased that the brightness emitted by the device didn’t hurt the eyes, and there was

Editor’s Note: WOC2020Virtual® was held from June 26-29, 2020. Reporting for this article also took place during the virtual WOC 2020 conference.

INDUSTRY UPDATE

APAO COVID-19 Guidelines

T The Asia-Pacific Academy of Ophthalmology (APAO) recently published the APAO COVID-19 Prevention Guidelines for Ophthalmic Practices.*

he World Health Organization declared the Coronavirus Disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 a “Pandemic” on March 11, 2020. As of August 28, 2020, Severe Acute Respiratory Syndrome Coronavirus 2 has infected >24.4 million people and caused >832,000 deaths, including many health care personnel. It is highly infectious and ophthalmologists are at a higher risk of the infection due to a number of reasons including the proximity between doctors and patients during ocular examinations, microaerosols generated by the noncontact tonometer, tears as a potential source of infection, and some COVID-19 cases present with conjunctivitis. This article describes the

ocular manifestations of COVID-19 and the APAO guidelines in mitigating the risks of contracting and/or spreading COVID-19 in ophthalmic practices. For the continued safety of physicians, staff and patients, we encourage you to read the full article, with additional tips, data and in-depth explanations. Free access here.

*Wong, R, Ting, D Lai K, et al. COVID-19: Ocular Manifestations and the APAO Prevention Guidelines for Ophthalmic Practices. Asia-Pacific Journal of Ophthalmology: July-August 2020;(9)4:281-284.

| Sept/Oct 2020

CAKE Issue 07: The ebook version (The 'Back to the Future' Issue, ESCRS 2020 Virtual Edition)

Articles inside

Why Can’t This Child See?

The New Normal

Amid the Pandemic

New Treatment Alternative

Transparency at Risk