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THE WORLD’S SECOND FUNKY OPHTHALMOLOGY MAGAZINE

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THE BUSINESS ISSUE Dec 2020/Jan 2021 cakemagazine.org

Cover Story

AN INDUSTRY ADJUSTS Pandemic Impacts, One Year On p18


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IN THIS ISSUE...

Cataract Matt Young CEO & Publisher

Robert Anderson

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Anterior Segment

How to Achieve Patient Satisfaction after Refractive Cataract Surgery

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Congenital Cataract Surgery Tips from Experts

Media Director

Hannah Nguyen

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The Battle of the Bulge Pathogenesis & Treatments of Thyroid Eye Disease

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Rates of Ocular Syphilis Increase in Developed Countries

Production & Circulation Manager

Gloria D. Gamat Chief Editor

Brooke Herron Editor

Mark Hillen Editor-At-Large International Business Development

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Conquering Presbyopia with Innovative IOL Technologies

Cover Story

Ruchi Mahajan Ranga Brandon Winkeler Writers

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Andrew Sweeney April Ingram Elisa DeMartino Hazlin Hassan Jillian Webster Konstantin Yakimchuk Olawale Salami Sam McCommon Tan Sher Lynn

An Industry Adjusts Pandemic Impacts, One Year On

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Society Friends

All India Ophthalmological Society

Kudos

Corporate Corner

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Back to Work Amid COVID-19 Developing Safety Practices & Effective Business Measures

Hybrid Conference Format — Here to Stay

Enlightenment

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Don’t Kick the Can, Make a Plan! Creating a Disaster Preparedness Plan in Ophthalmology A Guide to Helping Your Low Vision Patients

Conference Highlights

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What Drives Drug Delivery Strategies in Ophthalmology? Updates from APOTS 2020 Overcoming Challenges Faced by Ophthalmologists

38 Knowledge Without Borders A Q&A with Leading Experts

Asia-Pacific Academy of Ophthalmology

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LETTER TO READERS

Business as Usual in 2021 better. be l il w ar ye s hi T . er st sa di a as Last year w e. ar u yo re he w on s nd pe de er tt be How much

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e can all agree that 2020 was a bit of a train wreck, although how much of a train wreck depends on where you’re sitting today. If you’re in a country that locked down early and hard, things might be relatively normal by now. If you’re in a country that didn’t… you’re probably in lockdown right now, with sky-high COVID-19 case numbers. I live in one of those countries that didn’t manage to lock down promptly. For the second time in seven months, I’m forbidden from working in my office in the clinic. As I don’t see patients, I must work from home or face a large fine. The first lockdown was tough here: routine procedures had to be canceled, and only emergency patients were seen. Some clinics here in Switzerland never recovered from this drought of patients. And although our clinic was fine, it’s sobering to see colleagues going through rough times. However, the case numbers went down after the first lockdown, and things here were essentially back to normal for summer and autumn, apart from some face mask requirements in the clinic, shops, and public transport. The numbers (of patients seen) went up in the clinic. Those postponed transepithelial photorefractive keratectomy (trans-PRK) and cataract surgeries got performed in the end. And thanks to the mandatory mask requirements, it soon became clear to many fogged-spectacle wearers that refractive surgery might be a very smart move to improve the quality of their lives. It’s not boom times per se — mask requirements might have driven more patients to the clinic, but the combination of job losses, financial uncertainties, and furloughed workers receiving reduced pay has driven other prospective patients

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away. I think the general feeling here is that it could be worse.

few fun products in the pipeline coming our way. If you’re in a country where ophthalmologists have been put to use taking care of patients in COVID-19 wards, then frankly, 2021 is going to be a long year. I think the first few months, at least, will be more of the same. The only hope to be had is that the vaccines mop up the mess, and can be produced and deployed in sufficient numbers to make it happen (and hope that in the meantime, a mutant virus that these vaccines don’t work on doesn’t pop into existence).

In some respects, from a business perspective, we’re quite fortunate here. The current winter lockdown isn’t as draconian as before, and the eye clinics can remain open to all. Of course, this all ignores the human toll of the COVID-19 pandemic. I lost my father. Another colleague lost a grandparent. And as the year progressed, many more of my friends and family were infected by the virus. Foreign travel is essentially on hold until the world gains control over the virus. And although the COVID-19 vaccines are great news, they won’t stop COVID-19 completely. It looks like people will still be infected by the virus and be able to spread it — they just won’t be made so ill by it, or have the virus in their system for long. The virus can still mutate, and if it mutates to a point where the vaccine doesn’t work effectively, then we have a serious problem on our hands.

Here’s some good news: If you’re reading CAKE, you’re probably from a part of the world that has achieved good COVID control, and 2021 (in my view) will be far brighter than 2020.

Countries that remain vigilant in their quarantine, testing and tracing will do well. Those that can’t get their act together will suffer for longer.

In the meantime, I hope you all stay safe and well.

To be honest, I think this divide between regions that can get their act together and those that cannot will define the success of ophthalmic practices going forward. If COVID-19 is contained, people can go about their business with confidence. They can invest in the future and not have yet more disruption from lockdowns. Confident businesses and consumers tend to indicate more spending on the finer things in life, including refractive surgery. The rollout of vaccines throughout 2021 will further fuel confidence and a sense of normality, and there are a

The bigger picture is that no matter where you are, there will always be a demand for healthcare. Cataracts still need to be removed. Laser surgery still makes sense in terms of saving money on spectacles and improved quality of life. Life will go on, and livings will continue to be made. Who knows, maybe we’ll all see each other at Asia-Pacific Academy of Ophthalmology (APAO) 2021 in Kuala Lumpur in early August or the European Society of Cataract & Refractive Surgeons (ESCRS) Annual Congress in Amsterdam later in the month. If we do, then believe me, we will definitely celebrate the return to normality with CAKE.

Best,

Mark Hillen

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 SURGICAL PEARLS

Refractive cataract surgery can help prevent this very kind of situation.

How to Achieve Patient Satisfaction after Refractive Cataract Surgery by Olawale Salami

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esides visual acuity, patients demand a better quality of life after cataract surgery. At the American Academy of Ophthalmology (AAO) 2020 Virtual — held on November 13 to 15 last year — among the interesting topics discussed during one of the symposiums was how to provide patient satisfaction after refractive cataract surgery.

Preventing falls and reducing morbidity According to Dr. Daniel Chang of the Empire Eye and Laser Centre, California, USA, in routine cataract surgery, they start by extracting cataracts, and then they use glasses to correct astigmatism

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and presbyopia. “But in refractive cataract surgery, we try to do all these at the same time, surgically. Therefore, we should ask ourselves, what is the added advantage? Does refractive cataract surgery offer convenience for the patient,” he asked the audience. “By offering refractive cataract surgery, we can help prevent falls and reduce morbidity and mortality in our patients,” said Dr. Chang. “When we think about the option of refractive surgery in each patient, we try to weigh the risks and benefits,” he shared. Fundamentally, presbyopia treatment for each patient is not optional and will be treated either surgically or

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with glasses. “We consider convenience, patient satisfaction, safety, and quality of life from the surgical perspective, but we worry about the quality of vision, cost, night-vision symptoms and operating time,” he explained. On the other hand — as Dr. Chang elaborated — glasses’ benefits include noninvasiveness, adjustability, and fashion. However, risks include limited peripheral vision, depth perception, nose/ear irritation, and edge contrast sensitivity. The loss of edge contrast sensitivity and depth perception increases the risk of falls in patients using bifocal glasses. In the elderly, this is a particularly essential


data that suggests that over a third of falls in the elderly are attributed to depth perception problems with bifocal glasses.

to turn this frown into a smile,” he emphasized. “It is important to assess for possible occult macular pathology,” explained Dr. Swan.

These multifocal glasses-related falls result in over 250,000 hospitalizations and over 10,000 deaths. Those patients who are not injured develop post-fall anxiety syndrome. Overall, the impact of multifocal glasses-related falls in the United States is about 10 Billion USD every year. “Modeling has shown that if we adopted universal surgical correction of presbyopia in all patients, these would result in annual cost savings of about 14 Billion USD,” concluded Dr. Chang.

“Identifying patients who will be poor candidates for refractive cataract surgery goes a long way in reducing patient frustration,” explained Dr. Swan. There are many reasons for this, like irregular astigmatism or higher-order corneal aberrations or occult macular pathology. Preoperative testing should include topography, ACT, tear film analysis, aberrometry, K’s, and lens analysis.

Managing expectations of unhappy patients In the world of refractive cataract surgery, there are so many happy patients, according to Dr. Russel Swan, adjunct assistant professor at the University of Utah, USA. “However, occasionally, we find a patient who has some degree of frustration, and we want to find a way

“If we identify irregular astigmatism with a curable cause, such as Salzmann’s nodular degeneration, we can improve their higher-order corneal aberrations by repairing this or performing pterygium repair before cataract surgery,” added Dr. Swan. Preoperatively, it is also necessary to explain to patients that lenses have clarity and flexibility characteristics. Therefore, the limitations of glasses after cataract surgery must be well explained, vis-à-vis patients’ lifestyles

to understand their postoperative expectations. “Intraoperatively, some factors could be considered to improve patient satisfaction. These include the precise capsulotomy technique and the use of intraoperative aberrometry,’ Dr. Swan explained. “Overall, by far, the most common cause of low patient satisfaction is an uncorrected refractive error. Secondly, ocular surface diseases, like dry eyes, represent important causes of low patient satisfaction, which can be easily treated with medications and environmental modifications to maximize patient comfort,” he added.

Editor’s Note: A version of this article was first published in CAKE & PIE POST AAO 2020 Edition (Issue 4, page 4).

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ATARACT SURGICAL PEARLS

Congenital Cataract Surgery Tips from Experts by Tan Sher Lynn

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congenital cataract is the clouding of the lens of an infant’s eye, which happens before birth or during the first year of life. To enable normal vision development and prevent amblyopia or even blindness, congenital cataracts are typically removed by cataract surgery while the child is still an infant. During a CyberSight live webinar on congenital cataracts, held in August last year, Dr. Donny Suh, chief of pediatric ophthalmology and adult strabismus, Children’s Hospital and Medical Center, USA, and Dr. Serena Wang, associate professor at UT Southwestern Medical Center, USA, discussed various surgical techniques, instruments and tips for successful congenital cataract surgery. 

Dr. Suh on surgical planning and other important considerations In his practice, Dr. Suh usually operates when the baby is between 4 and 10 months old for unilateral dense congenital cataracts, and between 2 and 3 months old for bilateral dense cataracts. “Studies have shown that the risk of glaucoma is higher when cataract surgery is performed at less than 4 weeks of age,” he shared. “For bilateral cataracts, I usually wait two to four weeks before operating on the other eye. Bilateral surgery on both eyes on the same day is typically not recommended, with the exception of certain countries, where the cost and the risk of anesthesia is high, or

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when the treatment is not readily available,” Dr. Suh added. He stressed the importance of pre-surgery planning, which plays a critical role in ensuring surgical success. Factors he takes into consideration when planning for cataract surgery include: anterior chamber depth, size of eye/pupil, location of cataract, trauma, anterior segment dysgenesis, zonules status, and other anatomical abnormalities. Dr. Suh added that there are four factors which can cause a poor prognostic: unilateral cases, microphthalmia, other associated ocular abnormalities and systemic disease (e.g., uveitis).   “In my opinion, the most important aspect of cataract surgery, in pediatric as well as adult patients, is the anterior capsulotomy,” Dr. Suh said. “If you don’t have a good view of the anterior capsule, the surgery could become disastrous in a matter of a second. In order to avoid problems with the lens dislocating, the anterior capsulotomy opening should ideally

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be 5mm in diameter and the posterior capsule opening should be about 4mm, since the posterior chamber intraocular lenses (PC IOL) diameter is 6mm. If you make the anterior capsule opening bigger than that, there’s a chance of prolapse,” he explained. Another important consideration is whether or not to place the IOL. “Relative contraindications for IOL placement include chronic inflammatory disease such as juvenile


idiopathic arthritis (JIA), as well as nanophthalmos. I typically place an IOL in children who are 7 months or older and who have a corneal diameter of 9mm or more,” he added. According to Dr. Suh, the most critical part of cataract surgery is the anterior capsulorhexis as it sets the tone for the entire surgery. “Capsulorhexis is difficult to do in children because the anterior capsule is thinner, elastic, more convex in shape, and tears easily,” he explained. “The anterior chamber is also shallower in a smaller eye. And the sclera is less rigid, with a low IOP. So while you’re manipulating the tools, it can collapse and blur your vision easily.”  He further explained that the anterior surface of the adult lens is fairly flat. So when you’re trying to perform the tear in one direction, there’s a counterforce that’s going towards the opposite direction. “However, in pediatric patients, the anterior surface is pretty convex. When you’re trying to make a tear in one direction, there’s another force — the radial force — that’s going toward the center of the lens, resulting in the net vector force which is slightly diagonal,” Dr. Suh shared. “This is the reason why if you perform a 90-degree tear, it’s easy to tear into the periphery toward the equator and end up with a capsulorhexis that’s just small. To counteract the radial force, we want to tear it at 45 degrees.”  During lensectomy, it is advisable to remove all lens cortex as they tend to have a vigorous inflammatory response. Dr. Suh would typically remove the posterior capsule as well if he cannot perform the YAG laser within one year. “If they’re less than 5 years of age, or if they’re not going to be cooperative with the laser, I will directly perform the posterior capsulotomy and vitrectomy,” he advised.  

Dr. Wang on helpful techniques in using surgical equipment Besides pre-surgery planning,

an understanding of the surgical equipment is extremely critical in order to successfully perform congenital cataract surgery. Dr. Serena Wang shared the instruments that she’s been using and the special techniques she has developed for pediatric cataract management over the past 15 years. Her “cataract tray” comprises the Alfonso lid speculum without tabs, which works well for very small children; a 0.12 forceps (an essential instrument for pediatric cataract surgery) to hold the eyeball and keep it steady; knives, including the super sharp blade (for paracentesis); as well as the 2.5mm keratome and 3.5mm keratome. Another important instrument that she has been using for the past 15 years is micro-incision capsular forceps. “This instrument makes capsulorhexis so much easier and more controlled. As infants’ eyes are very soft and unstable, by keeping the incisions small, it is much easier to operate,’’ Dr. Wang explained, adding that she has two different tips for the forceps: normal scissors and side-cut scissors.  “These instruments are really helpful during complicated cases such as persistent fetal vasculature (PFV) and pupillary membranes, as they help you do the procedure better,” she added.   For bimanual procedures, Dr. Wang prefers to use the 20 gauge irrigation tip, which is more efficient as it helps to remove the cortex faster. “You can also use the 23 or 25 gauge, but I find the 20 gauge best. Whatever gauge you use, you want to choose the same size knife and you want to keep the wound tight in order to have a stable anterior chamber,” she explained.  At the webinar, Dr. Wang also showcased a video where she performed an anterior capsular vitrectorhexis bimanually. “I hold the 20 gauge irrigation cannula on my left hand, while my right hand holds the vitrector. Starting from the periphery, I go all the way across. I like to clean the subincisional first, as that is the most difficult part. The advantage of the bimanual procedure is that you can

switch hands. If you’re having trouble getting the subincisional cortex out, you can switch hands and start from the other end to remove the cortex. Before moving to the next step, I clean the periphery again to make sure that everything is removed. In any kind of surgery, the best way is the way that works for you. You will develop your own way as you find out what is the best and most efficient way to do things,” she shared.   During lens aspiration in adults, the nucleus is taken out starting from the center towards the periphery. But in children, due to the gel-like material of the lens, she prefers to start from the periphery using a “swipe clean” method. After that, she proceeds with posterior capsulotomy using the vitrector.  “During surgery, you want to keep the eyes fixated manually to maintain a stable anterior chamber,” Dr. Wang explained. “This is critical in pediatric cataract surgery, as a stable chamber makes the surgery easier.”  Another important thing to take note of, according to Dr. Wang, is to minimize the time you enter and exit the eye. “You don’t want to go in and out of the eye a lot. Every time you do that, you change the anterior chamber pressure, which increases the risk of the chamber collapsing and the posterior vitreous moving forward. Nevertheless, if something unexpected happens during surgery, do not take the instrument out immediately. The first thing to do is to stop and take a deep breath before deciding on the next step,” she concluded.

Editor’s Note: The CyberSight Lecture on Congenital Cataracts was held on August 21, 2020. Reporting for this story took place during the event.

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NTERIOR SEGMENT OCULAR INFECTION

The Diagnostic Value of Optical Coherence Tomography for Microbial Keratitis by Konstantin Yakimchuk

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nfectious keratitis is an ocular infection caused by various microbes, such as bacteria, fungi and protozoa. Some of its predisposing conditions include ocular trauma, contact lens wear, diabetes, ocular hypertension and rheumatoid diseases. Meanwhile, its clinical symptoms are hyperemia, pain, vision defects and inflammatory changes.

Diagnosing bacterial keratitis The choice of specific therapy demands identification of microbes causing keratitis. For bacterial keratitis, standard microbiological analyses are essential for the appropriate diagnosis. Classical Gram and Giemsa stainings provide a rather high specificity. Nevertheless, the culture of corneal scrapings remains a method of choice for diagnosing bacterial keratitis.1 However, microbiological analysis of corneal infection often provides negative results due to an insufficient amount of tissue in corneal specimens. Besides, an analysis might be subjective and the evaluation of therapeutic outcomes is challenging in the early phases. Several earlier studies have implemented coherence tomography for diagnosis of keratitis and related medical conditions. In particular, several clinical parameters, such as the thickness of corneal infiltration and retrocorneal morphology, were evaluated by coherence tomography in order to estimate the treatment outcomes.2

for visualization, analysis and monitoring the development of corneal inflammation. The process of recovery from corneal infection includes the early decrease of edema followed by declining infiltration.3 More recently, another study4 has identified localized and diffuse necrotic stromal cystic loci as histological patterns specific for fungal keratitis using spectral domain AS-OCT. This method applies infrared light and generates images of ocular tissues by capturing backscattered reflections. In the recent issue of Acta Medica Portuguesa, Dr. Mariana Almeida Oliveira et al., of Coimbra Hospital and University Center in Coimbra, Portugal, have considered AS-OCT to be an effective method to analyze bacterial keratitis.5 According to the authors, Spectralis® (Heidelberg Engineering, Inc., Heidelberg, Germany) OCT model S3300 (with anterior segment module) was performed on the patients enrolled in the study. Potential noise was reduced by averaging the images and angle variation. Following the scan, the patients were treated with antibiotics. In their study, Oliveira et al. aimed to identify specific patterns of microbial keratitis in patients diagnosed with bacterial, fungal or parasitic ocular infections.

A safer choice during the COVID-19 pandemic

Overall, anterior segment optical coherence tomography (AS-OCT) has been successfully implemented

Dr. Khor Wei Boon, a senior consultant with the Cornea and External Disease Service and the Refractive Surgery Service of Singapore National Eye Centre (SNEC), was invited to comment on the article of Dr. Oliveira and co-authors. According to Dr. Khor, “AS-OCT is an important instrument for anterior segment specialists, such

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The efficacy of anterior segment optical coherence tomography

as cornea, refractive and glaucoma surgeons. To date, the role of AS-OCT imaging in microbial keratitis has largely been used to demonstrate the extent of the infection, the depth of corneal thinning in advanced infections, and to monitor treatment progression.” As for the safety of AS-OCT, Dr. Khor confirmed that “as a non-contact form of anterior segment imaging, it is comfortable for the patient and also very safe, which is especially important in this age of COVID-19.”

Identifying morphological patterns Did the patients enrolled in the study have any risk factors? Ocular trauma and usage of contact lenses were the most common risk factors. Several patients had chronic diseases, such as diabetes and hypothyroidism. How does this study contribute to the current knowledge of microbial keratitis? By analyzing patients diagnosed with either bacterial keratitis, the authors have identified nine morphological patterns using the results of the scan. Among the identified patterns, the presence of solitary hyperreflective stromal lesions and edema indicated a more positive prognosis of keratitis, while pan-corneal inflammation correlated with more aggressive pathogens. In particular, corneal infiltration and edema have previously been found in microbial keratitis.5 Notably, infiltration and edema have been observed in nearly all keratitis patients at early stages. Furthermore, hyperreflective stromal edema was associated with better prognosis and might, therefore, indicate a low degree of keratitis severity. In the present paper, Oliveira et al. found these two patterns in nearly all patients in the initial stages of keratitis. Another pattern, corneal thinning, a serious symptom related to corneal melting, has been detected in severe bacterial keratitis caused by such pathogens as Pseudomonas aeruginosa and Streptococcus pneumoniae. In addition, hyperreflective lesions associated with the intact epithelium were observed by Oliveira et al. in Staphylococcus aureus-mediated


keratitis. Thus, AS-OST can be applied to estimate the size of hyperreflective loci and evaluate corneal thickness. Detecting patterns of fungal and protozoan keratitis In addition to bacterial infection, have the authors identified any specific patterns of fungal and protozoan keratitis? The authors reported that localized necrotic stromal cysts, which might be associated with necrosis, are not specific for fungal keratitis. On the contrary, such stromal cysts were found in both severe bacterial and fungal keratitis. For instance, Oliveira et al. observed cystic spaces in patients with keratitis induced by Citrobacter braakii. As for fungal infections, a previous study6 has detected hyperreflective dots in the corneal epithelium without spreading into the stroma in microsporidial keratitis. In addition, the dissemination of fungal abscesses into the anterior chamber was reported to be specific for the late stages of fungal keratitis.7 In Oliveira’s study, retrocorneal plaques were found in both fungal and bacterial keratitis. When it comes to findings specific for early protozoan infections, Oliveira et al. have identified similar patterns, such as hyperreflective stromal loci related to local edema and specific to the early stage of the Acanthamoeba infection. The hyperreflective features were observed mostly in the subepithelial tissue and might be associated with protozoan cysts. These observations were in line with earlier findings of hyperreflective round lesions

representing Acanthamoeba cysts.8 Another study has previously suggested that advanced stromal inflammation can be considered as a predictor of severity of Acanthamoeba-induced ocular infection. Limitations and alternatives Did the study have any weaknesses or limitations? Due to a cross-sectional design of the experiments, the authors were not able to evaluate the temporal sequence of corneal symptoms. Furthermore, the specimen size was too small to perform a statistical evaluation. Are there any alternatives to AS-OCT? Dr. Khor Wei Boon has suggested that “the use of confocal microscopy for the diagnosis of Acanthamoeba keratitis and fungal keratitis is well established. However, some of the drawbacks of confocal microscopy include the following: it requires contact with the ocular surface, it is dependent on the ophthalmologist’s experience in interpreting the images, and the confocal images are taken from only a very small area on the cornea.”

An effective tool in the analysis of microbial keratitis In conclusion, Oliveira et al. have demonstrated an effective application of AS-OCT for the analysis of bacterial keratitis. Thus, AS-OCT can be used for quantification and analysis of microbial keratitis. The authors have identified

REFERENCES: 1.

Kim, E. et al. Prospective comparison of microbial culture and polymerase chain reaction in the diagnosis of corneal ulcer. Am J Ophthalmol. 2008;146(5):714-723.

2.

Konstantopoulos A, Kuo J, Anderson D, Hossain P. Assessment of the use of anterior segment optical coherence tomography in microbial keratitis. Am J Ophthalmol. 2008;146(4):534-542.

3.

Konstantopoulos A, Yadegarfar G, Fievez M, Anderson DF, Hossain P. In vivo quantification of bacterial keratitis with optical coherence tomography. Invest Ophthalmol Vis Sci. 2011;52(2):1093-1097.

4.

Soliman W, Fathalla AM, El-Sebaity DM, Al-Hussaini AK. Spectral domain anterior segment optical coherence tomography in microbial keratitis. Graefes Arch Clin Exp Ophthalmol. 2013;251(2):549553.

5.

Oliveira MA, et al. Anterior Segment Optical Coherence Tomography in the Early Management of Microbial Keratitis: A Cross-Sectional Study. Acta Med Port. 2020;33(5):318-325.

6.

Thanathanee O, Laohapitakvorn S, Anutarapongpan O, Suwan-Apichon O, Bhoomibunchoo C. Anterior Segment Optical Coherence Tomography Images in Microsporidial Keratoconjunctivitis. Cornea. 2019;38(8):943-947.

7.

Vemuganti GK, et al. Evaluation of agent and host factors in progression of mycotic keratitis: A histologic and microbiologic study of 167 corneal buttons. Ophthalmology. 2002;109(8):1538-1546.

8.

Yamazaki N, et al. In vivo imaging of radial keratoneuritis in patients with Acanthamoeba keratitis by anterior-segment optical coherence tomography. Ophthalmology. 2014;121(11):2153-2158.

several histological features unique for different types of microbial keratitis. In conclusion, Dr. Khor said: “The article by Oliveira and colleagues has systematically documented the ASOCT findings of patients with microbial keratitis and tried to correlate it to specific pathogens. While it is very interesting work, larger studies need to be performed to see if these findings are replicable in other centers.” He added that although the diagnosis of microbial keratitis will still depend on a thorough history and clinical examination and the use of appropriate microbiological investigations, such as microscopic examination and cultures, AS-OCT might efficiently facilitate the assessment of inflammation in corneal layers and related prognosis.

Contributing Doctor Dr. Khor Wei Boon is a senior consultant with the Cornea and External Disease Service, as well as the Refractive Surgery Service of SNEC; head of the SNEC Eye Clinic at Sengkang Hospital; and the clinical director of Health Insights, the dataanalytics unit of SNEC. He completed his residency in ophthalmology with SNEC, and is a fellow of the Royal College of Surgeons of Edinburgh and the Academy of Medicine, Singapore. He then furthered his subspecialty training in cornea and refractive surgery with Professor Donald Tan in SNEC in 2011, and with Dr. Terry Kim and Dr. Alan Carlson at the Duke University Eye Center in North Carolina, USA, in 2012-2013. In 2006, Dr. Khor was part of the team of ophthalmologists that investigated an outbreak of Fusarium keratitis associated with a specific contact lens solution in Singapore. His published findings contributed to the worldwide alert over what was eventually found to be a global epidemic. In the same year, he, along with the rest of the team, was awarded Singapore’s first Minister of Health Award for Outstanding Performance in Public Health for his contributions. He has been published in respected peer-reviewed journals and has made presentations at numerous scientific meetings, both locally and internationally. His clinical and educational interests are in corneal infections, ocular allergies, lamellar corneal transplantation and the use of technology in ophthalmic education. khor.wei.boon@singhealth.com.sg

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NTERIOR SEGMENT OCULAR SURFACE

The Battle of the Bulge

Pathogenesis & Treatments of Thyroid Eye Disease by Jillian Webster

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lthough the ultimate causes of thyroid eye disease (TED) are not completely understood, there are significant correlations between genetic, environmental, and nutritional factors, as well as the location of TSH receptors of IGF1 receptors. For example, Graves’ disease — an autoimmune disease that causes an overactive thyroid, as well as demographics, may be correlated to the development of TED. In the future, this condition will hopefully be treated prophylactically. This and other topics about thyroid eye disease were discussed by Dr. Sathyadeepak Ramesh from Wills Eye Hospital in Pennsylvania, USA, during a webinar organized by CyberSight in November last year.

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Understanding TED’s pathophysiology According to a study by Ardley et. al., heredity may be a gateway into early detection of TED. Dr. Ramesh highlighted that there is evidence of genetic heritability of one of the early signs of TED — lid retraction. In a Punnett square presented by Dr. Ramesh, he showed that there are correlative characteristics in genetics regarding the experience of TED, especially in females. As well as genetics, the patient’s environment can also contribute to the development of TED. Patients with

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Graves’ disease are at much greater risk of developing TED. Although the inheritability of Graves’ disease is still debated, the attributes shown in the study display some correlation. Diet and other lifestyle choices may also be correlated to the risk of developing TED. Tobacco smokers with Graves’ disease are at the highest risk of developing it, with the risk diminishing if the patient stops smoking. Those with the least risk are patients who have never smoked tobacco and maintain a healthy body. A well-balanced diet is also a way to prevent many diseases, including TED. Dr. Ramesh referenced studies that may suggest a correlation between the presence of selenium, vitamin D, and other micronutrients, and the reduction in TED-related inflammation. He recommended regular ingestion of a multivitamin combined with a complete diet for dietary prevention.

TED’s clinical and medicinal manifestations The understanding of TED begins on a


molecular biological level. The disease is characterized by thyrotropin (TSH) receptors triggering antibodies that attach to other TSH receptors and cause stimulation of stem cells. Those cells can then grow into a multitude of different cells that then lead to orbital staining by thyroid receptors, inflammation, dryness of the eye, as well as several psychosocial impacts. Medical professionals should consider the individual case of each patient and look for ways to prevent the disease from occurring. If prevention is not possible, then there are a number of treatments available, depending on the stage of the disease and the comfort of the patient. A study highlighted by Dr. Ramesh looks at five patients from the onset of TED to quiescence. The study reports that TED continues in a curve fashion over the course of 18 months. Because of this research, ophthalmologists and endocrinologists can make accurate predictions regarding the progression of TED. According to Dr. Ramesh, TED has four clinical manifestations. The most common is eyelid retraction and occurs in 90% of cases. This is caused by inflammation in the levator palpebrae muscles surrounding the eyeball. It can be noticeable by pressure in the orbit that can cause discomfort or dryness of the eye. It can also cause significant physical changes. TED can not only affect the appearance of the orbital area but also to the lips, and cheeks — which can be a concern for patients. Common optical symptoms of TED are

proptosis (or displacement of the eye), congestion, and a feeling of ache in the orbit or the cranium. The most extreme orbital symptom is mild to severe optic nerve inflammation.

Treatment options Ocular surface disease is another clinical manifestation of TED. It can be divided into two types: inactive and active cases. Active cases are marked by severe inflammation of the eyelid as well and corneal staining. Treatment for active cases is usually topical steroids. Inactive cases normally do not display eyelid or cortical staining. However, the patient may find it hard to blink completely and might experience eye dryness. The treatment for an inactive case may be artificial tears or surgery. Steroids can help with inflammation. If the patient is bothered, then do a decompression on a stable patient. However, Dr. Ramesh suggests surgery for inactive TED. Surgical procedures are not the only treatment for TED. As mentioned before, Dr. Ramesh recommends a balanced diet in combination with a multivitamin to help prevent TED in all patients, especially those who may be prone to the disease. In addition, many recent clinical trials have received mixed reviews from the medical community. The most notable is one on teprotumumab. This FDA-approved drug and the only one approved for the treatment of TED, not only reduces symptoms but also

modifies the disease, altering the length and severity of its active phase. Topical and intravenous steroids may also be beneficial for individuals suffering from TED-related inflammation. Steroid application is useful in alleviating swelling and pain. However, it does not modify the disease itself. Orbital radiation is also a treatment that has produced some controversy. Dr. Ramesh said some researchers believe in the therapeutic abilities of this practice and some disagree. However, he does not recommend orbital radiation until orbital decompression has been performed. Surgery is the preferred method of treatment by Dr. Ramesh. He recommends orbital decompression after a patient has already had a reduction in inflammation due to steroid therapy. This procedure involves removal of bone in order to relieve the pressure from the orbital tissue. This procedure also has positive psychosocial outcomes. Orbital decompression not only can improve double vision due to orbital pressure but it can also allow for the physician to recreate the face of the patient before affliction with the disease.

Prevention is key Currently, treatment is aimed at improvement and stopping progression. However, in the future, molecular therapy will be used as a permanent solution before complications become permanent. These current treatments will not only help but also revert fibrosis. Prevention of fibrosis is key, but in the future, there will be a medication that will reserve this very difficult aspect of TED.

Editor’s Note:

During the CyberSight webinar, ophthalmologists peer into the future of TED treatment.

The CyberSight Lecture on Thyroid Eye Disease: Past, Present and Future was held on November 19, 2020. Reporting for this story took place during the event.

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NTERIOR SEGMENT OCULAR INFECTION Hospital in Cape Town, South Africa, reported that 52.1% of patients with ocular syphilis also had HIV.2 Similar findings have been reported in countries as varied as Ethiopia, Malaysia and China. The diagnosis of ocular syphilis in and of itself can be challenging due to lack of pathognomonic findings. This difficulty spurred a group of researchers in Shanghai, China to describe risk factors for ocular syphilis and clinical features of blindness. The study examined patients at the Shanghai Skin Disease Hospital; in the study, there were 8,310 new cases of syphilis, of which 213 had ocular disease and 50 were blind due to syphilis.

Rates of Ocular Syphilis Increase in Developed Countries by Andrew Sweeney

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f you followed Media MICE’s coverage of the World Ophthalmology Congress (WOC 2020 Virtual), you may recall some of the conditions we highlighted during the event. A national anti-cataract project in Ghana stood out, as did the treatment of ocular trauma in countries like Somalia where resources are limited. Another condition we focused attention on was ocular syphilis. We wrote at the time that ocular syphilis is not everyone’s “favorite medical malady,” but to be sure, it is a fascinating condition. Syphilis is insidious, diffuse and complex with a variety of symptoms and various stages of development. While it is, of course, most widely known in the lay community for its association with sexual contact, to ophthalmologists, it is most interesting because of a complication known as ocular syphilis.

syphilis, with onset of three to 15 years post-infection; however, it may occur at any stage of the syphilitic process. Ocular syphilis can involve almost any eye structure, with posterior uveitis and panuveitis being the most common. However, additional manifestations may include anterior uveitis, optic neuropathy, retinal vasculitis and interstitial keratitis.1 Ocular syphilis may lead to decreased visual acuity — including permanent blindness — and is most associated with neurosyphilis, the infection of the central nervous system.

Syphilis can literally rot your skull away

Ocular syphilis is usually associated with the tertiary or late stage form of

Our reporting on ocular syphilis during WOC 2020 Virtual focused on its frequent presentation concomitant with human immunodeficiency virus (HIV), a common problem in Africa. One study carried out by researchers from Stellenbosch University and Tygerberg

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The authors found that blindness from syphilis was restricted predominantly to patients with optic nerve involvement and not patients with isolated uveitis. At last follow-up, vision had improved in 24 of 67 eyes (35.8%) after treatment. The conclusion was that early recognition and diagnosis is vital to avoid permanent visual loss.3

Pandemics and the pox return However, before you start to believe that this is a problem of the developing world alone, think again. Over the last decade rates of syphilis have been rising in the developed world too, and it is rapidly becoming a silent public health crisis. As rates of syphilis infection increase in the Westen world, so too do rates of ocular syphilis. Take France, for example: The country has one of the highest rates of syphilis infection in Europe and the situation is worsening every year. This is driven by unsafe sex practices among men who have sex with men (MSM), with nearly two thirds (62%) of reported transmissions.. In one study, 21 cases of ocular syphilis were reported between 2012 and 2015 at a tertiary reference center in Paris, France.4 The occurrence of ocular syphilis increased from 1 case in 2012 to 5 cases in 2013; 6 cases in 2014; and 9 cases in 2015 (2.22–25.21/1,000 individual patients/year for the period). Among these cases, an annual 20


to 33% were co-infected with HIV. This study highlights both the growth in ocular syphilis in one country, while following a familiar pattern of association with HIV. These findings concur with another study into ocular syphilis in North Carolina, which examined 7,123 patients living with syphilis. Of these cases, 2,846 (39.9%) were living with HIV, 109 (1.5%) had ocular syphilis and 59 (0.8%) had both, with ocular syphilis being more prevalent in

patients with HIV compared to HIVnegative/unknown-status patients. The study went on to conclude that HIV-related immunodeficiency possibly increases the risk of ocular syphilis development in co-infected patients.5 So what conclusions can we draw about the increasing rates of ocular syphilis? For clinicians, it is recommended to screen for syphilis and especially ocular syphilis in patients who are HIV positive. For the general public, especially MSM individuals

in developed countries, increasing measures to ensure safer sex via protection should be taken.

Editor’s Note: A version of this article was first published in cakemagazine.org on January 29, 2021.

References: 1.

Clinical Advisory: Ocular Syphilis in the United States. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/std/syphilis/ clinicaladvisoryos2015.htm. Accessed on January 27, 2021.

2.

Matthew D, Smit D. Clinical and laboratory characteristics of ocular syphilis and neurosyphilis among individuals with and without HIV infection. Br J Ophthalmol. 2021;105(1):70-74.

3.

Gu X, Gao Y, Yan Y, et al. The importance of proper and prompt treatment of ocular syphilis: a lesson from permanent vision loss in 52 eyes. J Eur Acad Dermatol Venereol. 2020;34(7):1569-1578.

4.

Pratas AC, Goldschmidt P, Lebeaux D, et al. Increase in Ocular Syphilis Cases at Ophthalmologic Reference Center, France, 2012-2015. Emerg Infect Dis. 2018;24(2):193-200.

5.

Cope AB, Mobley VL, Oliver SE, et al. Ocular Syphilis and Human Immunodeficiency Virus Coinfection Among Syphilis Patients in North Carolina, 2014-2016. Sex Transm Dis. 2019;46(2):80-85.

CASIA2 A3 ëpîΩ_Resized-02-29-20.pdf

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2/29/20

11:55 PM

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image contrast under all lighting conditions. The wavefront-designed optic corrects spherical aberrations to almost zero and provides a sharp quality of vision. Furthermore, the design and optic material are not associated with glistenings and minimize light scatter. Less capsular phimosis has been observed with IOLs based on the TECNIS® platform resulting in minimal IOL decentrations and improved vision quality.6

Conquering Presbyopia with Innovative IOL Technologies TECNIS® IOLs take the lead with breakthrough technology for high-quality visual

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ith innovations in Intraocular Lens (IOL) technologies, the aim of presbyopia treatment has shifted from mere improvement in functional vision to total visual rehabilitation with reduced dependence on glasses, minimal refractive errors and improved quality of functional vision.1 The use of digital technology encompasses a significant portion of our daily activities today, making goodquality intermediate vision a necessity. The importance of intermediate vision in presbyopia correction is further highlighted by its requirement for potentially risky daily activities such as driving cars and navigating stairs.2

Though monofocal IOLs are the most widely used option for cataract surgery, they do not provide adequate intermediate vision.

Surgical success factors

Traditional monofocal IOLs do not improve intermediate vision and patients often require bifocal/ multifocal glasses for intermediate and near activities.3 However, these come with safety concerns, as bifocals have been associated with falls and hip fractures, a serious consequence for the elderly.4

The key to success in surgical correction of presbyopia lies in choosing the most suitable IOL and optic design for a particular patient. In the past, increasing the depth of field with presbyopia- correcting IOLs compromised visual quality and caused dysphotopsias.5 However, the TECNIS® platform from Johnson & Johnson Vision is made of superior optic material and has a unique design for high-quality visual outcomes. The optical material (mid-index, low dispersion) used induces the lowest amount of chromatic aberrations and provides the highest

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Though monofocal IOLs are the most widely used option for cataract surgery, they do not provide adequate intermediate vision. Further, despite meticulous biometry and power calculation, the refractive targets are often not met. The TECNIS EyhanceTM is a next generation monofocal IOL which extends the depth of focus to improve intermediate vision while maintaining distance vision similar to that of a standard aspheric monofocal IOL.7 The power in the TECNIS EyhanceTM increases continuously from the periphery to the centre of the lens, resulting in enhanced intermediate vision than a standard aspheric monofocal IOL.8 While the distance vision is maintained comparable with that of a monofocal IOL, there is no statistical difference in rates of photic phenomenon.9 Due to its larger landing zone it is more forgiving to inaccuracies in biometry, providing the patient with good uncorrected visual acuity even if emmetropia is not achieved.10

Increasing penetration of LED lighting into our homes and offices poses a challenge to presbyopia correction.

Innovations that enhance While multifocal IOLs offer greater spectacle-independence compared with monofocal IOLs, they are associated with symptomatic glare and reduced contrast sensitivity. Within multifocal IOLs, diffractive IOLs are associated with better near vision and decreased symptomatic glare and halos, compared to refractive ones. However, it is seen that extended depth-of-focus (EDOF)


presbyopia-correcting IOLs provide a superior or similar intermediate visual acuity, with similar or reduced rates of glares and halos compared with diffractive multifocal IOLs.11 The TECNIS SymfonyTM is an EDOF IOL with a proprietary diffractive echelette design, which elongates the depth of focus and provides an extended range of vision. The near and intermediate visual acuity is improved, while the distance visual acuity maintained is comparable to an aspheric monofocal IOL.12 In addition, the proprietary ChromAlignTM technology corrects chromatic aberrations and enhances the image contrast.13 As a result, the TECNIS SymfonyTM IOL is associated with a low incidence of glare and halos. Patients enjoy a continuous range of highquality vision from functional near to far, with no visual gaps between focus points, as seen with multifocal IOLs.14 Additionally, increasing penetration of LED lighting into our homes and offices poses a challenge to presbyopia correction. LED lighting produces a higher level of scatter due to the emission of shorter violet wavelengths resulting in dysphotopsias.15

Working with light TECNIS SynergyTM IOL is an innovation in presbyopia-correcting IOL technology to combat this challenge. It combines the EDOF and multifocal technologies along with a proprietary violetlight filtration system. The result is continuous high-contrast 20/25 vision from far through near without any vision gaps as experienced with other multifocal IOLs. Its performance

at near vision is outstanding, even at a distance of 33cm.16,17 The ChromAlignTM technology corrects chromatic aberrations and optimizes vision contrast. The IOL’s violet-light filtration system blocks the shortest wavelengths of light (violet), resulting in reduced light scatter, and consequently decreased halos. However, it allows transmission of the longer wavelengths of light for improved scotopic sensitivity and better low- light/night-time vision. The resultant superior low-light contrast delivers high-quality vision that patients need day and night. In clinical studies, violet-light filtration has been associated with improved daytime and nighttime driving.18 Additionally, the action of TECNIS SynergyTM IOL is pupil- independent, which translates into the best low-light performance compared to leading trifocal IOLs.19 The performance of TECNIS SynergyTM IOL has been praised by Dr. Francesco Carones, Medical Director and Physician CEO of Carones Vision, Italy who observed that “the TECNIS SynergyTM IOL smooths out visual gaps and continues to perform even as the light dwindles”. Dr. Frank Kerkhoff, Scientific advisor to Johnson & Johnson Surgical Vision endorsed the same view. After implanting the TECNIS SynergyTM IOL, he noted that his patients were able to read in low and dim-light conditions, which is unseen with other PC-IOLs. As Dr. Con Moshegov of George St. Medical Centre Sydney, Australia, attests for the continuous vision provided, “With the TECNIS SynergyTM IOL, seeing computer screens, dashboards, sheets of music and people’s faces across a small table is easy!”20

The TECNIS® family of IOLs continues to provide innovative solutions to cater to the visual needs of all patients with its revolutionary breakthroughs in presbyopia-correcting IOL technologies.

For more information visit the new Johnson & Johnson Surgical Vision Hub.

References: 1.

Talley-Rostov A. Patient-centered Care and Refractive Cataract Surgery. Curr Opin Ophthalmol. 2008;19(1):5-9.

2.

Data file on PP2019CT5038, The Burden of Cataracts

3.

Ibid.

4.

World Health Organization, (2004). What are the Main Risk Factors for Falls Amongst Older People and What are the Most Effective Interventions to Prevent These Falls? Retrieved from https://www.euro.who.int/__data/assets/ pdf_file/0018/74700/E82552.pdf

5.

Balgos MJTD, Vargas V, Alió JL. (2018). Correction of Presbyopia: An Integrated Update for the Practical Surgeon. Taiwan J Ophthalmol. 2018; 8(3): 121–140.

6.

Data file on PP2020CT4825, TECNIS® Portfolio of IOLs

7.

McNeil R. (2019) New generation IOL platforms designed for high quality visual performance after cataract surgery. Eye News Volume 25, Issue 6. Retrieved from: https://www.eyenews. uk.com/features/ophthalmology/post/newergeneration-iol-platforms- designed-for-highquality-visual-performance-after-cataract-surgery

8.

Data file on PP2019OTH4059, TECNIS Eyhance launch workshop

9.

Ibid.

10.

McNeil R. (2019) New generation IOL platforms designed for high quality visual performance after cataract surgery. Eye News Volume 25, Issue 6. Retrieved from: https://www.eyenews. uk.com/features/ophthalmology/post/newergeneration-iol-platforms- designed-for-highquality-visual-performance-after-cataract-surgery

11.

Sieburth R, Chen M. Intraocular Lens Correction of Presbyopia. Taiwan J Ophthalmol. 2019;9(1):4-17.

12.

Data file on PP2018CT5730, Getting Started Guide TECNIS Symfony TM IOL and TECNIS Symfony TM Toric IOL

13.

Ibid.

14.

Data file on PP2020CT4825, TECNIS® Portfolio of IOLs

15.

Data on file PP2019CT5141 TECNIS Synergy™ KOL Deck

16.

Johnson & Johnson Vision (2019). Johnson & Johnson Vision Introduces TECNIS Synergy™ IOL, a Continuous-Range-of-Vision Intraocular Lens (IOL) at the ESCRS 2019 Congress

17.

Data on file PP2019CT4746, TECNIS SynergyTM IOL Limited Launch (Emea) Message Map Guidance Document

18.

Ibid.

19.

Ibid.

20.

Johnson & Johnson Vision (2019). Johnson & Johnson Vision Introduces TECNIS Synergy™ IOL, a Continuous-Range-of-Vision Intraocular Lens (IOL) at the ESCRS 2019 Congress PP2020CT5522

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COVER STORY

An Industry Adjusts

Pandemic Impacts, One Year On by Brooke Herron

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nfortunately, 2020 will be forever known as the year that brought us COVID-19. With new common phrases like “Disruptions in Treatment,” “Emergent Procedures Only,” and “This Congress is Virtual” — both ophthalmologists and industry partners were left to navigate the pandemic’s new normal in the quest to deliver eye care.

2020: What the heck happened? In January 2020, the coronavirus was busy making its jump from China. It would then spread ruthlessly throughout the world, crippling healthcare systems and economies along its way. However, even then, not many of us realized COVID-19’s full “potential” — and that one year later, we still wouldn’t be out of the woods. Below, we speak with ophthalmology and industry experts to learn more about the pandemic’s impacts on anterior segment practice.

Let’s talk cash flow Dr. Lisa Nijm is a board certified ophthalmologist at Warrenville EyeCare and LASIK in Illinois, USA. She said that overall, as a specialty, surgical and in-office volumes are still not at pre-pandemic levels. “We have all had to make financial adjustments from the pandemic — ophthalmology has been hit harder than other specialties because of the

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greater proportion of our patients who are elderly, and therefore in a high risk category for COVID,” said Dr. Nijm. Dr. Harvey Uy is the medical director at the Peregrine Eye and Laser Institute in Makati, Philippines. He said that COVID-19 and the ensuing lockdowns hit practices like a freight train in the second quarter of 2020. Like elsewhere in the world, patient visits and surgeries decreased substantially. These devastating effects are still being felt a year later. “The pandemic hit both sides of the financial statement,” said Dr. Uy. Revenues plummeted at the start of the lockdown as patients were afraid of contracting COVID-19, while operational costs increased for things like added disinfection, personal protective equipment (PPE), and transportation. “Due to early shortages, the cost of these items was very high at the start.” Thanks to additional safety measures, he said they have been able to bring their practice back to a sustainable level. “Over time, business has improved and I believe we will end the year at least breaking even,” shared Dr. Uy. Dr. Cynthia Matossian, M.D. is the founder and CEO of Matossian Eye Associates, a combined ophthalmology and optometry practice with offices in New Jersey and Pennsylvania, USA. She said the pandemic has impacted her practice in incalculable ways. “The lockdown last March, which lasted a few months, created an unanticipated disruption in our cash flow as we were restricted to only see urgent and emergent vision-threatening cases,” shared Dr. Matossian. She said that today, all physicians are currently working longer hours to make up for

the months their practice was closed. Dr. Sudhir Singh is a senior consultant and head of ophthalmology at the Global Hospital and Research Centre in Mount Abu, India. He shared that the COVID-19 pandemic has changed medical practice significantly. “Now, we have ‘new normal’ protocols for office patients, and for medical and surgical treatments, which are more time and money consuming than before COVID-19,” said Dr. Singh. In addition, the number of medical and surgical patients has decreased. Working for a not-for-profit organization, there were limited opportunities to raise fund during the pandemic. To continue their charitable work, salaries were cut for six months. Dr. Singh shared that he has managed well during the pandemic due to his lifestyle, which is based on minimum necessities in his professional and personal life. “My fraternity in private practice had a substantial impact on their practices and business for the first six months of the pandemic. Most of them have had some financial strain to meet their expenses,” said Dr. Singh. Dr. Sibylle Scholtz is an international science correspondent and associate senior research fellow at the Institute of Experimental Ophthalmology, Saarland University, in Homburg, Germany. She, along with Prof. Achim Langenbucher, described the pandemic’s impacts in regard to IOLCon, an international platform with data on intraocular lens (IOL) characteristics and optimization of lens constants. In her line of work, Dr. Scholtz said COVID-19 has led to fewer patient visits and treatments, and less time to enhance lens biometry and lens power calculations while quality control systems were established. “Planning just isn’t possible as regulations are changing day-byday,” she said. However, Dr. Scholtz and colleagues have found time

to establish and enhance internal standards. This includes the use of databases for transferring the best formula constants to get the best visual performance after cataract surgery. They have also presented information about IOLCon at several international webinars.

Does anyone remember the “old” normal? In addition to financial losses, much time was spent to create the “new normal” in ophthalmology. This included hours spent developing protocols for the “new way” of seeing patients, as well as completing government financial relief documents. “Since most physicians are not accountants, nor do they have expertise in this area, many ophthalmologists found the completion of these documents to be very stressful,” said Dr. Matossian. Further, supplies like hand sanitizer, masks, PPE, and gloves were in short supply, as everyone was scrambling to procure these items simultaneously. Mail and distribution disruptions also caused them to run out of other commonly used products. In the Philippines, Dr. Uy agreed: “Resources were directed towards screening for COVID-19, sourcing PPE, instituting aggressive disinfection practices — all at a time when everyone was simultaneously pursuing the same items.” Thankfully, they were fortunate to receive PPE donations from patients and disinfectant from the Department of Health. He said that his greatest challenge was ensuring the safety of patients and staff as they formulated and implemented more stringent antiinfection policies and procedures. Dr. Uy credits the ophthalmic societies for being proactive and sharing information, which he said was “immensely helpful for formulating pandemic countermeasures”. Back in the United States, Dr. Nijm

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COVER STORY

She has also incorporated more digital education, which allows patients to learn more about their condition from the comfort of their home. “I also have conducted hybrid visits that allow patients to come in for testing and examination, while having most of the discussion via phone or video call,” shared Dr. Nijm.

Safety matters: Keep your COVID to yourself Around the world, ensuring the safety of both patients and staff has been paramount during the pandemic. New safety measures included limiting patients on-site, both in the waiting and operating rooms. said they were challenged to rethink each step of the patient journey to be more efficient and reduce waste. Further, constant mask-wearing posed its own set of problems: “From a patient perspective, many people rely on lip reading to assist with hearing — this has presented challenges when our lips are covered with a mask. From a physician and staff perspective, wearing a mask is an absolute necessity but it makes something as simple as drinking water throughout the day an extra chore.” 

Telemedicine offers a lifeline Telemedicine has also become a popular necessity to maintain patient care. And while ophthalmologists generally don’t shy away from new technology (at least as it relates to eyeballs), Dr. Matossian said that learning about telehealth and integrating it into practice within one to two weeks was quite a hurdle to clear. Meanwhile, Dr. Uy said they focused on developing a more “friendly”

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telemedicine system. Improvements included a dedicated mobile phone number for scheduling consults, an increased number of available telemedicine platforms, and more payment modes. Even so, telemedicine couldn’t cover everything. Many patients still needed to come in for diagnostic testing and a thorough eye exam, said Dr. Uy, who noted that home visits have also increased. Dr. Nijm said that since they’ve resumed office visits, the use of telemedicine has dropped. However, the door remains open for technology that enhances patient care. “I have been impressed with the number of patients who are willing to learn how to utilize technology,” she shared. “As holding family gatherings over Zoom has become more of the norm, patients who might not otherwise have been keen to use their smartphone or computer to connect with their doctor now consider that a reasonable option.”

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According to Dr. Uy, they created a “surveillance system” that involved rapid testing to screen and monitor patients and staff for potential infection. “Patients appreciated the rapid testing we instituted to screen for surgery — no one objected to the additional cost,” shared Dr. Uy. “We also designed and transferred Peregrine Eye and Laser Institute to a new and larger ambulatory surgery center [with more room for] social distancing.” Dr. Nijm also said that all patients must be preoperatively tested for COVID-19. “In the clinic, we have also employed additional precautions to protect patients and staff — from conducting screenings over the phone and temperature checks, to hand washing and social distancing in the office,” she said, adding that her patients appreciate the additional precautions. “They have been grateful for the extra time and attention to detail to ensure their safety.” Patients’ desire to make in-person office visits correlates with their condition, added Dr. Matossian. Those needing cataract or cosmetic blepharoplasty surgeries are waiting, while patients with progressive, sightthreatening conditions like age-related macular degeneration (AMD) are


keen to come in for their scheduled anti-vascular endothelial growth factor (VEGF) treatments. Dr. Nijm agreed with Dr. Matossian: Patients’ comfort level has been significantly affected. “I have had many patients who delayed seeking treatment for various eye conditions during the height of the pandemic,” she shared. “While most of them have returned, there are some who still do not leave the house very much and are not comfortable enough to have their second eye cataract surgery or glaucoma check.” Unfortunately for some conditions, not seeking treatment can have devastating consequences. “We witnessed many heartbreaking cases of patients with macular degeneration, uveitis, and acute glaucoma permanently losing vision because of delayed access to eye care —  these cases spurred us on to continue operations. Much credit goes to our frontline staff for braving the dangers and coming in to help care for patients,” said Dr. Uy. Meanwhile, in India, ophthalmologists face similar circumstances. “It is a challenge for medical professionals to serve society [during the pandemic]. We have lost thousands of medical professionals worldwide. We have lost hundreds of medical doctors in India, too,” said Dr. Singh. “It was an unprecedented challenge for me, like other medical professionals, to stay physically and mentally strong to serve society.” According to Dr. Matossian, these staff shortages are a continuing ramification of COVID-19. “Many of our staff either did not wish to return to work since they live in a multi-generational household and were concerned about bringing COVID home, or they felt the need to stay home to help their children with virtual school.   “Some of our staff had compromised medical conditions themselves, and did not wish to take the risk of

working closely with patients. For all of the reasons mentioned, we are short staffed. And according to many of my colleagues and experts in the field, this is a nationwide trend,” shared Dr. Matossian.

Silver linings appear, despite COVID-19’s best efforts Even though it may have felt that 2020 dealt us a bad hand, the year that brought us COVID also brought some positives, like more time with family. And this reduction in workload left many ophthalmologists with extra time on their hands — perhaps for the first time in a long time! “The greatest opportunity presented by the pandemic was the increased time to bond with family members and to focus on improving health and wellness. Many of our staff lost weight, exercised more, and had better interactions with their families,” shared Dr. Uy.  “The pandemic taught us that what really matters is family support and basic amenities,” agreed Dr. Singh, who has spent more time with family doing activities like going for nature walks, taking wildlife photography, and growing vegetables in the garden. He also used time during the lockdown to connect with his MBBS and MS mates, which wouldn’t have been possible preCOVID due to their busy schedules: “It was so refreshing and a stress-buster for us.”  Besides doing clinical work, Dr. Singh said he also used the downtime to catch up on studying, editing, and archiving surgical videos, and mentoring his postgraduate ophthalmology student’s research. “I evaluated free papers and video films for our All India Ophthalmological Society’s upcoming conference in 2021 and contributed to some of the national ophthalmology webinars,” he added.

productively: “I took advantage of the extra time during the height of the pandemic to design my first clinical trial. A quiet office was the perfect opportunity to set up the infrastructure needed for success in research.”   Additionally, Dr. Nijm launched a new website to help physicians improve their negotiation skills: www. MDNegotiation.com. “The pandemic highlighted the need for physicians to not only focus on lean practices, but to sharpen their business skills as well. After coaching and teaching negotiation skills for a number of years, I made the decision to launch this new educational venture to help ophthalmologists improve this crucial life skill during the pandemic,” she shared. Another silver lining? More efficiency and creativity with visits to ensure patients receive the highest level of care, all while minimizing the risk of exposure to COVID-19. “I also think this pandemic has challenged us to be better prepared for future unexpected interruptions in practice. I have spent a lot of time working with my staff to ensure we are well prepared to care for our patients should a resurgence of COVID occur in the future,” said Dr. Nijm.  Further, Dr. Uy saw the benefits of shifting physical meetings to an online format. “Physicians were able to learn just as much — or even more — by attending some of the countless webinars, virtual congresses and accessing online learning resources,” he said, noting the environmental benefits as well. Meanwhile, Dr. Matossian said at her practice they’re looking forward to a less stressful work environment in 2021. “Our goal is to exceed our pre-COVID levels by working in a more streamlined fashion and by shortening the patient throughput by compartmentalizing the non-diagnostic portions of the visit and completing those online beforehand in a HIPPAsecure manner.”

Dr. Nijm also used the downtime

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COVER STORY

The View from Within:

Industry Insights from Geuder Mr. Hamadi El-Ayari is vice president of sales and marketing at Geuder AG in Heidelberg, Germany. Geuder is a leading manufacturer of ophthalmic surgical instruments, devices and ultrapure biomaterials. As an industry partner, Mr. ElAyari shared his perspective on the pandemic’s implications. Mr. El-Ayari said the biggest impact is the loss of resources. “Geuder went into a government-sponsored ‘short-time working program’ to counterbalance the decline in demand,” he explained. “Many of our service and cooperation partners lacked resources, which caused delays in various projects and affected innovation. Implementation of the new medical device regulations has consumed resources, too.” Looking at specific segments, we’d likely see COVID-19’s impacts on an individual country basis. For example, when did the virus arrive, when did the government lock down, and which surgeries were elective, continued Mr. El-Ayari. “The number of phaco surgeries declined significantly in some regions (because they were postponed or cancelled). DMEK and corneal surgeries recovered rather fast, but we see a lack of donor availability in some countries. While vitrectomy was less affected, as many posterior pathologies are progressive, it’s not recommended to delay those surgeries,” he explained. “I believe refractive surgery experienced a boom as everybody got sick of foggy glasses while wearing masks.” Although physicians may embrace the virtual meetings and webinars, industry partners may find them to be less efficient and personal. “Ophthalmology and its technologies are complex. A personal conversation, wetlab, OR visit, or a hands-on discussion is difficult to replace with a video call,” said Mr. El-Ayari. He credits Geuder’s longevity — the company celebrates its 70th anniversary this year — with its

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success during this challenging time. “We maintain excellent and longlasting personal contacts with many ophthalmologists around the globe, as well as with our distribution and cooperation partners.” He said this has likely made it easier for Geuder to move into the more non-personal online realm versus a start-up, which may not have those established relationships. However, he said that as a mid-sized company, personal contact is also a key to their success. “You can’t have a chat with Mr. Zeiss, Mr. Alcon or Mr. Bauch & Lomb — but you can talk to Mr. Geuder.” So, how has the absence of physical congresses impacted Geuder’s business? Mr. El-Ayari said it’s difficult to measure, though it’s certainly had an impact. “Ideas for innovative new products always came from cooperation and personal conversations with surgeons… and the virtual alternatives did not really focus on personal exchange and communication. The visitor might follow the session live, or months later offline, but it’s more challenging for companies to directly interact with the key opinion leaders (KOLs),” he explained. “In a real conference, we are all there at the same time and place. We do not only meet at scheduled meetings, but we also meet casually [throughout the venue]. ‘Live’ is all about communication.” “Ultimately, we miss the personal contact very much and we look forward to the next bigger conference in order to feel like a fish in the water again,” said Mr. El-Ayari. Like the physicians we spoke with, industry folk are also optimistic about new opportunities in ophthalmology. Mr. El-Ayari said Geuder has recently launched various exciting innovations. This includes a comprehensive suture portfolio for glaucoma, like the Kodomskoi suture-probe for nonfiltrating glaucoma surgery — which has shown significant reduction of intraocular pressure (IOP) and offers a price-sensitive, state-of-the-art alternative to stent insertion, and the bi-manual intraocular micro-suture technique for IOL fixation or iris reconstruction, developed by Prof. Hattenbach.   “We launched new highly efficient

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phaco tips that reduce surgery time and a revolutionary multifunctional phaco distal chopper in cooperation with Dr. Jacobovitz,” shared Mr. ElAyari. “We also have a new DMEKunfolding cannula developed with Dr. Saad and have established the game-changing Descemet membrane endothelial keratoplasty (DMEK)RAPID preloading system — the first CE-certified system to preload a human donor Descemet-membrane, directly at the cornea bank.” Geuder has also enhanced its portfolio for posterior segment products. “There is so much more to come — and this is why we’re missing the personal communication and in-person meetings, and to celebrate our 70th anniversary and share our innovations,” he continued. “I do hope we will get back to inperson meetings, where you can meet the publishing doctor in front of his poster, drop your forceps for repair at the Geuder booth, or have a drink and chat and share gossip about God knows what — as this is vital, too,” concluded Mr. El-Ayari.

Editor’s Note: Mr. El-Ayari recently survived COVID-19 and we at CAKE Magazine are glad to hear it and wish him all the best.

Contributor Mr. Hamadi El-Ayari is vice president of sales and marketing at Geuder AG in Heidelberg, Germany. He also serves on the company’s executive board. In this role Mr. El-Ayari is responsible for the entire interface between Geuder and its customers, including its sales force in Germany and distributors in 120 countries, and serves as board director for the two sales subsidiaries in Singapore and India. He attended the University of Applied Sciences Frankfurt, Technical Engineering, where he focused on biotechnology, synthetics and polymer technologies and thermodynamics. In addition, Mr. El-Ayari holds six patents, with three pending. hamadi.el-ayari@geuder.de


Looking toward optimism and innovation in 2021 At press time, COVID-19 vaccines are in various stages of development and distribution around the world — but there is still a long way to go until things can return to “normal”. Until then, there is plenty of space for ophthalmic innovation. In 2021, Dr. Singh shared that, as a firm believer and proponent of affordable health for all, he will continue to focus on innovative surgical techniques that eliminate the need for expensive machines and technologies without compromising outcomes. “This was my focus, even before the pandemic,” he said. Dr. Singh invented an intratunnel

phacofracture MSICS technique. It costs about US$10 and eliminates the need for expensive phaco machines and consumables.

will likely be at least a short-term shift from tertiary hospital eye care to smaller, out-patient clinics,” concluded Dr. Uy.

While the pandemic continues, there are also opportunities in home diagnosis, monitoring, and sustained release drugs, said Dr. Uy. “There will also be a need for affordable, portable OCT, high-resolution fundus cameras, long-acting intravitreal medications, and drug eluting medical devices. Artificial intelligence will also be needed to interpret remotely generated images,” he continued. Further, home COVID-19 testing, such as saliva tests, will be the dominant method for screening patients in the future; while automated chatbots will take over routine practice queries and appointment scheduling. “There

Dr. Nijm said she is looking forward to new developments and innovations in diagnosis and treatment of myopia, presbyopia, and dry eye. “These are three very common diseases that affect a huge portion of the population worldwide and what I have seen coming down the pipeline is very exciting,” she shared. “In the surgical arena, I think the incorporation of AI, virtual reality and visualization will elevate the next generation of IOLs and cataract surgery. And as the number of patients with cataracts rises, we will need these advancements in technology to provide much needed care for these patients.”

Contributing Doctors Dr. Sibylle Scholtz is a biologist, chemist, Ph.D. in medicine, international science correspondent, and associate senior research fellow at the Institute of Experimental Ophthalmology, Saarland University Faculty of Medicine in Germany. She has long-standing experience in the ophthalmic medical device industry and in national and international medical device law. sibylle.scholtz@gmx.de] Dr. Cynthia Matossian, M.D., FACS, is the founder and medical director of Matossian Eye Associates, a practice with three offices in Pennsylvania and New Jersey. She is a consultant to numerous pharmaceutical and medical device companies and is on the leadership team of the American College of Eye Surgeons, the NY IOL Implant Society, and Women in Ophthalmology. She serves on multiple editorial boards, has published numerous articles, received the prestigious Ophthalmic World Leaders Visionary Award, and was included in the Ocular Surgery News’ Premier Surgeon 300 list. She is a clinical assistant professor of ophthalmology (adjunct) at Temple University School of Medicine. cmatossian@cmassociatesllc.net] 

Dr. Lisa Nijm is a boardcertified ophthalmologist at Warrenville Eyecare and LASIK, a licensed attorney, and an assistant clinical professor of ophthalmology at University of Illinois Eye and Ear Infirmary in Chicago. She also serves as the CEO of Women in Ophthalmology, mentors physicians through www.MDNegotiation. com, and advises leading medical device and pharmaceutical companies on new innovations in ophthalmology. She was the first surgeon in central Illinois to perform femtosecond LASIK, has taught over 2500 ophthalmologists as co-director of the Osler National Ophthalmology Board Review, and has received numerous honors and awards — including being named one of the top 50 most influential ophthalmologists in the world on The Ophthalmologist’s Power List in 2019. lmnijm@uic.edu] Dr. Sudhir Singh is a renowned ophthalmologist and is currently senior consultant and department head at JW Global Hospital Research Centre in Mount Abu, India. He completed his MBBS and SMS, M.S. Ophthalmology from Medical College Jaipur. He was trained in pediatric ophthalmology and strabismus by Orbis International. Dr. Sudhir Singh has been an invited speaker for various national and international conferences and has

performed live surgeries at various conferences as well. He has intratunnel phacofracture technique MSICS, SquintMaster software, and many other innovations to his credit. He has more than 30 national and international publications to his name, and is an awardee of the All India Ophthalmological Society’s prestigious “International Ophthalmic Hero Award 2020. drsudhirsingh@gmail.com] Dr. Harvey Uy, M.D., is a clinical associate professor of ophthalmology at the University of the Philippines, and medical director at the Peregrine Eye and Laser Institute in Makati, Philippines. He completed fellowships at St. Luke’s Medical Center and the Massachusetts Eye and Ear Infirmary and has been a pioneer in femtosecond cataract surgery, accommodation restoration by lens softening, modular intraocular lenses, and intravitreal drugs. He has published over 30 peer reviewed articles and is on the editorial board of American Journal of Ophthalmology Case Reports. He is a former president of the Philippine Academy of Ophthalmology and current council member of the Asia Pacific Vitreo Retina Society. harveyuy@gmail.com

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eR h o T

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ne thing is for certain: 2020 was one roller coaster of a year. Now, as we embark on a new year, many of the previous year’s challenges persist — the main challenge, of course, is COVID-19 and its related consequences.

Throughout 2020, Media MICE CEO Matt Young kept in virtual touch with both surgeons and ophthalmic industry partners as part of the Q&A from Quarantine video series. Below, we take a look at some of those highlights.

On twists and turns: “We’re very committed to doing the right thing. It’s a privilege for a company to be in a position where we can allocate our resources in this way.”

“I honestly don’t think we will come out of this and go back to the way that we were living. The idea of getting on a plane to go to a meeting and sit down in front of somebody, then discuss business as before is almost unthinkable,” — Kuntal Joshi, director, Asia -Pacific, SIFI Group

— Scott Korney, COO, Avellino

“[Practices should] stay solvent and look carefully at cash flow because it is going to be somewhat reduced. Now is not the time to go out and make a major purchase. I think that’s also going to impact the industry a little bit and that many of us probably won’t be buying the next instrument or diagnostic device right away ... most of us are going to be pretty careful about capital expenditures.” — Dr. Richard Lindstrom, founder and attending surgeon, Minnesota Eye Consultants, USA

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On reaching new heights: “Smart people who utilize this time and reinvent themselves probably will create new business models to add value to customers. [For example], in optometry, going away from lenses and frames to focusing on healthcare is a business model people should look at. From an ophthalmology point of view, business will have to go back to normal because patients will still need care.”

“We’re trying to look at what we can do to support our customers, ophthalmologists and patients. And I think we’ll end up with a bunch of best practices that we’ll continue to provide.[Medications to lower treatment burden] are going to be a major focus for our research and development teams... to look at areas where we can actually help ophthalmologists and patients to relieve burdens. I think that if you look over the next five to 10 years, the products coming from Allergan will have a major focus on lessening burden and helping patients.” — Charles Holmes, former associate VP and former head of Eyecare Global for AbbVie

— Shane Hage, regional director for AsiaPacific, Icare Finland

“You can do an awful lot without being in the office, and I think that’s going to be the new norm going forward. We are going to be living in a new era post-COVID. And I think it’s been a big eye opener for all of us, the whole world. Virtual care is going to become a standard of care for a lot of us. It’s not going to ever fully replace being in person — obviously we still have to do surgery, we still have to see people for certain things — but we’re going to be doing a whole lot of virtual visits. I find it to be very intriguing, very fascinating, and I certainly hope to help innovate it to some degree in this field going forward.” — Dr. Christopher Starr, ophthalmologist at Weill Cornell Medicine, New York, USA

On ups and downs: “A lot of the dry eye procedures are premium, cash procedures. Now, patients may say that ‘I’m going to use artificial tears, warm compresses, baby shampoo, tissues, etc.’ — then I might think about paying for a more premium procedure. As for cataract surgeries, you’re still going to have the Baby Boomers who are retired and whose finances didn’t really take much of a beating, unlike the working class — those of us under 65 to 70-years-old who are working toward retirement. I think that it will be the younger group that will be more conservative, financially. Those who are 40 to 50-years-old, they might not be coming in for LASIK or LipiFlow as often.” — Dr. Francis Mah, advanced corneal, cataract and refractive surgeon, California, USA

“How do you stay in touch with surgery when you’re not in the operating room as much as you want or need to be? There is a lot of anxiety about this — and there’s a lot of different ways we’re adapting to it. I tell people it’s like riding a bike: You’re gonna be okay. You’ll feel funny for your first couple of days back and then you get right back to it. We’re making sure that when there are surgical cases, our residents and fellows are in the operating room, so that they’re getting exposure to the limited amount of surgery that’s going on right now. For young eye surgeons that is by far the biggest concern that they’re facing during the COVID-19 pandemic, preserving their surgical skills.”

“In order to launch a product, historically, it required having individual conversations, professional education discussions, etc. Typically, these things happen at an in-person congress such as ASCRS, where we had plans to launch some products. Along with the safety of our people, having the right empathy for our customers is also very important. We would much rather try to understand how we can partner today and prop up ophthalmology. Then we can come together and help patients as we go forward — that is really the focus for us, and I want to make sure that our customers hear that.” — Warren Foust, worldwide president, surgical vision, Johnson & Johnson Vision

— Dr. Julie Schallhorn, ophthalmologist, San Francisco, California, USA

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UDOS COVID-19 SPECIAL REPORT

Back to Work Amid COVID-19 Developing Safety Practices & Effective Business Measures by Tan Sher Lynn

A

s restrictions ease in some parts of the world amid the ongoing COVID-19 pandemic, many are eager to get back to life and business. Nevertheless, there are various considerations in this new normal for doctors and ophthalmologists to take note of in order to resume their practices safely and efficiently. Kudos to the brave frontliners, medical practitioners and ophthalmologists around the world who have paved the way and established safety protocols for the rest of us to follow. During the American Academy of Ophthalmology (AAO) 2020 Virtual, US-based CEOs and ophthalmologists shared some of the effective protocols and business measures they’ve instituted to get back to practice safely and successfully amid the still ongoing threat of the pandemic.    

Managing finances in a reduced service environment

USA, ophthalmologists face various challenges as they prepare to reopen their practice. “For me, the challenge is to resist the urge to plan as though this is a brief practice closure after which all patient volume, cash flow, staffing and processes will return to previous levels. This is not likely to happen,” shared Dr. Hulett.   Instead, she recommended adopting a philosophy of zero-based budgeting — looking at purchasing and staffing anew, based on the business you have or will have in the next few months, as opposed to last year or what you hope to have in the coming years.  “The most valuable staff members you have are those who can and are willing to fill multiple roles in your smaller volume practice, such as techs who can triage and scribe, and surgery schedulers who can staff the phones and check in patients,” she said. 

According to Dr. Ann M. Hulett, CEO of EyeHealth Northwest in Oregon,

She also stressed the importance of knowing one’s current financial state

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(regardless of the point in the recovery process). This includes being aware of account balances and lines of credit, keeping track of and projecting cash flow, as well as knowing how much stimulus money has been used, and when it needs to be repaid.

Transforming patient experience For Dr. Sonny Goel from Maryland, USA, in the post-COVID new normal, it’s important to make changes to increase the safety of employees, physicians and patients.  “Patients won’t come to the clinic if they don’t feel safe. So, how can we do this? Some ways include communicating this goal to employees and patients, maximizing the use of telehealth, ensuring in-office precautions are in place and limiting patient movement, as well as time in the clinic,” said Dr. Goel. Pre-COVID, patient histories and examinations were done in-office, exam results were discussed, and the patient called if they had any questions. But post-COVID, Dr. Goel suggested that physicians take patient history in advance via telemedicine, then educate and discuss surgery online.  “When patients arrive at the clinic, the examination is done to confirm the diagnosis and discuss consent. The patient will make three stops at the clinic: at the door for a temperature check, at the technician room and


finally, the examination room before exiting. This ensures a smooth flow and minimizes the time they spend in the clinic,” he added. In terms of the office environment, Dr. Goel suggested placing fewer chairs in the waiting room, installing plexiglass screens at the front desk, using air purifiers, removing magazines, and limiting visitors by asking them to wait in the car.

Safety tips for reopening According to Dr. Julia Lee, CEO of Vantage EyeCare, USA, as physicians resume their operations, it’s essential to understand federal guidelines as well as regional implementation, and check for updates early and often, as not every change is announced. As for staffing, Dr. Lee shared: “After years of staffing for efficiency and optimization, we suddenly find ourselves having to staff for safety,” noting that higher risk of transmission from infected individual comes from close contact (within six feet), prolonged contact (greater than 10 to 15 minutes), and unprotected contact (without universal masking).  She added that the effort is about mitigating the risk of transmission.

This means assuming that everyone is COVID-19 positive, screening for signs and symptoms with enhanced universal precautions; and finding out if the patient has recent exposure to people who are COVID-19 positive. She also advocated controlling the pace of patient flow and adopting social distancing within the facility, as well as enhancing environmental cleaning.   Dr. Lee suggested that for patients coming for appointments, cloth masks are sufficient, but they should be clean and secure over the mouth and nose. Meanwhile, health care workers who are in direct contact with patients should wear medical or surgical masks.  As for hand hygiene, gloves are recommended for all contact with patients and should not be reused. “Gloves should not be washed or sanitized between use. If gloves are in short supply, use it for the dominant hand only and do not touch the patient with your ungloved hand. Wash both hands immediately after,” she said.  Dr. Lee also recommended having frequent “hand hygiene breaks” for staff, keeping nails no longer than one quarter inch beyond the fingertips and discouraging artificial nails on healthcare workers, and wiping down

all high touch surfaces and objects frequently.

Human resource considerations Dr. Benjamin M. Higginbotham, chief operating officer of West Coast Retina, USA, recommended paying staff bonuses and using pandemic-related incentives to compensate for the added risk of returning to the office. “Having a flexible work schedule can help alleviate some of the stress that staff who are parents face, as schools may be closed. And even if they are open, it may take more time to drop off or pick up their children due to social distancing,” Dr. Higginbotham shared.   “It’s also time to reimagine your workflow. Discuss this with your employees. Will you continue to work from home? What can and should you automate? What can you do to limit the time your patients spend in your office? Should you outsource? Will you be deleting or adding roles, for example, hiring a daytime cleaning staff?” According to Dr. Higginbotham, hiring, training and retention of staff are expensive. “Making the decision to terminate an employee causes shortterm savings but a long-term increase in expenses. However, one bad apple does spoil the whole barrel. Forcing a negative employee to come back early could hamper your recovery efforts,” he added.  “Lastly, take breaks. You don’t have to have all the answers all the time. Share the responsibility whenever possible. Remember to take time for yourself to prevent burn out,” he advised.

Editor’s Note: The American Academy of Ophthalmology annual meeting (AAO 2020 Virtual) was held from November 14 to 17, 2020. Reporting for this story took place during the event.

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CORPORATE CORNER

with COVID-19. What made this outstanding was that it was published according to the hybrid format, too, vastly increasing consumption opportunities. The 200-page document is still available to be read online.

Hybrid Conference Format — Here to Stay by Andrew Sweeney

T

he nature of ophthalmology’s various conferences abruptly changed this year. In fact, we are now all experts in webinars and online networking. And we all know that when any change is repeated over a long period of time, it has the habit of becoming permanent. Thus, it’s safe to say that expert webinars and other online events are set to become a permanent feature in the postCOVID-19 world.

Old-school, but hybrid However, this does not mean that this is the end of old-school, in-person conferences. Far from it — there is still considerable demand for real world events, as the recent Evolving Practice of Ophthalmology Middle East Conference (EPOMEC) held last month in Dubai, United Arab Emirates, proved. “Real world” conferences will continue to go ahead, they will just be somewhat different.

It is this last factor in particular that will likely make the hybrid model permanent in the coming years, as it opens up ophthalmology conferences to new audiences. That is according to Dr. Namrata Sharma, Hon. General Secretary of All India Ophthalmological Society (AIOS) and professor of ophthalmology at the All India Institute Of Medical Sciences (AIIMS), New Delhi.

Slowly and steadily getting back to normal Sitting down with Media MICE CEO Matt Young, Dr. Sharma revealed AIIMS’ conference plans for this year. “The future meeting that we plan to hold is in 2021, and it is going to be held on a hybrid platform, as most will now be. Some halls are going to be physical and some are going to be virtual. We made this decision as people from overseas may not be able to travel to India,” shared Dr. Sharma.

EPOMEC was organized and held according to a hybrid format — that is to say the conference was still organized in-person with the usual symposiums, concession stands, and schmoozing. But it was also held online. Visitors were able to check into the virtual lobby from around the world without having to endure a diminished experience. This allowed both those living under travel or financial restrictions to attend and enjoy the full EPOMEC experience.

“With a click of a button, you would still be able to learn and educate yourself on whatever you wanted — the nuances of surgery or procedures or investigative modalities, etc. It really opens up the ophthalmological field,” she said.

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Dr. Sharma reported that AIIMS renewed its educational efforts for staff during the pandemic, producing guidelines on many aspects of coping

This effort was achieved in tandem with other stakeholders, including the Oculoplastic Society of India and other subspecialty societies. Another note for optimism is an increase in non-emergency ophthalmological procedures, which were stymied by the pandemic. Dr. Sharma said clinics are reporting more activity and more procedures are planned. “I think ophthalmology is getting back to normal, say to about 70% of normality. When the pandemic is over, there will also be a bounce effect, so I am optimistic. Once the physical world comes back, the online world will be able to supplement it too,” Dr. Sharma concluded.

Contributing Doctor Prof. Namrata Sharma is a professor of Cornea, Cataract and Refractive Surgery Services at Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. She has done her fellowship at Moorfields Eye Hospital in London, UK. She is Hon. General Secretary of All India Ophthalmological Society, as well as Regional Secretary of Asia-Pacific Academy of Ophthalmology (APAO). Prof. Sharma has two patents under her belt (Natasol & Natamatrix), and is a brand ambassador for The Tear Film and Ocular Surface Society (TFOS-DEWS II) in India. Among her international awards include the following: Senior Achievement Award, American Academy of Ophthalmology ( AAO); International Ophthalmologist Education Award, AAO; Best Video awards by ESCRS, RANZCO and “Best of Show” awards 6 times by AAO; APAO Leadership award; and APAO Achievement Award. Prof. Sharma has also published 450 publications in international peer reviewed journals and authored 17 books and instruction courses at several International and national platforms. In addition, Prof. Sharma is a principal investigator in many multicentric international, FDA trials, and RCTs which, have changed the clinical practice. secretary@aios.org


NLIGHTENMENT DISASTER S.O.P.

n a ! t C ’ n n e a o l h D kt P a c i K ake —M dne e r a rep on P r e ast by Sam McComm Creating a Dis

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obody likes to think about disasters. Whether you’re talking about wildfires, earthquakes, tornadoes, hurricanes or extraterrestrial invasions, our minds have a tendency to relegate such possibilities to some distant, non-real future. After all, who wants to spend time worrying about something you can’t do anything to stop? Unfortunately, as a medical practitioner, it’s your responsibility to prepare for disasters. Fortunately, on the other hand, you can do plenty to be prepared for such events — even if you lack the power to prevent them in the first place. A presentation at the American Academy of Ophthalmology annual meeting (AAO 2020 Virtual) by Mrs. Shawn Carter (COE, OCS), held on November 17, 2020, provided valuable insight as to how best to prepare your practice for disasters. While you certainly shouldn’t spend all of your time worrying about and preparing for catastrophe, getting ready for such an eventuality can spare you and your practice significant pain in the long run. As the saying goes, “When

lan P s s

in

gy o l o lm a hth p O

disaster strikes, the time to prepare has passed.” So, let’s dive into the steps laid out — none of which are radical, but all of which are practical.

Do some research Before you begin, of course, you’ll need to consider your particular circumstances. What natural disasters might affect you? Which ones have occurred recently? Are natural disasters common in your area? For example, while it would be silly for someone in California to prepare for a tornado or hurricane, making plans for a wildfire or earthquake would be prudent, indeed. And while someone in Florida need not prepare for a devastating blizzard, hurricane preparation is simply a necessity. Each region of the planet comes with its own risks. You get the drift. There’s plenty to research when it comes to your own practice, too. What are the critical areas or functions you

can’t do without? What would you be willing to sacrifice in a disaster? Mrs. Carter recommends conducting a stress test on your business to see just how you’d do afterward: construct a scenario or set of scenarios and see how they play out. This is how the military prepares for all sorts of eventualities. If you’re in the U.S., ready.gov has some valuable advice for disaster preparedness. Other websites like NOAA Disaster Preparedness can be useful as well. Plenty of others specialize in disaster preparedness. You don’t need to reinvent the wheel.  You should also have plenty of contacts available. Besides the obvious emergency services, think about writing down contact information for utilities, insurance, the local sheriff, and create an employee phone tree. 

Map out emergency action plans Mrs. Carter recommends creating an emergency action team based on

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NLIGHTENMENT DISASTER S.O.P. individual skills. For example, assign equipment removal to certain staff members, or delegate patient and staff assistance to others. Keep in mind your staff’s individual skills and knowledge sets and feel free to ask them for suggestions for suitable roles. You should also create a disaster box, with backups of all sorts of goodies you might find useful: flashlights, batteries, non-perishable food, bottled water and first aid supplies. This could be one short-term expense that you forget about entirely until you actually need it.  Create an evacuation plan that’s up to date, and consider updating it if circumstances have changed. In a single-story building, this can be very simple; in a large complex, less so. Every employee should know the plan and it should probably be rehearsed once a year.  Perhaps most importantly, create a checklist that helps you determine how to act in given circumstances. At what point do you cancel patient appointments? What compels you to call emergency services? When would you continue with business as usual? Who handles emergency liaison with patients and emergency services? Each type of disaster comes with its own set of factors you’ll need to consider when making these decisions. A checklist can

greatly help everyone be on the same page.

Protect your practice Of course, you’ll want to protect your practice and the people in it. While people aren’t replaceable, much as medical equipment is — data isn’t, unless it’s backed up. Talk to your IT department to ensure you have appropriate backup plans for any valuable data. Similarly, make sure you’re familiar with your insurance policies and that they cover the disaster you’re preparing for. And even if they do, how much are your deductibles?  As mentioned above, make a plan to protect your equipment. Have a plan in place to move it somewhere safe, if possible. 

Plan post-disaster recovery steps Mrs. Carter points out that it’s quite hard to plan for any recovery postdisaster because you’ll have no idea of the effects until it’s over. Perhaps nothing will happen, or perhaps your clinic could be swept away by a tornado and land in Oz.

The steps you take afterward will depend on the circumstances, but there are some guidelines to keep in mind. The following steps assume no one has been injured, which should clearly take first priority. First, make sure to take note of any damage with a notepad, pen and camera. That will be valuable for insurance. Rank the damage in terms of significance and note any financial costs. This can help you get an idea of just how hard you’ve been hit.  Second, reassess your financial position. If you’ve been badly hit, will you need to talk to your bank, the tax office or your accountant? Will you need a loan? Projecting recovery costs can help you determine the amount of work you’ll need to do.  Third, look for help if you need to. Colleagues, family, employees or the community may be willing to pitch in to help. There’s absolutely nothing wrong in asking for help if you need it — especially since you provide both medical care as well as jobs.  Fourth, and related to the third, find a way to get your employees back to work. They’ve got financial obligations and families to feed. Consider telework or a temporary location, and arrange for replacement equipment while making sure your employees’ workspace is safe.  An ounce of prevention… Physicians of all people understand how important prevention is. With your plan in place and rehearsed, you’ll be ready for the worst. Hopefully, it never comes — but if it does, you don’t want to be caught like a deer in the headlights.

Editor’s Note: The American Academy of Ophthalmology annual meeting (AAO 2020 Virtual) was held from November 14 to 17, 2020. Reporting for this story took place during the event.

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NLIGHTENMENT VISION REHABILITATION

A Guide to Helping Your Low Vision Patients by Elisa DeMartino

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n the next 10 years or so, we’re going to see a growing number of visually impaired individuals — particularly in the aging baby boomer population. However, low vision also disproportionately affects other vulnerable people, such as those with low-income, smokers, diabetics, and people with chronic diseases. In a knowledge-packed, on-demand session on the first day of the American Academy of Ophthalmology (AAO) Virtual 2020 — held on November 13, 2020 — four experts outlined the importance of incorporating the needs of low vision patients into your practice.

Recognize the impact of vision loss Dr. Marc D. Bona introduced the topic by calling to attention the importance of visual impairment treatment in ophthalmology. He sought to increase ophthalmologists’ understanding of vision rehabilitation and how to approach the issue with patients. A patient-centered approach is crucial because people have different demands and will tolerate varying degrees of vision loss. Dr. Bona also pointed out that low vision makes someone twice likely to fall and four times likely to experience a hip fracture — along with that, a tendency for activity restriction, increased depression, and social isolation. They may also have difficulty driving, working, or even just carrying out simple daily tasks. “Developing strategies to overcome these barriers is a key part of the vision rehabilitation process,” Dr. Bona stressed, going over what ophthalmologists can do in their process of diagnosing low vision, educating patients, and directing them towards appropriate rehabilitation.

Understand the benefits of a low vision test Dr. Donald Calvin Fletcher — with over 30 years of low vision practice in his Wichita office — covered several of the same points but elaborated on testing technique. He is, in particular, a proponent of the SK Read test, explaining that the jumbled words can identify a pattern of mistakes where patients’ vision compensates. For instance, if the patient has a scotoma to the right, they may see the word “saved” as “save”. Another main focal point in his presentation was the need for better training with assistive devices. “Too often, we think about low vision rehab being, ’oh, give the person a magnifier [and] we solve all the problems for them’ — not the case.” He elaborated by telling a touching story of a patient who had loved to bowl but stopped since becoming visually impaired. His therapist accompanied him to the bowling alley and demonstrated how to use the magnifier. “With that little magnifier,” Dr. Fletcher explained excitedly, “he felt like he could be part of his social network again. He could push the buttons and be with the guys. And that was significant to him.”

Outline strategies for helping your patients Michelle Eileen Buck, OT and CLVT with the Henry Ford Health System, continued to outline in detail what specific tasks become impossible for low vision patients. She provided simple tips to incorporate, such as increasing lighting, minimizing glare with visors or light-colored sunglasses, and maximizing background contrast by, for instance, choosing a colored cutting board during meal prep. She also reviewed vision technology,

audio technology, and transportation alternatives while offering a final plug for low vision support groups. “Interacting with others who are going through the same circumstances will give low vision patients the opportunity to ask questions to the group and get new ideas and strategies about how to manage everyday tasks,” Dr. Buck shared.

Plan different models of care in low vision rehabilitation The session was brought to a close by Dr. Anne Riddering, OT and CLVT with 25 years working in rehabilitation with the Henry Ford Health System’s Center for Vision and Neuro Rehabilitation. She narrated a brief history of vision rehabilitation from the 1920s until now. Afterwards, Dr. Riddering got into some numbers, predicting that the amount of elderly and legally blind people in the United States would double between 2015 and 2030. She pointed to three studies that emphasized the prevalence of multimorbidity in vision-impaired people. After stressing that vision rehabilitation is a prevention tool for falls, lack of independence, problems taking medication, and depression, Dr. Riddering provided some final encouragement. “Studies examining outcomes have shown that after participating in visual rehabilitation programs, subjects show improvement in the following areas: visual abilities or function, including reading and mobility tasks, self-esteem, quality of life, and general health. We don’t just save eyes, we save lives,” concluded Dr. Riddering.

Editor’s Note: A version of this article was first published in CAKE & PIE POST AAO Edition (Issue 2, page 4).

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CONFERENCE HIGHLIGHTS OIS COVERAGE

What Drives Drug Delivery Strategies in Ophthalmology? by Olawale Salami

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rug delivery technologies are often designed to improve the pharmacological and therapeutic properties of already approved drugs. While they offer an obvious way of tackling high unmet needs, like treatment burden reduction or creating lifecycle management solutions for existing products, these strategies are still not widely adopted by many companies, but instead looked upon opportunistically.

Are we there yet? During a panel discussion at the OIS Retina Innovation Showcase — held on September 10, 2020 — Dr. Sharon Bakalash, founder and CEO at SB Strategic Development Consultants, an expert in drug delivery technologies, along with other expert panelists in the field, shared her thoughts on accelerating the most promising innovations in the field of ocular drug delivery.

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Dr. Bakalash noted: “Historically, pharmaceutical companies have shown some unwillingness to acquire or invest in drug delivery technology companies”. What are the possible reasons for this? The panelists shared their thoughts. Dr. Joshua Horvath, Ph.D., director, device and packaging development, Genentech: “We don’t always have the skill sets in pharma companies to evaluate these technologies, specifically in ophthalmology, where we’ve seen many failures in drug delivery technologies — mostly at the preclinical level. While we might have the money to invest, we don’t have the workforce needed to thoroughly review these ideas. So we need our partners to do some of that legwork upfront.” Dr. Casey C. Kopczynski, Ph.D., chief scientific officer and co-founder Aerie Pharmaceuticals: “I think the reason for this is that for drug delivery technologies, there must be some form

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of relatively advanced proof-of-concept and a lead that demonstrates the power of the technology — that should at least be clinic ready. I think platform technologies, in general, are more difficult to value because you are trying to agree with a potential partner on the value of a product that perhaps hasn’t been fully contemplated yet.” Dr. Jim Cunningham, executive director of drug delivery and pharmaceutical development, Allergan: “I think the addition of novel delivery technologies to new molecules adds time, costs and risks. But the added risk is justified in areas like eye care when we’re focused on local delivery and where outcomes in real-world use are limited by poor compliance.” Dr. Reza Haque, MD, Ph.D., senior vice president and global head of ophthalmology innovation, Santen: “One of the critical challenges we have today in developing new drug delivery solutions is improving


our understanding of these drugs’ kinetics.”

Roadblocks ahead Dr. Bakalash stated that drug-device combinations’ commercialization has always been seen as a challenge for many big companies. The panelists discussed this extensively, drawing from their wealth of pharma industry experience. According to Dr. Horvath: “Regarding plans to bring these combinations to market, it’s not enough to have a drug that works with these combination products. The user can make or break the product. Therefore, having these products in the hands of an ophthalmologist as early as possible in the development process can save many troubles later.” Dr. Kopczynski said: “The potential for commercialization depends on whether the delivery system is combined with an approved or new drug. For an approved drug, therefore, the question is, how well does the pair have to work for the patients to pay a premium for that technology? These questions have huge implications on pricing.” Dr. Cunningham noted: “Demonstrating differentiation and value in a realworld setting is vital. One of the unique challenges with combination products is that these are traditionally distinct worlds, and a combination product is more than the sum of its constituent parts. Integration is critical throughout the entire development and commercialization life cycle, and the earlier this is done, the better. Ultimately, it depends on the need. In certain areas with high unmet patient need, it can be worth taking the risk of combining a new molecule with a new drug delivery system.”

Next stop: The age of gene therapy for ocular diseases Eyevensys, a French biotech company with dreams the size of a 747, has developed a superb way to deliver gene therapy for the treatment of eye diseases — the EYS606 non-viral gene therapy.

“Once injected, the ciliary muscle becomes a biofactory that secretes specific therapeutic proteins into the posterior segment.” – Prof. Francine Behar Cohen According to Prof. Francine Behar Cohen, the CEO of Eyevensys: “Using an innovative technique that allows the expression of any therapeutic protein inside the eye through a nonviral method, this minimally invasive procedure has excellent potential for improved safety, patient compliance, and clinical outcomes.” Impressive preclinical results have led to ongoing phase 1/2 trials that aim to evaluate this technology’s proof-of-concept in patients. What exactly is EYS606? According to Prof Cohen: “Eyevensys’ EYS606 is a technology made of three components: first, a plasmid DNA with a proprietary plasmid backbone that allows the incorporation of any gene encoding any therapeutic protein; second, a device applied on the eye surface under topical anesthesia; and third, an electrical pulse generator. Once injected, the ciliary muscle becomes a biofactory that secretes any therapeutic protein into the vitreous and posterior segment. Direct administration of plasmid into the ciliary muscle is carried out using a proprietary electrotransfection method. We have a robust pipeline covering several indications, including wet and dry AMD, geographic atrophy, retinal vein occlusion, diabetic macular edema and glaucoma.”

Extended delivery: Time to drop the bottle Dr. Mark Blumenkranz, CEO, and his colleagues at Kedalion (California, USA), addressed age-old challenges of drug delivery to the anterior chamber. According to Dr. Blumenkranz: “Up to 25% of eye drop bottles, even those with preservatives, are contaminated, and up to a third of patients who think they have good technique miss

the eye under observational studies. Unfortunately, up to half of all patients stop using eye drops within one year of starting. We believe that Kedalion’s AcuStream provides the best solution for these issues.”

“We have developed AcuStream, with superior comfort ergonomics and ease of use profile for patients. It is Bluetooth enabled, capable of extended delivery for up to 90 days, and consistent across multiple viscosities and solution types.” – Dr. Mark Blumenkranz AcuStream is a novel, preservative-free, horizontal delivery system applicable to various topical pharmaceuticals in different indications. What makes AcuStream such a unique product? It has a multidose, preservative-free capability that delivers microdoses at less than 20% of an average eye drop volume, with exact proprietary aiming technology, including suspensions. More importantly, it is low cost, creating exciting commercial incentives. Multidose preservative-free delivery improves patient outcomes and eliminates preservative-related side effects. “AcuStream technology was challenged in multiple independent laboratory studies. It showed no bacteria in the drug reservoir and comparable topical performance to paired preserved dropper bottle,” Dr. Blumenkranz added. Furthermore, smart connectivity allows patients and physicians to monitor dosing and compliance metrics and is a useful tool for compliance monitoring in clinical trials. “The results of our prospective, randomized, double-masked clinical trial in patients with symptomatic presbyopia showed that Kedalion’s leading dose significantly outperformed other dose groups, with two-thirds of patients achieving 3 lines of near vision gains. Kedalion will use series B funding to meet several key

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CONFERENCE HIGHLIGHTS OIS COVERAGE vital role in controlling inflammation. TA-A001 binds more tightly to CB2 receptors than any other receptors found in the body and is 10 times more effective than NSAIDs in pain control models. It has a rapid onset of action and produces long-lasting effects after a single administration,” said Dr. Smith. “We deliver TA-A001 using our proprietary SmartCelle technology. These are 30nm micelles which promote deep penetration of the cornea, allowing TA-A001 to combat surgical pain and inflammation more effectively,” he added. Trans-corneal delivery to the aqueous humor trabecular meshwork and iris also generates an opportunity for glaucoma and uveitis treatments.

milestones,” shared Dr. Blumenkranz. Kedalion also has a differentiated presbyopia candidate in its lead program, and the company is on track toward its next phase 3 study and NDA submission.

A better ride: Painless keratoconus treatment? “If we could treat pain more effectively, we believe that more patients with keratoconus will have surgical treatment earlier, and outcomes would be better.” – Dr. Damon Smith TALLC pharmaceuticals is developing a new generation of anti-inflammatory, analgesic drugs delivered by SmartCelle technology to address unmet patient needs. In his presentation, Dr. Damon Smith, CEO of TALLC, explained: “Our lead indication is keratoconus, an orphan disease, usually first seen in teenagers, that causes a progressive thinning, weakness, and eventually,

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bulging of the cornea and vision distortion.” He added: “Current treatment options for keratoconus, such as corneal transplant or cross-linking surgery, do not address patient needs. Corneal cross-linking surgery is incredibly painful and unbearable in many of our patients. This is why many patients delay early treatment because of fear of surgery,” explained Dr. Smith. “Therefore, if we could treat the pain effectively and believe that more patients with keratoconus will have surgical treatment earlier, outcomes would be better. Unfortunately, we cannot do this well today since opioids have a huge risk of addiction, topical non-steroidal anti-inflammatory drugs (NSAIDs) delay wound healing and increase infection risk, and steroids don’t act fast enough, delaying healing and increasing intraocular pressure (IOP).” So what is TALLC’s solution for adequate pain control during keratoconus surgery? “We developed a new drug called TA-A001, which acts by stimulating human CB2 receptors which are found throughout the body and extensively on immune cells, where they have a

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“Topical administration to get to the back of the eye is the holy grail, but we believe that TA-A001 delivered by SmartCelle has the potential to reach the back of the eye and treat retinal diseases,” said Dr. Smith. TA-A001 has a unique mechanism of action, with superior efficacy, compared to any available analgesic on the market today. The topical installation makes it convenient to administer on the day before surgery and up to three days post-surgery. It does not affect wound healing or intraocular pressure and helps promote effective pain management. Further, CB2 receptors are found both in the cornea, the trabecular meshwork of the uvea and in the retina, where inflammation is shown to be an issue with AMD. The ability to bind to CB2 receptors in the retina can have significant value for treating these diseases, perhaps without the need for intraocular injections.

Editor’s Note: The OIS Drug Delivery Innovation Showcase was held on November 5, 2020. Reporting for this story took place during the event.


CONFERENCE HIGHLIGHTS WEBINAR COVERAGE

Updates from APOTS 2020

Overcoming Challenges Faced by Ophthalmologists by Hazlin Hassan

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t the Asia Pacific Ophthalmic Trauma Society (APOTS) virtual conference held in September 2020, eye surgeons from around the region discussed ways to handle some of the most common challenges faced by ophthalmologists today, including traumatic hyphema, persistent hypotony, and corneal transplantation in the time of COVID-19, among others.

Management of traumatic hyphema Post-injury accumulation of blood in the anterior chamber — or hyphema — can be one of the most challenging clinical problems faced by ophthalmologists. It is usually painful, and if left untreated, can cause permanent vision problems. “It is important to do a proper work-up and take the patient’s detailed history, including the mechanism of injury and

time of injury, with the time of visual loss, if any,” said Dr. Shams Noman, senior consultant and head of glaucoma from the Chittagong Eye Infirmary and Training Complex, Bangladesh. The most common cause of a hyphema is blunt trauma. It can also sometimes be caused by strenuous health issues, such as whooping cough or asthma. Blood dyscrasia — such as aplastic anemia, leukemia and hemophilia — are also some of the causes of a hyphema, as well as intraocular tumors, such as retinoblastoma and iris melanoma.  Rarely, a hyphema occurs as a consequence of medical problems that can affect the eye, such as juvenile xanthogranuloma. It may be secondary to ocular surgery or laser, and some medications with anticoagulant properties (aspirin, non-steroidal antiinflammatory drugs or NSAIDs, warfarin,

or clopidogrel) may also cause hyphema. According to Dr. Noman, the principles of management include quick absorption of blood, prevention of complications, and avoidance of recurrence. “Any anticoagulation medication should be discontinued and activities should be limited. The patient should rest in a semi-upright posture, including while sleeping,” he advised. Medical treatments include sedation or complete bed rest with limited activities, cycloplegics, atropine 1% E/D, anti-inflammatories such as steroids, mild NSAIDs, as well as ocular hypotensive agents, and treatment of the cause. Noted complications include obstruction of the trabecular meshwork with associated intraocular pressure (IOP) elevation, peripheral anterior synechiae (PAS), posterior synechiae, corneal blood staining, rebleeding, pupillary block, and amblyopia in pediatric patients. As for the challenges that ophthalmologists face? One — in children, it’s not always possible to get them to rest. Another challenge is that associated bleeding disorders or intake of blood thinners also come with risks. Therefore, a cardiologist’s opinion should be sought before stopping blood thinners. And if rebleeding occurs, the rates and severity of complications increase and visual prognosis is reduced from 75% to 65%.

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CONFERENCE HIGHLIGHTS WEBINAR COVERAGE diagnosis of the condition, as well as the extent of the cleft.” The aim of the treatment is to normalize IOP in the long-term and prevent complications. For small cyclodialysis clefts, observation or the use of topical cycloplegic agents is the preferred treatment. “But in my experience, there is limited success with conservative management. My preferred approach to repairing this cleft is through direct suture cyclopexy,” shared Dr. Koh. Other repair techniques include: argon laser photocoagulation, capsular tension segment technique, cryotherapy, scleral buckling and vitrectomy with gas tamponade.

During APOTS 2020, experts build bridges to help ophthalmologists manage challenging cases.

In cases of raised IOP, anti-glaucoma medication can be given. Meanwhile, systemic antifibrinolytic agents reduce the incidence of rebleeding after traumatic hyphema. Therefore, antifibrinolytic agents, such as aminocaproic acid and tranexamic acid, prevent the activation of plasminogen. Dr. Noman noted that tranexamic acid is 8 to 10 times more potent than aminocaproic acid. Additional challenges during intervention include hypotony and ruptured globe. To best face these challenges, timely intervention is needed and a systemic history should be excluded. It’s critical to never stop blood thinners without an internist’s opinion, and tranexamic acid may prevent rebleeding and glaucoma. Last but not least, Dr. Noman concluded: “Take care of the cornea.”

Persistent hypotony after blunt trauma Hypotony is an intraocular pressure (IOP) of 5mmHg or less. Low IOP can adversely impact the eye in many ways, including corneal decompensation, accelerated cataract formation, maculopathy and discomfort.

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“We have to first make sure there is no open globe injury because occult defects can be missed, especially in situations where the mechanisms of the injury are not well-established, or in patients who are difficult to examine — especially in young children,” advised Dr. Victor Koh, consultant ophthalmologist, from the Department of Ophthalmology at National University Hospital, Singapore. Some common causes include cyclodialysis, ciliochoroidal detachment, ciliary body injury, retinal detachment and anterior proliferative retinopathy. Causes of cyclodialysis include trauma or iatrogenic injury after anterior segment surgery. Meanwhile, complications can range from hypotony maculopathy or edema, choroidal effusion and cataract. Gonioscopy is one of the imaging modalities to diagnose and localize a cyclodialysis cleft, but it can be difficult due to corneal opacity, hyphema, chronic hypotony after globe trauma, or the cleft may be obscured by peripheral anterior synechiae. Therefore, high-frequency ultrasound biomicroscopy (UBM) is Dr. Koh’s preferred choice. “It allows me to plan the surgery much better, including the

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“Direct surgical cyclopexy is an effective treatment for large cyclodialysis clefts with good IOP control and visual outcomes postoperatively,” he added. Dr. Koh closed his presentation by emphasizing that a cyclodialysis cleft is an important cause of traumatic hypotony, and that UBM is the current gold standard imaging modality in the localization of cyclodialysis clefts.

Prosthetics in ophthalmic trauma patients According to Ms. Suriya Abu Waled, senior ocular prosthetic specialist from the Department of Ophthalmology, National University Hospital, Singapore, the most important role of an ocularist is to handle patients with mechanical trauma, such as phthisical eyes, post-enucleation or evisceration that requires ocular prostheses, chemical or burn injuries, and Stevens-Johnson Syndrome — a rare serious disorder of the skin and mucous membranes. “It is not just cosmetic, it is also physical and structural, psychological and economic rehabilitation,” noted Ms. Waled. One case presented by Ms. Waled was a 17-year-old patient who suffered a globe rupture with the loss of intraocular tissue, phthisis bulbi and entropion. Treatment entailed emergency right globe rupture repair and right lower lid epiblepharon correction with tarsal strip. Meanwhile, post-surgery options included observation and an ocular prosthesis.


To conclude, post-enucleation socket syndrome with superior sulcus deformities, mild to moderate ptosis, and enophthalmos may be corrected with modifications to the prosthesis. Reducing the superior aspect, adding acrylic on the anterior corneal area, reducing the anterior-inferior surface, and adding acrylic on the posteroinferior surface produced satisfactory results. For those who have lost one or both of their eyes, prosthetics can give hope and confidence to patients.

Preparing corneal tissue donors in emergency cases Corneal transplantation, also known as corneal grafting, is a surgical procedure where a damaged or diseased cornea is replaced by donated corneal tissue. Corneas can be injured by central abrasions; foreign bodies; burns from

chemical, thermal and radiation sources; perforations by saws, grinders and metal objects; among others. As the COVID-19 pandemic continues, developments in the understanding of the SARS-CoV-2 virus and the screening of donors has allowed for the continued provision of safe corneal tissue. According to Mr. Eros Rosikin, a corneal transplant coordinator from Indonesia, donors are screened for history of disease, COVID-19 symptoms, and any direct contact with COVID-19 patients. “If there is any suspicion that the donor may have COVID-19, their cornea cannot be taken,” he said. There have been no reported cases of transmission of SARS-CoV-2, MERSCoV, or any other coronavirus via transplantation of ocular tissue. Current medical standards of the Eye Bank Association of America (EBAA) require the use of a double povidone-iodine donor prep. 

Povidone-iodine has documented in-vitro viricidal activity against coronaviruses. Before the procedure for the excision of the donor cornea, informed consent must be taken. The procedure only takes 10 minutes, does not leave blemishes or bleeding, and must maintain the quality of the cornea — which should be taken less than six hours postmortem. The cornea can then be stored for up to 14 days in OptisolGS.

Editor’s Note: The Asia Pacific Ophthalmic Trauma Society (APOTS) Virtual Conference was held from September 3 to 6, 2020. Reporting for this story took place during the event.

INDUSTRY UPDATE

ZEISS Launches Updated IOLMaster 700 Software

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EISS announces new software for the IOLMaster® 700, with enhanced features and connectivity designed to improve the cataract surgeons’ workflow efficiency and support better outcomes for surgeons and patients. This latest software update includes Central Topography for more insights on corneal shape, empowers doctors to access surgical planning data on their mobile device with EQ Mobile® from ZEISS, and offers Barrett True K with Total Keratometry (TK®) formula. “ZEISS is dedicated to advancing eye care through the development of new and innovative solutions, like the enhanced software features of the IOLMaster 700,” said Euan Thomson, PhD, President of Ophthalmic Devices and Head of the Digital Business Unit for Carl Zeiss Meditec. “With our comprehensive portfolio of ophthalmic solutions, we will continue to help make the cataract workflow a better experience for both

surgeons and patients.” Cataract surgeons need data insights that enhance their workflow efficiency. Using the Central Topography software feature, surgeons can gain additional information and detect visually relevant asymmetries on central corneal shape with the standard ZEISS IOLMaster 700 measurement. Central Topography, a new feature based on Telecentric 3zone Keratometry and SWEPT-Source OCT, improves the cataract workflow without needing extra measurements, extra hardware, or extra time — a more intuitive reading without changing the cataract surgeon’s workflow. When practicing at multiple sites, cataract surgeons need access to approved calculations in real-time. With the latest ZEISS IOLMaster 700 software,

doctors can send their biometry data and scleral reference images via ZEISS EQ Mobile to CALLISTO eye® from ZEISS for computer assisted surgery, streamlining the cataract workflow. EQ Mobile, a cloud-based connectivity option, accesses IOL calculation reports on the doctor’s mobile device and allows them to transfer surgical planning data via the cloud to the operating room. To improve predictions for post-refractive surgery patients, the ZEISS IOLMaster 700 software update features the new Barrett True K with TK formula with up to 12 percent more post-myopic LASIK patients within ±0.5D compared to the classic K calculation formula*. Barrett True K with TK formula uses ZEISS IOLMaster 700 TK without the need for online calculators and manual data input. The cataract workflow doesn’t change.

* Lawless M, et al. Total keratometry in intraocular lens power calculations in eyes with previous laser refractive surgery. Clin Exp Ophthalmol. 2020;48(6):749-756.

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CONFERENCE HIGHLIGHTS WEBINAR COVERAGE

Knowledge without Borders A Q&A with Leading Experts in Ophthalmology

Question 2:

What is the best intraocular lens (IOL) option for a patient with biometry readings of +17D right eye and +14D left eye using the Barrett formula? — Dr. Akanda, Bangladesh

by Olawale Salami

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n November 19, 2020, the Alcon Experience Digital Academy organized the ”Ask the Expert” session, where a panel of leading experts in ophthalmology responded to questions from ophthalmologists worldwide. Hot topics included cataract surgery equipment, refractive and vitreoretinal surgery, dry eye and ocular health.  The expert panel was made up of the following ophthalmology experts: Dr. Soon-Phaik Chee, senior consultant for both Cataract and Comprehensive Ophthalmology Service and Ocular Inflammation and Immunology Service at the Singapore National Eye Centre (SNEC); Dr. Stephanie Watson, clinician-scientist at the University of Sydney and Sydney Eye, Sydney Children’s and Prince of Wales Hospitals; Dr. Harvey Uy, medical director at Peregrine Eye and Laser Institute in Makati, Philippines; Dr. Pravin Vaddavalli, head of the Refractive Surgery, Cataract and Contact Lens Service at the LV Prasad Eye Institute in Hyderabad, India; and Dr. Mun Wai Lee, consultant ophthalmologist, vitreoretinal surgeon, and the medical director of Lee Eye Centre in Ipoh, Malaysia.

Question 1: What are the

best ways to address dry eye preoperatively in cataract and refractive surgery? — Dr. Stad, Netherlands Dr. Stephanie Watson: From a practical point of view, patients could present in three possible clinical scenarios: asymptomatic ocular surface disease, symptomatic ocular surface disease discovered postoperatively, and finally, an overt ocular surface disease that

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Patient education and reassurance are beneficial, and it is advisable to document dry eye symptoms if they are present preoperatively. Clear communication with the ongoing patient assessment will help allay patients’ fears.

Dr. Harvey Uy: The best option for this patient, and any patient, is an IOL that is most satisfactory and best matches the patient’s lifestyle. Therefore, it is essential to discuss patients’ postoperative goals. requires preoperative treatment.   Next, it is important to remember the issues caused by concurrent dry eye and cataract surgery. Postoperatively, with both cataract and refractive surgery, these include inflammation, toxicity from medications, corneal nerves damage from incisions and increased tear evaporation.  Undiagnosed dry eye can be identified during preoperative screening, and this is best accomplished using questionnaires, including assessing possible risk factors, completed before the consultation in the clinic.  Is dry eye a common preoperative finding in cataract patients? Dry eye is quite a common disorder, and studies have shown that up to 70% of patients have some form of dry eye symptoms, and in some cases, unmasked by cataract surgery.  In eyes with established dry eye disease, screening is not required, and the clinical examination is useful in finding underlying risk factors and grading disease severity. Subsequent investigations are tailored towards the severity. 

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Equally important is the posterior segment examination to ensure that a multifocal lens can be used. The Barrett formula is a very accurate and easy formula to use. With pre-existing myopia in this patient, a trifocal lens would be useful to enable the patient to see at different distances, or the patient could be comfortable with a monofocal lens and wearing reading glasses. With the 3D difference in IOL power, there is a concern for amblyopia in this patient. And in such cases with a history of amblyopia, multifocal lenses may not be feasible.

Question 3: How do you

differentiate the Johnson & Johnson TECNIS Synergy, Johnson & Johnson TECNIS +2.75, and Johnson & Johnson TECNIS Symfony in terms of distance visual acuity? — Dr. Quesnel, Canada Dr. Soon-Phaik Chee: The most crucial factor needed for great distance visual acuity with all these three premium lenses is to achieve the correct refractive target using the most accurate biometry. However, in patients with dense cataract, those with


dry eyes and with advanced posterior subcapsular cataract where optical biometry is challenging, the extended depth of focus (EDoF) lenses (TECNIS Synergy and Symfony [Johnson & Johnson Vision, Florida, USA]) would be the safest lens to use to achieve good distance acuity because they are more forgiving when the refractive target is missed slightly. Therefore, among the three lenses, the EDoF lens is preferred if good distance visual acuity is of primary importance.

anterior chamber during surgery.

Question 4: Concerning the

surgeon decide when to implant an anterior chamber IOL and choose the correct one? — Dr. Humphry, United Kingdom

long-term perspective, how safe are laser vision correction treatments compared to spectacles and contacts? During IOP measurements and keratometry measurements, how do we estimate values with laser in-situ keratomileusis (LASIK)corrected eyes? — Dr. Athreya, India Dr. Pravin Vaddavalli: Concerning the safety of laser vision correction, I decided to get laser vision correction myself. And if I didn’t believe it was safe, I would still be wearing contact lenses or spectacles. The stability of refractive correction after myopia is relative. And from the perspective of the patient, any change in refractive error could mean that the surgery has resulted in unstable refraction. Long-term studies have shown that stability after 8 to 10 years is excellent after LASIK in low to moderate myopia. However, it tends to be a little less stable for high myopia, mainly due to regression caused by the thickening of the epithelium around the cornea’s central part. 

Question 5: What is the latest

phaco machine from Alcon? Is it the Centurion? — Dr. Suliman, Saudi Arabia Dr. Mun Wai Lee: The Centurion is the latest machine from Alcon. Today there has been a shift away from gravitybased fluidics to active fluidics, and the Centurion is the first machine to achieve this. It incorporates a proprietary feedback mechanism that maintains stability within the eye so that the input and egress of fluids are accurately balanced. This results in optimal control and a very stable

The Centurion is more intuitive when it comes to intraocular pressure (IOP) and allows surgeons to operate at more physiological pressures with optimal control. Changes in the anterior chamber are detected by the active sentry handpiece sensor, which provides rapid feedback to the machine, controlling the input fluid and maintaining excellent stability.

Question 6: How does a

Dr. Soon-Phaik Chee: Anterior chamber IOLs are placed in the anterior chamber of phakic eyes and are used to treat myopia or nearsightedness. These are usually flexible, open-looped IOLs, or those with iris claws, which are clipped to the iris. When using the iris-claw IOLs, which are in the anterior chamber in front of the pupil, sizing is not an issue as these come with standard haptic lengths. However, with the open-looped IOLs, sizing becomes essential. And here, the IOL inventory will be needed to select the most suitable size. The appropriate way to size the IOL is to measure the horizontal white-to-white and add 1mm to the reading. An anterior chamber lens should be avoided in children, patients with uveitis, and glaucoma. On the best methods, I would suggest that surgeons use methods that attach the haptics of the lens to the sclera rather than the IOL resting on the iris.

Editor’s Note: The “Ask the Expert” Session organized by Alcon Experience Digital Academy was held on November 19, 2020. Reporting for this story took place during the session.

Contributing Doctors Dr. Soon-Phaik Chee, MD, is a professor at the National University of Singapore and Duke-National University of Singapore Graduate Medical School, Singapore. She is a senior consultant for both Cataract and Comprehensive Ophthalmology Service and Ocular Inflammation and Immunology Service at the Singapore National Eye Centre (SNEC). In addition to her clinical commitments, Dr. Chee also serves as group lead member of the Cataract research team at the Singapore Eye Research Institute. Dr. Lee Mun Wai is a consultant ophthalmologist, vitreoretinal surgeon, and the medical director of Lee Eye Centre, Ipoh, Malaysia. Dr. Lee underwent ophthalmic training in the United Kingdom and Singapore and trained in vitreoretinal surgery at Lions Eye Institute, Western Australia. Active in ophthalmic research, he has published over 20 papers in peerreviewed journals. Dr. Harvey Uy is a clinical associate professor of ophthalmology at the University of the Philippines and Medical Director at Peregrine Eye and Laser Institute in Makati, Philippines. He has published over 50 peer-reviewed articles and book chapters and serves on the American Journal of Ophthalmology Case Reports editorial board. Dr. Pravin K. Vaddavalli serves as director of the Tej Kohli Cornea Institute at LV Prasad Eye Institute and is head of the Refractive Surgery, Cataract and Contact Lens Service at the LV Prasad Eye Institute in Hyderabad, India. He has over 70 publications, peer-reviewed Ophthalmology journals, and over 300 presentations at international and national meetings and has written chapters for mainstream Cornea textbooks. Dr. Stephanie Watson is a clinician-scientist known for her ground-breaking research in corneal therapies, appointed at the University of Sydney and Sydney Eye, Sydney Children’s and Prince of Wales Hospitals. She has over 106 publications, is often invited to speak internationally, and has raised over $10 million for her research program. She is chair of Ophthalmic Research Institute of Australia, chair-elect to ARVOs Advocacy and Outreach Committee, expert advisor to the $150M Stem Cell Therapies Mission, and editor for the Cochrane Eyes and Vision Group.

| Dec 2020/Jan 2021

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