CAKE Issue 09: The ebook version (The Wild West Issue) by Media MICE

THE WORLD’S SECOND FUNKY OPHTHALMOLOGY MAGAZINE

THE WILD WEST ISSUE March/April 2021 cakemagazine.org

6 Cover Stor y P1

CONQUERING t h e

U n t a m e d

F r o n t i e r

o f

DRY EYE DISEASE

Introducing

Continuous vision across the range to empower patients to see at their ideal distances.1 Exceptional near visual performance at 33cm.2-4 Superior* low-light contrast with high-quality vision that patients can trust day and night.5 1. DOF2019OTH4003 - Clinical Investigation of the TECNIS® Next-Generation IOL Model ZFROO (TECNIS SynergyTM IOL): 6-Month POC Data. 23 Apr 2019. 2. DOF2019OTH4004 – Perez G. Simulated VA of the TECNIS SynergyTM IOL and PanOptix IOL. 12 April 2019. 3. DOF2019OTH4005 – Perez G. Simulated VA of the TECNIS SynergyTM IOL and AT Lisa Tri IOL. 5 May 2019. 4. DOF2019OTH4006 – Perez G. Simulated VA of the TECNIS SynergyTM IOL and FineVision IOL. 5 May 2019. 5. DOF2019OTH4002 – Weeber H. MTF of the TECNIS Synergy OptiBlue IOL, and the other lens models. 27 Mar 2019. For healthcare professionals only. Please read the Directions of Use for Important Safety Information and check with a J&J representative about the availability of this product in your country.

Surgical Optics, Inc. 2020 PP2020CT4171

LETTER TO READERS

Where Have All The Cowboys Gone?

n 2013, I genuinely thought that the world of medical devices was like the Wild West. This was naïve, to be sure, but I had just moved into the world of ophthalmology, whereas before I’d been medical writing my way through all of the phases of a pharmaceutical trial (rivaroxaban, if you care) from one through three, then to the launch. The phase III trials involved needed tens of thousands of patients for each of the big indications. Then I discovered what was involved in bringing new intraocular lens (IOL) designs to the market — and looking at what was on clinicaltrials.gov was eyeopening. Trials with tens or hundreds of patients, not tens of thousands. In fact, I checked again today, when searching for “IOL”, I see that only four cataract/ IOL trials on clinicaltrials.gov have ever enrolled over 1000 patients. Who were all of these cowboys running roughshod over the prairie of evidence base that underpins the most commonly performed elective surgery in the world? Implants that patients will have for the rest of their natural lives? I’ve looked up the “Top 100 Cowboy Expressions and Phrases”, so please don’t crawl your hump when I ask: Were the industry back then… varmints? I did say I was being naïve. I came to understand that these lenses

are built on prior art. That the materials — principally silicone and polymethyl methacrylate (PMMA) — are ones that we have millions of patient years of experience with now. That the adverse events are rarely serious (and many are a function of the patient’s anatomy, like weak zonules or a surgical complication) and rarely have anything to do with the IOL’s design or material. That there were different considerations when doing power calculations for IOLs instead of anticoagulants. Anyway, this speeds innovation: Huge trials would pull back the reins on the pace of development, when we’d all prefer to get a wiggle on when it comes to better outcomes, rather than hang fire. And to be fair, look at the outcomes. The ultimate trial is at the population level, and you can see that cataract surgery nowadays is one of the safest, efficient and most successful surgeries in the history of medicine. Cataract surgeons and industry: Pat yourselves on your back until I tell you to stop. But boy, getting there was a difficult birth. Ridley and Kelman’s adventures in IOLs and phaco really did embody the “pioneer spirit” and then some. Their critics were certainly airin’ their lungs back then. (I’ve written about this in previous editorials, so explore our website to read more about that). I suppose that conquering uncharted territory requires bravery and, frankly, both the pioneer surgeons at the time, and their patients, were certainly brave. How? [MH1] Brave, in the extreme. We’ve certainly had some bags of nails along the way, and even in the modern era, we have seen events like certain phakic IOLs had to be withdrawn or redesigned because they either caused excessive corneal endothelial cell loss or accelerated cataract development, and the little adventures in smooth-edged IOL optics had surgeons and patients in a bad box. But again, everyone here is a professional; the issues were promptly and efficiently identified and rectified.

Vigilance has and always will be key. One might ask: Where have all the cowboys gone? What’s going to be interesting going forward is what the tech bros bring to the game. Smart IOLs are achingly cool, but as soon as you bring complex tech inside the body, you have to be certain that it’s going to remain functional, and more importantly, safe for the rest of the patient’s natural life. When Samsung Galaxy Note 8s get withdrawn from the market after launch because their batteries can spontaneously combust, and old iPods die because their batteries swell, powering future IOLs with lithium-ion batteries might not be the way forward. Medical devices aren’t something that you can really launch with problems and fix it with a firmware update later. Beta tests aren’t really appropriate. And if it’s cataract surgery, the recalls will be more of a hidin’ than Tesla’s recent requirement to replace the central dashboard display on every Tesla Model S and X made before 2018, as the sheer volume of patients who might opt to receive such “wonderlenses” might be enormous. And so if this is the new frontier, the new Wild West, one wonders whether we’ll have hair in the butter while the kinks are worked out. Yee-haw!

Best,

Mark Hillen

Dr. Mark Hillen

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

IN THIS ISSUE...

Cataract

The Jig is Up An Honest Comparison of Visual Performance in Multifocal IOLs

Anterior Segment Matt Young

CEO & Publisher

Robert Anderson

ABiC for Glaucoma Navigating Uncharted Trabecular Meshwork

Learning from the Big Guns of Cataract Surgery From India and Around the World

Media Director

Hannah Nguyen

COVID-19 and the Great Cornea Bank Stickup

Production & Circulation Manager

Gloria D. Gamat

Cover Story

Chief Editor

Brooke Herron

Editor

Mark Hillen Editor-At-Large International Business Development

Ruchi Mahajan Ranga Brandon Winkeler Writers

Corporate Corner

Kudos

21 30

TECNIS SynergyTM Bridging the Gaps in Surgical Correction of Presbyopia Volk Optical Introduces ClearPod to Address Fogging During Fundus Examinations Four IOL Delivery Devices to Rule Them All

Enlightenment

9 Tips for Writing an Effective Research Paper Advice for Young Ophthalmologists

A First-of-its-Kind Corneal Lenticule Banking Service 5 Things You Need to Know

Dr. Lucy Mathen Making a Difference, One Eye at at Time

Andrew Sweeney April Ingram Chris Higginson Elisa DeMartino Hazlin Hassan Jillian Webster Olawale Salami Sam McCommon Tan Sher Lynn Maricel Salvador Graphic Designer

Dr. Sanushka Moodley On Gender Inequality in Ophthalmology

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We are looking for eye doctors who can contribute articles to CAKE magazine. Interested? Let's talk! Send us an email at editor@mediamice.com. To place an advertisement, advertorial, symposium highlight, video, email blast, or other promotion in CAKE magazine contact CEO Matt Young at matt@mediamice.com. | March/April 2021 4

ADVISORY BOARD MEMBERS SOCIETY FRIENDS

Prof. Jodhbir S. Mehta

jodmehta@gmail.com

All India Ophthalmological Society

Asia-Pacific Academy of Ophthalmology

Prof. Jodhbir S. Mehta, MBBS, FRCOphth, FRCS(Ed), FAMS, PhD(UK), 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 Duke-National 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. Prof. Mehta has won several awards from the AAO and ARVO, among others, the latest of which was from the ASCRS in 2018. Prof. Mehta is also a favorite keynote speaker and presenter in several international conferences.

Dr. William B. Trattler

Dr. William B. Trattler, MD, 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 sutureless 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. wtrattler@gmail.com

Ophthalmology Innovation Summit

Dr. Chelvin Sng

Dr. Chelvin Sng, BA, MBBChir, MA(Cambridge), MRCSEd, FRCSEd, MMed, FAMS, 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. 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. When not working, Dr. Sng can be found volunteering in medical missions in India and across Southeast Asia. chelvin@gmail.com

He Eye Specialist Hospital

Dr. Harvey S. Uy, MD, 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 his fellowships at St. Luke’s Medical Center (Philippines) and the Massachusetts Eye and Ear Infirmary (USA). Dr. Uy is 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 the American Journal of Ophthalmology Case Reports. He is a former president of the Philippine Academy of Ophthalmology (PAO) and current council member of the APVRS.

Asean Ophthalmology Society Dr. Harvey S. Uy

harveyuy@yahoo.com

| March/April 2021

ATARACT

MULTIFOCAL IOL

The Jig is Up An Honest Comparison of Visual Performance in Multifocal IOLs by April Ingram

Once upon a time (in the West) In a not so distant past, the new hightech IOLs were bifocal multifocal IOLs that provided two foci of sharp vision, distance and additional power for near. However, the image quality at intermediate distances was less than ideal. Eventually, trifocal multifocal IOLs came to the rescue and provided the intermediate focus that was lacking in the bifocal IOLs. This technology was also needed for intermediate tasks like computer use, while also delivering good visual acuity at both near and distance.

“New IOL technologies are being designed to extend the range of vision of presbyopic patients after cataract surgery,” Dr. Zapata-Díaz explained. “The total depth-of-focus of the new multifocal implants is probably the most important information for surgeons and patients.” Dr. Zapata-Díaz and his colleagues recognize that being spoiled for choice comes with its own challenges on how to select the best IOL for the patient and how to compare IOLs. “The market of multifocal implants is evolving rapidly with lots of new different technologies, making it difficult to do a direct comparison between them,” he said. “Hence, my colleagues and I want to give important information about some of the new premium multifocal intraocular lenses in the market.”

dvancements in intraocular lens (IOL) design and functionality have changed the outcomes and expectations of both surgeons and patients. Today, the decision of which lens to choose is far removed from the hardscrabble days of the Old West, where a cowboy simply had to decide between the saloon’s finest whiskey or ale to cap his journey. IOLs are way more complicated than that.

de Investigaciones Clínicas, Vista Ircovisión Oftalmólogos, Murcia, Spain, to help us break it all down. Their study¹ was recently published in the Journal of Refractive Surgery.

As technology improved, patient and surgeon expectations heightened. The three foci of sharp vision from trifocal IOLs came with disappointing gaps of poor image quality between them. Today, we have extended depth of focus (EDOF) lenses that come with the promise of an extended range of sharp vision across a continuum from far to intermediate distances. These premium multifocal IOLs provide the ability to compensate for the loss of near and intermediate vision due to presbyopia by restoring functional vision at several distances. But hold your horses … there are still so many options of EDOF IOLs in the market. So, how do you choose? Are all EDOFs created equal?

Howdy! Doctors to the rescue! Luckily, we have Dr. Juan F. Zapata-Díaz and colleagues from the Departamento

| March/April 2021

The team designed a study that compared the in vitro optical performance of five premium multifocal IOLs, using a single-valued metric that shows the total range of distances where a specific multifocal IOL generates an acceptable image quality. Dr. Zapata-Díaz explained: “Our new metric is intended to provide this information to the ophthalmology community.”

A new metric? Well, that’s a bee in your bonnet... Why do we need a new metric? Don’t we currently have a way to compare? The authors explained in their publication the challenges of comparing subjective visual outcomes between multifocal IOLs due to inter-subject variability in the eye’s optical parameters. The International Organization for Standardization provides guidelines to determine the image quality of ophthalmic implants, including two model eyes in which the IOL should be

inserted before measurements, and proposes the use of the modulation transfer function (MTF) as an image quality measure. Through-focus MTF at 50 cycles/mm provides information for several defocus values and has been adopted in research as the standard objective metric to compare the optical quality of different multifocal IOLs. Albeit interesting, does MTF provide useful information that can be interpreted outside of the research and allow us to predict clinical outcomes? Because as we know, the data can tell us what the optical quality should be, but a patient will tell you, with great honesty and possibly great volume, about their post-op quality of vision.

“The intention of the TDOF metric is to provide ophthalmologists and patients with further knowledge to make it easier to select the appropriate IOL to match patient expectations.” – Dr. Juan F. Zapata-Díaz The new metric from Dr. Zapata-Díaz and colleagues compared the total depth of focus (TDOF) of different multifocal IOLs objectively, using optical bench measurements of the MTF at 50 cycles/mm for several defocus values. “The intention of the TDOF metric is to provide ophthalmologists and patients with further knowledge to make it easier to select the appropriate IOL to match patient expectations,” shared Dr. Zapata-Díaz. “We also provide threedimensional maps of the through-focus MTF at all spatial frequencies from 0 to 100 cycles/mm to illustrate the variation of performance of diffractive IOLs according to the size of the details within the object.”

Presenting, the five contenders The researchers evaluated five multifocal IOLs: the Tecnis Symfony

(Johnson & Johnson Vision, New Brunswick, Jacksonville, Florida, USA), FineVision Micro F (PhysIOL, Liege, Belgium), Acrysof IQ PanOptix (Alcon, Geneva, Switzerland), and Artis Symbiose Mid and Plus (Cristalens Industrie, Lannion France) and provide the technical specifications of each within the publication. In notable, breaking news, this was also the first measurement of in vitro optical performance of the Artis Symbiose Mid and Plus IOLs. The study assessed the MTF measurements of each IOL for a 3mm pupil and a spherical aberration-free cornea from 0 to 100 cycles/mm, which corresponds to a visual acuity of 20/20 at distance. In order to cover all focal planes of the multifocal IOLs, throughfocus MTF was obtained in 0.10-D steps for approximately 5.00D. They used illustrative images of a United States Air Force resolution target for defocus values between 0.00 and -5.00D in 0.50-D steps. Additionally, in order to be sure to include the intermediate focus of the FineVision Micro F and the Tecnis Symfony, a -1.75D step was added. Dr. Zapata-Díaz and colleagues found that as a result of the different optical designs, as might be expected, energy is distributed differently between far, intermediate and near focus for each multifocal IOL. “The light distribution of the Symbiose Mid and Plus multifocal IOLs was similar, concentrating the energy into far focus and the intermediate into near focus, but extending the intermediate focus more (plus) or less (mid) toward the near focus,” Dr. Zapata-Díaz explained. Translating findings into TDOFs for each of the five IOLs, they were quite similar: 1.58D (FineVision), 1.71D (Tecnis Symfony), 1.73D (Artis Symbiose Plus), 1.74D (Artis Symbiose Mid), and 1.90D (Acrysof IQ PanOptix). The maximum difference was 0.32D.

Getting an overall idea So how are these TDOF values applicable to clinical practice? As an example, the research team suggested that by implanting a combination of the Symbiose Mid and Plus IOLs, one in

each eye, it would theoretically provide the largest clinical TDOF of 2.90D. This result was predicted by the United States Air Force resolution target image assessment as well. What does a TDOF of 2.90D mean? Early studies from Le Grand et al. found that 3.00D represents an interval of vision large enough to cover all visual necessities of individuals with presbyopia, and presbyopia is usually defined when the amplitude of accommodation falls below 3.00D.² This work introduces an objective metric based on a single value, the TDOF, that allows for eye care professionals to have a quick idea of the optical performance of a multifocal IOL for the whole range of vergences, useful in IOL selection.

REFERENCES: 1.

Zapata-Díaz JF, Rodríguez-Izquierdo MA, OuldAmer N, Lajara-Blesa J, López-Gil N. Total Depth of Focus of Five Premium Multifocal Intraocular Lenses. J Refract Surg. 2020;36(9):578-584.

Le Grand Y. La dioptrique de l’oeil et sa correction, 3rd ed. Optique Physiologique; Vol 1. Editions de la Revue d’Optique, 1964.

Contributing Doctor Dr. Juan F. Zapata-Díaz, PhD, even from a very young age — thrilled by rainbows, mirages and optical illusions — was already interested in physics and more specifically in optics. He studied optics and optometry at the University of Murcia (Spain), and at the suggestion of his professor, Norberto López-Gil, participated as an internal student in the CiViUM (Vision Science Research Group of the University of Murcia), an ongoing collaboration for more than 10 years. Dr. Zapata-Díaz completed his optometry PhD at the University of Manchester, working with the Physiological Optics Research Group, led by Hema Radhakrishnan. Upon returning to Spain, he became research manager at Dr. Lajara’s Vista Ircovisión ophthalmology clinic, working with IOL clinical and technical research, which led to a product manager position with IOL manufacturers, Cristalens. Currently, Dr. Zapata-Díaz combines his research work at the clinic with his position at Cristalens, remaining near to his patients and sharing his knowledge with the ophthalmology industry. juanf.zapata.diaz@gmail.com

| March/April 2021

ATARACT

SURGICAL PEARLS

The expert offered preparation tips for embarking upon this surgery, including making sure small pupils can be managed well; understanding the phaco machine and its settings; making sure irrigation and aspiration are excellent; and overall, what machine or technique to use and when. Interestingly enough, Dr. Arshinoff presented studies by his own society and others, which use his guidelines in their procedures, that show that there is no increased incidence in infection with bilateral surgery.

Learning from the Big Guns of Cataract Surgery

in every country in the world, there’s a backlog of patients needing some sort of medical care.

As AIOS President Dr. Mahipal Sachdev pointed out in his opening words during the symposium, India today performs more cataract surgeries than the U.S., Europe, and maybe China, combined. Knowing this made it particularly compelling to hear from the 18 experts on this topic.

His topic became particularly interesting regionally because, as other members pointed out, some Indian doctors are still reluctantly doing bilateral surgeries full time. While they found Dr. Arshinoff’s methods to be convincing, they still have hesitations because, for instance, in tropical countries, the risk of infection is higher.

Obviously, trying to cover each and every speaker’s presentation would not do a single one of them justice. So, at the risk of skipping over some fascinating demonstrations (which the AIOS has graciously posted online), let’s take a look at what three of these big guns had to offer when it comes to cataract surgery.

Another speaker, Dr. Jeewan Titiyal, pointed out that with COVID, bilateral surgeries at his practice and others in India are becoming more common for practical purposes: less staff is exposed to the patient, the patient is less exposed to the outside world, and less disinfecting has to be carried out at the clinic.

Dr. Steve Arshinoff, USA: On immediate sequential bilateral cataract surgery

Dr. Mahipal Sachdev, India: On FLACS for challenging situations

One of the speakers to kick off the symposium was Dr. Steve Arshinoff, an American pioneer in bilateral cataract surgery. Dr. Arshinoff is president of the International Society for Bilateral Cataract Surgeons, which (probably by no coincidence) shares its acronym with immediately sequential bilateral cataract surgery (ISBCS). Many doctors have now adopted the Principles of Excellence for the surgery published by the organization.

About midway through the symposium, we heard again from Dr. Sachdev, whose self-proclaimed passion is routinely using femtosecond-laser-assisted cataract surgery (FLACS), particularly in posterior polar cataracts. Dr. Sachdev offered encouragement and advice on the use of femto lasers, explaining that if there is pre-existing weakness in the posterior capsule, the cortical cleaving hydrodissection can cause hydraulic rupture, but the femto laserassisted pneumodinealation eliminates

From India and Around the World by Elisa DeMartino

ecently, the All India Ophthalmological Society (AIOS) hosted its first-ever International Ophthalmic Conclave (IOC). And in true COVID-era format, the meeting was held digitally, spanning the weekend of February 19 to 21. Settling into the couch with a freshly brewed cup of coffee to binge-watch Sunday’s cataract surgery symposium was a pleasantly educational way to spend the day.

Cataract surgery: Still hard to access? Cataract removal is common around the world, but it has particular significance in India. The country was the first to carry out cataract surgery, performed by ancient Indian physician Sushruta via couching in 700 B.C. However, today, cataracts are still the most common cause of treatable blindness — and the cause of up to 80% of bilateral blindness in the country, overall. Financial reasons, distance from clinics, lack of awareness about the condition, and seasonal temperatures can all be obstacles of access to care for patients and create somewhat of a backlog of patients needing care.* But that’s not too surprising — in fact,

ISBCS poses a lower cost to the patient and the clinic, and requires less healing time overall. “The reason I perform bilateral surgery in most of my cases — I think between 80% and 90% — is because it’s better for the patient and really, everybody else concerned,” said Dr. Arshinoff.

| March/April 2021

the need of doing hydrodissection or hydrodelineation. At the same time, he also recommended a study he worked on regarding this titled, Femtosecond laser-integrated anterior segment optical coherence tomography to detect preexisting posterior capsular dehiscence and increase safety in posterior polar cataracts. Dr. Sachdev is a strong proponent of using femto, not only in routine cases but also in complex ones, such as those involving rock-hard cataracts and subluxations. According to him, the pros outweigh the cons. “There are various indications for the femto machine that can help you in these difficult and tough cases … things become much easier. One of the things that has been said about femto is that it slows you down. But, actually, if you have teamwork, you can have someone else doing the femto outside while you do the procedure inside and vice versa,” he explained. “My time has actually gone down by about 40%.”

Dr. Mohan Rajan, India: On managing rock-hard cataracts Ending the session was Dr. Mohan Rajan’s rockin’ presentation on rockhard cataracts. He provided his “Top 10 Tips” for ophthalmologists when treating this condition. Some of his suggestions included good preoperative assessment with specular microscopy; using Trypan blue rhexis and sizing; using peribulbar or parabulbar anesthesia; using high phaco power at 80%-100% for trenching; and using minimal hydrodissection to avoid being aggressive. Dr. Rajan also went over the ins and outs of the chopping technique for suprahard cataracts. “The Quick Chop Express makes life easy, effective and enjoyable both for the patient as well as for the surgeon,” he said. He also shared that a vertical chop is more effective than a horizontal chop in treating this condition.

A great day to learn from experts It was a gift to observe these experts engage back and forth on the best way to do a certain procedure, or how they can improve a technique. Some of the other symposiums that day were on the topics of ophthalmic trauma, pediatric ophthalmology, updates on AMD/PCV and women in ophthalmology. No doubt all were fascinating!

Editor’s Note: The All India Ophthalmological Society-International Ophthalmic Conclave (AIOS-IOC) 2021 was held from February 19-21, 2021. Reporting for this story also took place during the AIOS-IOC 2021 virtual conference.

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Optimis Fusion® + Vitra 2®

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www.ellex.com www.quantel-medical.com

| March/April 2021

NTERIOR SEGMENT

GLAUCOMA

ABiC for Glaucoma Navigating Uncharted Trabecular Meshwork by Olawale Salami

n recent years, there has been an increasing interest in ab-interno canaloplasty (ABiC) as a treatment for mild to moderate primary open-angle glaucoma (POAG). This isn’t surprising considering the procedure’s ease of use, comprehensive approach and low-risk profile. However, while ABiC requires an understanding of the patency of the aqueous humour outflow system of patients’ eyes, there are, unfortunately, very limited practical options to enhance this.

Tracing canalogram patterns with trypan blue In a paper* published in the Journal of Glaucoma, Gavin Docherty and colleagues at the Department of Ophthalmology, University of Calgary, elegantly described canalogram patterns observed during ab-interno canaloplasty with trypan blue. The primary aim of the study was to demonstrate canalogram patterns observed when trypan blue tracer was combined with an ocular viscoelastic device during ab-interno canaloplasty, and evaluate potential

implications for diagnosis, prognosis and treatment of open-angle glaucoma. In this retrospective case series, the authors performed ABiC on 5 eyes, and all surgeries were free from complications. Patients were followed up for 8 to 18 months, during which the surgeons recorded an average intraocular pressure (IOP) of 13mmHg in the treated eyes, down from an average preoperative level

“Patients who would benefit from ABiC are those with open-angle glaucoma with medically uncontrolled IOP, or those unable to tolerate topical drops but are nSot yet at the level of requiring trabeculectomy or glaucoma drainage device surgery.” – Dr. Ammar Khan

| March/April 2021

of 16.4mmHg. Furthermore, the average number of topical glaucoma medications was halved, from 3.6 preoperatively to 1.8 postoperatively. These results suggest that ABiC may play a vital role in our understanding of the aqueous outflow system and its role in the underlying pathophysiology of glaucoma.

Hold your horses: Do not disturb the conjunctiva Dr. Ammar Khan, from the Department of Ophthalmology, University of Calgary, shared his insights into the patient population that stands to benefit the most from this procedure. “Patients who would benefit from ABiC are those with open-angle glaucoma with medically uncontrolled IOP, or those unable to tolerate topical drops but are not yet at the level of requiring trabeculectomy or glaucoma drainage device surgery,” Dr. Khan shared. “In these patients, the moderate reduction of IOP through ABiC would be beneficial as a surgical option, either performed

singly or in combination with cataract extraction.” Furthermore, he said: “Additional patients who could benefit from this procedure are those with inadequate conjunctiva precluding successful trabeculectomy, as another advantage of this ab-interno procedure is the sparing of conjunctival tissues. This sparing of tissues allows preservation, should trabeculectomy or other interventions be required in the future.” Other benefits of this procedure include the avoidance of trabeculectomy and blebrelated complications, such as bleb leak and blebitis, and reduced risk of choroidal hemorrhage or effusions.

No odd stick: Tailoring patient management Dr. Khan provided vital suggestions and tips to anterior segment surgeons who would be interested in this technique to optimize patient outcomes. “Patient selection is crucial and ABiC should be considered in those with mild to moderate glaucoma,” he said. On preoperative screening, he noted that preoperative evaluation should include a thorough gonioscopy. “It is vital to identify those with a relatively functioning trabecular meshwork. This is because ABiC may not be successful in those with significantly diseased trabecular meshwork,” Dr. Khan explained. “A highly cohesive viscoelastic is helpful (but not required) to create space and optimize the angle

structures. This may also be of benefit for canaloplasty, although this subject is not confirmed in the literature.” Commenting on the tailored use of this procedure in patients, Dr. Khan said: “The extent of goniotomy can be modified on a case by case basis. For patients on anticoagulation, goniotomy should be avoided or minimized. In monocular patients, goniotomy is not preferable due to the risk of hyphema. If combined with glaucoma drainage device surgery, the goniotomy should be done inferiorly and the drainage device placed superiorly.”

Pushing the boundaries of aqueous humour outflow systems What kind of research do we need to expand the frontiers of our current understanding of the aqueous humour drainage? Dr. Khan shared: “Regarding the conventional pathway of aqueous humour drainage, further elaboration and understanding are required on the collector channel system, and whether earlier interventions are beneficial in preventing the collapse of the distal collector channels. Ideally, future research will develop ways to visualize the outflow system preoperatively.” He said this will allow surgeons to determine if outflow scarring is present, if patients with severe outflow scarring may benefit more from a primary filtering surgery as opposed

“Substantial research is required to delineate potential lymphatic channels in the eye and how this uveolymphatic pathway plays into aqueous humour drainage and regulation of intraocular pressures.” – Dr. Ammar Khan to a minimally invasive canal-based surgery. “Substantial research is required to delineate potential lymphatic channels in the eye and how this uveolymphatic pathway plays into aqueous humour drainage and regulation of intraocular pressures,” he explained. “If we can understand this system and assess it preoperatively, we may have improved ability to select a surgery with better outcomes for patients,” he concluded.

REFERENCE: * Docherty G, Waldner D, Schlenker M, Crichton A, Ford B, Ahmed IIK, WGooi P. Ab Interno Canaloplasty in Open-angle Glaucoma Patients Combined With In Vivo Trypan Blue Aqueous Venography. J Glaucoma. 2020;29(12):e130-e134.

Contributing Doctor Dr. Ammar Khan is a fifth year ophthalmology resident at the University of Calgary. He began his academic journey at Simon Fraser University in British Columbia, where he majored in biomedical physiology and kinesiology. During this time, he was introduced to anatomy and physiology, and subsequently decided to pursue these interests further in medical school at the University of Calgary. While studying medicine, he had the opportunity to gain exposure to the world of ophthalmology and decided this would be a rewarding and gratifying career path. He is currently in the final year of his residency and will continue his training with a fellowship in glaucoma surgery in Calgary this summer.

Like charting a course through high seas, determining the right procedure for glaucoma patients can be a tricky business.

ammar34@gmail.com

| March/April 2021

NTERIOR SEGMENT

EYE BANKING

COVID-19 and the Great Cornea Bank Stickup by Sam McCommon

hat eye banking was hit by the COVID-19 pandemic perhaps won’t come as a shock to most people. Indeed, we’re all painfully aware of just how much it turned the world upside down, so we needn’t further belabor that point. If we can imagine the eye bank as a dusty, small-town deposit bank and the virus as a masked, gun-slinging robber — well, that’s not far off. The eye banking system in general deserves a closer look vis à vis the virus because there are still some unanswered questions. So, the All India Ophthalmological Society (AIOS) during its first International Ophthalmic Conclave (IOC), or AIOS IOC 2021, turned to Dr. Jennifer Li, professor of ophthalmology and vision sciences at the University of California at Davis and chair of the Medical Advisory Board at the Eye Bank Association of America (EBAA) to shed some light on the situation.

Sand in the gears It’s an unusual virus we’re dealing with, to be sure, and extreme caution in eye banking has been the go-to rule. This extreme caution led to what was essentially a complete, worldwide collapse of cornea transplants in March and April of 2020. Just to make that clear, there were for all practical purposes no cornea transplants during that period. That’s unprecedented — another word we’re all likely sick of by now.

international eye banks lag behind. It’s great to see the eye bank world spring back to life, but it’ll take some time before things are running as smoothly as before. We’re not out of the woods yet, anyway. Just to chart a clear path through said woods so we don’t get lost, let’s take a quick step back and see how we got to that collapse and then how things have progressed from there.

Sticky stuff

As Dr. Li noted, U.S. eye banks have recovered to around 80% to 85% of their pre-COVID levels, though

Early on in the pandemic, information on just how the virus affected the eyes was scarce. We’ve come a long way,

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however. The virus behind the pandemic is well known to bind to angiotensin converting enzyme 2 (ACE2) receptors most notably, but others as well. The ACE2 receptor is present in the conjunctiva, limbus and cornea, as are TMPRSS2 and DC-SIGN/DC-SIGNR. Dr. Li pointed out that TMPRSS2 can allow the virus to enter a cell after it’s bound to an ACE2 receptor via its spike protein. Alternatively, the DC-SIGN/DCSIGNR could be another transmission method for the virus. So we know that the virus can infect ocular tissue. That’s the bad news. The good news is that it doesn’t appear to be able to replicate in ocular tissue, or

survive there in deceased patients. To wit, Dr. Li presented a study by Bayyoud et al.¹ consisting of 10 eyes from five patients who had died of COVID-19. Quantitative reverse transcription polymerase chain reaction (RT-PCR) testing for viral ribonucleic acid (RNA) was performed on corneal stroma and endothelium, the bulbar conjunctiva, conjunctival fluid swabs, anterior chamber fluid, and the corneal epithelium. The result? No viral RNA was detected in any of the ocular tissue or intraocular fluid. So, we’re done here, right? Not quite. Another, earlier study by Casagrade M. et al.² appears to contradict that notion. Of 11 patients deceased from COVID-19, viral RNA appeared in the corneal tissue of 6 (that’s 55%). The infectivity or structure of the viral proteins couldn’t be confirmed, but it sure left its signature, like a wanted criminal’s calling card. This leaves researchers scratching their heads wondering if the cornea was contaminated via blood or aqueous.

Gimme a clue, Doc Thus, the sheriff rushed to the scene. The EBAA was quick to consider the implications of the virus in the corneal tissue, with discussion beginning as

early as January 21, 2020 — just after the first confirmed case in the U.S. The first screening recommendations were sent on February 3, 2020, not long afterward. Since then, the guidelines have been continuously evolving and we can likely expect them to evolve further. The most recent update was released on October 20, 2020. Crucially, it aims to balance the needs of transplant recipients and doctors with the safety of the donor pool — and there are some good ways to do this.

Guidelines and rationale So, for now, we’re left to sort out eligible and ineligible donors. For example, was a deceased person known to be infected with the virus in the last 28 days? They’re not eligible for donation. If they’re negative, or if they were asymptomatic at the time of death? It’s currently not necessary to perform a PCR test to determine if a donor is eligible. They’re good to go. Before you get concerned, the rationale here is that this relies on a more decentralized system, anchored by the medical expertise of the people on the scene. An overall increase in testing has led to improved screening, and local medical directors are more capable of making decisions regarding the safety of donor tissue than before. In some cases, still, a negative PCR test may be

required to check some corneal tissue. Ocular inflammation, like conjunctivitis, keratitis, and so on, is a contraindication for harvesting corneal tissue. That’s a no-go. In the event tissue has been deemed safe to harvest, it must be washed at least twice with a 5% povidone-iodine solution between the time of the donor’s death and tissue harvesting.

What happens when things go wrong? In the event that, somehow, infected corneal tissue is transplanted to a recipient, it’s not the end of the world. This has in fact happened, but no one has been harmed by it. As far as we know right now, there’s no indication of COVID-19 transmission from corneal tissue. Dr. Li noted there are currently eight known cases of accidental transplant of tissue from donors infected with the virus at the time of their death. Of these eight cases, the recipients are all fine. They did not develop COVID-19 during the postoperative period, and all the grafts were successful. So, hey, even when mistakes happen, people somehow come out of it okay. Thank goodness for that.

REFERENCES: ¹ Bayyoud T, Iftner A, Iftner T, et al. Absence of Severe Acute Respiratory SyndromeCoronavirus-2 RNA in Human Corneal Tissues. Cornea. 2021;40(3):342-347. ² Casagrande M, Fitzek A, Püschel K, et al. Detection of SARS-CoV-2 in Human Retinal Biopsies of Deceased COVID-19 Patients. Ocul Immunol Inflamm. 2020;28(5):721-725.

Editor’s Note:

A successful bank robbery takes split-second timing… or dozens of dynamites.

AIOC IOC 2021 was held virtually from February 19 to 21. Reporting for this story took place during the event. A version of this article was first published at cakemagazine.org on April 1, 2021.

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TECNIS Synergy™ Bridging the Gaps in Surgical Correction of Presbyopia TECNIS Synergy™ unites EDOF and Multifocal technologies for continuous vision that gets the best of both worlds.

dvances in intraocular lens (IOL) technologies have increased patient expectations for postoperative refractive outcomes tremendously. Patients today seek not just good vision, but also total spectacle independence. Indeed, the goal of implanting IOLs for the physician has transitioned from the mere treatment of disease to providing complete visual rehabilitation. The visual demands of daily life have also changed in the last few decades. Intermediate vision is increasingly crucial in carrying out daily activities such as cooking, using computers and smartphones and even looking at the car dashboard.¹ Despite multiple presbyopia-correcting

IOL options being available, most have limitations and are not able to meet all of the demands. Patients continue to struggle to achieve high-quality vision at ideal distances at all times of the day. The Extended Depth of Focus (EDOF) IOLs provide good distant and intermediate vision, but adequate near visual acuity. Multifocal IOLs including trifocals IOL technologies can provide good near, intermediate and distant visual acuity. However, the light rays are split at distinct focal points, leaving gaps in the visual acuity. Advanced optics that splits light or extends the range of vision is associated with an increase in photic phenomena, which is the leading cause of dissatisfaction among patients

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after uncomplicated cataract surgery. Achieving good visual acuity at home and in the office is further challenged by the increasing utilization of LEDs in indoor spaces. LEDs emit shorter wavelengths of light that scatter to a greater extent, hindering vision quality.²

Improving vision quality under different light conditions The TECNIS Synergy™ IOL was designed to overcome the limitations of current IOL technologies. Its innovative design combines EDOF and Multifocal technologies to deliver continuous high-

contrast vision across the range, even in low-light conditions.³ The lens is based on the TECNIS® platform, recognized for minimal spherical and chromatic aberrations, Grade 0 glistenings and minimally observed capsule phimosis. The TECNIS® IOLs correct spherical aberrations to essentially zero and provide a sharp quality of vision.4 They have a high Abbe number of 55, which reduces light dispersions and chromatic aberrations.5 The superior material and unique design provide a sharp quality of vision and unmatched image contrast under all lighting conditions.6 Its proprietary ChromAlignTM technology further reduces chromatic aberrations and optimizes contrast vision.7

on follow-up. It was observed that the TECNIS Synergy™ provided 20/20 to 20/25 visual acuity continuously from far, intermediate, through near. The defocus curve testing showed a full range of vision with near up to 33 cm. Overall, the TECNIS Synergy™ provided intermediate and distance

vision comparable or better than the multifocal IOL.12

The performance of TECNIS Synergy™ IOLs is further enhanced by the proprietary violet-light filtration system and a pupil-independent design. The violet-light filtration blocks the shortest wavelengths of visible light (violet), which produce the highest levels of scatter while transmitting the longer wavelengths of light (blue). Blocking the high-energy wavelengths improves vision quality and reduces light scatter, improving safety during daytime and night-time driving.8 The pupilindependent design contributes to the best low-light performance compared to leading trifocal IOLs.9 The unique technology and design of the TECNIS Synergy™ IOL delivers continuous 20/25 vision from far to near, with high contrast vision even in low-light conditions.10 Continuous vision across the range bridges the gaps in vision experienced by patients with trifocal IOLs, and TECNIS Synergy™ empowers the patients to see at their ideal distances.11

* Not all products are approved in each market. Please contact your local sales representative for further information.

In conclusion, TECNIS Synergy™ IOL overcomes the limitations of existing IOLs to provide continuous highcontrast vision from distance to near, even in low-light settings.

Scan the QR code to visit J&J Surgical Vision APAC website for more information and discover innovative solutions.

REFERENCES: 1.

Tognetto D, Cecchini P, Giglio R, Turco G. Surface Profiles of New-generation IOLs With Improved Intermediate Vision. J Cataract Refract Surg. 2020;46(6):902-906.

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

Data file on PP2019CT5141TECNIS SynergyTM IOL — The Continuous-Range-of-Vision IOL from Johnson & Johnson Vision

Data file on PP2020CT4825 TECNIS® Portfolio of IOLs

Data file on PP2019CT5141 TECNIS SynergyTM IOL — The Continuous-Range-of-Vision IOL from Johnson & Johnson Vision

Data file on PP2020CT4825 TECNIS® Portfolio of IOLs

Data file on PP2019CT5141 TECNIS SynergyTM IOL — The Continuous-Range-of-Vision IOL from Johnson & Johnson Vision

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

Ibid.

10.

Ibid.

11.

Data file on PP2019CT5141 TECNIS SynergyTM IOL — The Continuous-Range-of-Vision IOL from Johnson & Johnson Vision

12.

Chang D. Visual Outcomes and Defocus Curve Profile of a Next-generation Diffractive PresbyopiaCorrecting Intraocular Lens. 2019. Paper presented at 37th Congress of ESCRS, Paris

Johnson & Johnson Surgical Vision, Inc, 2021 PP2021CT4610

Clear vision, no matter the distance The breakthrough innovative technology has been thoroughly tested through bench and clinical studies with promising results. The TECNIS Synergy™ was compared with the TECNIS Multifocal® +3.25D in a prospective, masked randomized clinical study in patients undergoing cataract surgery with bilateral IOL implantations. The visual acuity was assessed under photopic conditions and defocus curve testing was conducted

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COVER STORY

by Sam McCommon

icture this scene: A dusty, leatherfaced cowboy hitches his horse to the post on a dirt street, throws open the double doors of the saloon, ambles, bow-legged, to a bar stool, and orders a bourbon, neat. He throws it back quickly, grits his teeth, and rubs his sore, dry eyes with the heels of his palms. He’s been roping young steers all day and the dust they’ve kicked up,

combined with hours of squinting from the sun, has left his eyes red and raw.

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Now, swap out that cowboy for a modern office worker, the horse for a Toyota, the saloon for a café, the cows for numbers in a spreadsheet, and the dust in the air for smog. The result of these occupational concoctions is the same: a marked increase for the risk of

developing dry eye. The itchiness and irritation that come with dry eye disease (DED) are all too familiar to many, and the prevalence of the condition is spreading like a prairie fire. Roughly 10% of the American population and around 350 million people worldwide suffer from the disease in one form or another,

and ophthalmologists are well aware that DED is one of the most common reasons for clinic visits.

Why DED remains an unconquered territory Amazingly enough, for a problem that’s plagued mankind since the beginning of time, DED represents a frontier yet to be conquered by ophthalmic science. It’s only been in the last few decades that DED was even recognized as a condition in its own right. Indeed, the first definition of it was as recent as 1995, when, we should note, the second “D” stood for “disorder.” So, why did it take so long to get recognized by the medical community? It’s a valid question, so we asked Dr. Laura Periman to help us better understand it. For reference, she's a board-certified, cornea-trained ophthalmologist based in Seattle at her own clinic that specifically focuses on dry eye. To say she’s made DED her life’s work would be right on the money. “We didn’t have the right language to diagnose it and talk about it until not too long ago,” Dr. Periman said. “We didn't have the right tools to treat it. Scientific growth needed to happen first.” “There’s a medical awareness layer that needed to come in,” she continued. “There’s an innovation layer that needed to come in. We needed all the wheels on the wagon before we could really get anywhere.” One of the major problems in treating

DED is it’s a multifactorial condition. Diagnosing the actual cause of a person’s DED is often a challenge. That’s why Dr. Periman had to change the structure of her clinic. “Dry eye is a busy, noisy and messy disease state,” she said. “It’s a big umbrella diagnosis with a bunch of different diagnoses and you can’t solve

it in just six minutes. You need more time. The traditional medical care model doesn’t serve the dry eye patient, and it can be an exercise in frustration for both doctor and patient.” A deeper dive into a proper DED diagnosis often requires a bit of sleuthing on an ophthalmologist’s part. When the cause of the condition could be anything from allergies leading to meibomian gland dysfunction (MGD), to autoimmune disorders like Sjogren’s syndrome — or even environmental, dietary, cosmetic or hygienic factors — ophthalmologists may need to connect the dots between the differing medical specialties. There’s good news, though. There have recently been significant developments for DED treatment, and more are on the way. The condition is finally getting the medical recognition it deserves — because it’s a true quality of life issue, and not simply a minor inconvenience to be brushed off and ignored. Dr. Periman noted that in the ophthalmic community, there’s been a significant uptick in DED recognition in just the last four or five years. And the pharmaceutical industry has been making significant strides in treatment options as well — which we’ll discuss just now.

well be a seriously overlooked problem. Demodex blepharitis is caused by an infestation of pesky, eight-legged mites. These little varmints just love to make eyelashes their home, which can lead to eyelid inflammation, meibomian gland dysfunction, chalazia and severe dry eye, especially in older patients. A 2010 study¹ showed that 84% of 60-year-olds and 100% of those older than 70 hosted demodex infestations. As aging is a known predisposing factor for dry eye, there may be something to really chew on here. The mites can cause mechanical damage via collarettes — their waste — and can also carry bacteria that leads to other problems, including rosacea. Almost half (45%) of blepharitis cases are caused by demodex mites, so they’ve got to go. One such treatment that may soon be available is from Tarsus Pharmaceutical (Irvine, California, USA). The company is currently developing the first treatment specifically for demodex blepharitis, and things look promising. Their eye drop, currently named TP-03, has undergone multiple successful trials and is currently in phase 2b/3. Dr. Periman told us that TP-03 can kill the mites for up to six months after a twice daily, four-week treatment regimen.

Novel Dry Eye Treatments: The Sheriff’s New Posse Samuel Colt’s revolver changed the nature of the American “Wild West” because it was the first gun that could fire multiple shots before being reloaded. New

treatments for DED effectively give doctors multiple shots to target DED’s numerous causes, which at least gives them a fighting chance.

Demodex blepharitis: Mighty overlooked mites Demodex folliculorum infestations may

Interestingly, TP-03 is a lotilaner .25% solution — and was borrowed from the veterinary world, where it’s used to kill ticks and fleas on dogs. In this case, what’s good for Fido may also be good for Fred. Another potential treatment for demodex infestations is intense pulsed light (IPL). The in-vitro study² published

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COVER STORY

by Dr. Periman and her collaborators, Harvey Fishman MD and Ami Shah MD, showed that IPL can lead to “complete destruction of the organism.” In other words, it kills them dead.

TearClear: More than a lick and a promise Interestingly, the way topical ophthalmic medications are delivered may soon change — and this can have a significant benefit for dry eye patients. Dr. William Trattler brought our attention to a company called TearClear (Boston, Massachusetts, USA) that’s working to produce a special filter that removes preservatives in eye drops. Benzalkonium chloride (BAK) is a common eye drop preservative. In the past, it was viewed as potentially beneficial — it appeared to help drugs penetrate the ocular surface and allow for better drug delivery.

it’s been strongly implicated to worsen dry eye. A 2017 study³ pointed out that BAK reduces mitochondrial function in corneal epithelial cells, which could be what causes adverse reactions.

specifically indicated as a shortterm dry eye treatment. Because it’s tailor-made for dry eye, it’ll likely be one of the most popular choices for ophthalmologists going forward.

TearClear is currently focusing their efforts on glaucoma medication, but dry eye is in their sights as well. Keep an eye on this startup: A functional preservative filter would be a gamechanger indeed.

Then there are antihistamine treatments for dry eye, which can often be a result of allergies. Rather than take a systemic antihistamine, doctors can recommend Zerviate (Eyevance, Fort Worth, Texas, USA) as a topical antihistamine. It relies on cetirizine, and was approved by the FDA just a few years ago in 2017.

DED treatments: Keep ‘em comin’ Another up-and-coming dry eye treatment is Eysuvis (Kala Pharmaceuticals, Watertown, Massachusetts, USA). It’s a topical corticosteroid that was approved by the FDA as recently as October 2020, and is the first prescription medication

However, BAK has come under scrutiny, with many arguing against its use — and

Biologics may have an interesting role to play as well. Lubricin (Lubris Biopoharma, Framingham, Massachusetts, USA) naturally found in the ocular surface, may be a valuable addition to a dry eye regimen. The “lubri-” part of the word is a good clue as to what it does: It prevents friction between the cornea and the conjunctiva during blinking. Studies4 have shown it’s extremely effective at reducing this friction, thus reducing mechanical wear and tear on the ocular surface. It feels good to blink smoothly, doesn’t it? Reimagining human nerve growth factor drugs has also led to potential success in treating DED. Cenegermin in the form of Oxervate (Dompé, Boston, Massachusetts, USA) was originally developed and approved to treat neurotrophic keratitis, but it has also shown promise as a DED regimen. A recent British study5 showed the drug was safe and effective. It’s very good news for a product that’s already on the market to have multiple uses. Even Botox has been shown to be useful in the fight against DED, as Dr. Periman pointed out. “You can use Botox right above the lacrimal sac to decrease the tear clearance pump function in order to create tear conservation without punctal plugs,” she said.

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The true grit of Azura’s AZRMD-001 Meibomian gland dysfunction (MGD) is becoming better understood as one of the chief causes of dry eye disease, but there are currently no approved treatments for it. Azura (Tel Aviv, Israel) is looking to treat that, and in early March 2021, they released compellingly positive phase 2 results for their drug, unpoetically named AZRMD-001. Interestingly, the company brands itself as taking a dermatological approach to ocular surface diseases. The drug’s goal? To reduce the hyperkeratinization of meibomian glands, which blocks the release of sebum. Essentially, a blocked meibomian gland means there’s not a thick enough meibum protecting the top layer of tears from evaporation and lubricating the eyes. Azura argues that MGD is significantly underdiagnosed, and they may be right. If the treatment proves to be a big of a hit as the company seems to expect, someone could stand to make significant money. We’ll be keen to keep up for further developments.

Hold your horses! Neurostimulators are on the way Two interesting treatments rely on neurostimulation to induce tear production — a novel, non-eye drop approach. One is Olympic Ophthalmics’ (Issaquah, Washington, USA) iTear100, a device that relies on external vibrations. It was approved by the FDA specifically for this purpose in May 2020. Dr. Periman participated in the

phase 3 FDA trials and was a co-author on the paper6 published late 2020.

soft tip gently cleans the eyelids while stimulating the meibomian glands.

The iTear100 is pocket-sized and delivers vibrations to the side of the nose for about 30 seconds — which then stimulates tear production. One study demonstrated a 22mm change in the Schirmer score, and another longterm study showed significant Schirmer score improvements over 30 days. Overall, the iTear100 is a neat, reliable buzzy device that produces a complete tear and improves tear production, corneal staining and meibomian gland secretion scores. Simple solutions can be very refreshing sometimes.

There’s an additional bonus: The device also helps remove any potential mites in your eyelids by simply sweeping them away. Cool, right?

Another neurostimulation treatment is a preservative-free nose spray relying on varenicline, a drug often used to treat nicotine addiction. Oyster Point Pharma (Princeton, New Jersey, USA) submitted a new drug application to the FDA as recently as December 2020, for their spray, dubbed OC-01. The spray stimulates the trigeminal nerve via the nose, which stimulates tear production.

The eye’s tears are its natural defense mechanism, and not having enough of them is ironically something to cry about.

Good ole at-home treatments It wouldn’t be 2021 if we weren’t discussing at-home treatments, as doing everything at home has been all the (necessary) rage. But patients suffering from DED will likely continue to appreciate these home treatments, even if they can now return to their favorite ophthalmologist. One notable at-home treatment Dr. Periman is very keen on is called NuLids (NuSight Medical; Rancho Santa Fe, California, USA). It looks like an electric toothbrush and, in fact, has a similar purpose. Its

REFERENCES: 1.

Liu J, et al. Pathogenic role of Demodex mites in blepharitis. Curr Opin Allergy Clin Immunol. 2010;10(5):505-510.

Fishman HA, Periman LM, Shah AA. Real-Time Video Microscopy of In Vitro Demodex Death by Intense Pulsed Light. Photobiomodul Photomed Laser Surg. 2020;38(8):472-476.

Datta S, Baudouin C, Brignole-Baudouin F, et al. The Eye Drop Preservative Benzalkonium Chloride Potently Induces Mitochondrial Dysfunction and Preferentially Affects LHON Mutant Cells. Invest Ophthalmol Vis Sci. 2017;58(4):2406-2412.

Schmidt TA, Sullivan DA, Truitt ER, et al. Lubricin Functions as an Ocular Surface Boundary Lubricant. Invest Ophthalmol Vis Sci. 2010;51(13):3399.

Sacchetti M, Lambiase A, Schmidl D, et al. Effect of recombinant human nerve growth factor eye drops in patients with dry eye: a phase IIa, open label, multiple-dose study. Br J Ophthalmol. 2020;104(1):127-135.

Ji MH, Moshfeghi DM, Periman L, et al. Novel Extranasal Tear Stimulation: Pivotal Study Results. Transl Vis Sci Technol. 2020;9(12):23.

Giddy-up! Make DED dead It’s taken a lot of work to get where we are now with DED treatments, and a lot more are on the way. Any civilian would probably be shocked to learn just how complicated DED can be, and just how many factors are at play.

We’re very pleased to see the progress occuring in the DED world, and the next few years should turn up further significant improvements. Shining the medical world’s flashlight on DED has proven to be enlightening in more ways than many even in the industry would have anticipated not long ago. So, let’s conquer this frontier of medicine and get DED corralled for good. If it can be done, it should. Just like any good sheriff protecting his town, it’s the doctors’ job to make sure the townspeople are taken care of.

Contributing Doctor Dr. Laura M. Periman is a boardcertified ophthalmologist, fellowship-trained cornea and refractive surgeon and ocular surface disease (OSD) expert. Dr. Periman completed her ophthalmology residency and cornea/ refractive fellowship at the University of Washington in Seattle. She has 11 peerreviewed publications and has written extensively on the topic of OSD. As founder and director of Dry Eye Services and Clinical Research at Periman Eye Center in Seattle, Washington, USA, Dr. Periman combines her clinical care passion, scientific drive, and innovative creativity to provide first class OSDmanagement. dryeyemaster@gmail.com

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DEAD or ALIVE Ringleaders reward: $$$$$

Ocular Allergies

Meibomian Gland Dysfunctio n

Demodex Blephariti s

Known accomplices reward: $$$$$

Prolonged screen use

Autoimmune Skin diseases like rosacea and eczema disorders like Sjogren’s

Preservati ves in eye drops

* Systemic medication s

Cosmetics

Syndrome, Lupus, or Rheumatoid Arthritis

Postmenop ausal estrogent herapy

Vitamin A deficiency

Diabetes

Air pollution and low air humidity

Recent ophthalmi c surgery

Aging

*(antihistamines, antihypertensives, anxiolytics/benzodiazepines, diuretics, systemic hormones, non-steroidal anti-inflammatory drugs, systemic or inhaled corticosteroids, anticholinergic medications, isotretinoin (causes meibomian gland atrophy), and antidepressants) 1. 2. 3.

Golden MI, Meyer JJ, Patel BC. Dry Eye Syndrome. Treasure Island (FL): StatPearls Publishing; 2021. Messmer EM. The Pathophysiology, Diagnosis, and Treatment of Dry Eye Disease. Dtsch Arztebl Int. 2015;112(5): 71–82. Liu J, Sheha H, Tsenga SCG. Pathogenic role of Demodex mites in blepharitis. Curr Opin Allergy Clin Immunol. 2010;10(5): 505–510.

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INDUSTRY UPDATE

Volk Optical Introduces ClearPod to Address Fogging During Fundus Examinations by Chris Higginson

olk Optical has released the ClearPod, a new product that aims to solve the problem of mask-related fogging during fundus examinations.

That’s why Volk Optical and their collaborators, Dr. Bradley Sacher, a cataract specialist, and Dr. Jeremy Wingard, a glaucoma specialist, have developed the ClearPod.

Over the course of a single year, face masks have gone from being used only by a small number of medical professionals to becoming a huge part of everyone’s everyday life, with many cities, states and countries requiring a face mask to step outside the door. However, those of us who routinely wear glasses quickly discovered the frustration of warm air being directed upward out of our masks and onto our glasses, resulting in fogging and frustration.

Designed to clip onto the Volk fundus lens, the ClearPod forms a barrier, directing warm air currents away from the lens surface, stopping fogging, and allowing a clear and uninterrupted view. This means the examination can be completed quickly and efficiently with the patient’s mask still in place.

The same problem was noticed by ophthalmologists and Volk Optical during fundus examinations. Patients’ masks would fog the instruments resulting in frustration and delay, at a time when everyone is trying to complete their examinations as quickly and efficiently as possible. Often, these issues were severe enough that ophthalmologists would require the patient to remove their mask in order to complete the examination properly.

The ClearPod is designed to be small and light, allowing professionals to retain a natural grip on the lens as they use it. According to Volk Optical, the device’s shield is carefully designed to accommodate the right working distance while providing maximum fog diversion, so the examination can continue without being interrupted by warm air fogging up the instruments. In addition to counteracting the problem of fogging during an examination, the ClearPod can be used as an aid for teaching new ophthalmoscopy students.

“Even after COVID, I think this is a great tool for teaching medical students and residents ophthalmoscopy techniques, as the flange guides and supports to better accommodate the proper working distance,” shared Dr. Francesco Comacchio, an ophthalmologist at the Hospital of Merano-Südtirol, Italy. “The ClearPod is a perfect solution to prevent non-contact lenses from fogging up. I strongly recommend this device to every ophthalmologist examining a mask-wearing patient, allowing a normal examination of the retina.” Although we are all hoping COVID will soon be a thing of the past, it seems unlikely that face masks will completely leave us, especially in medical settings. And the ClearPod will allow patients to keep their masks on if that’s what they choose. The ClearPod is currently available for the 90D and the 78D lenses. Volk Optical plans to release the ClearPod for their Digital Wide Field and Super Field lenses early next year.

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UDOS

OPHTHALMIC CHARITY

London. She refused to be discouraged by the fact that most of the other students were half her age. She cited her mother as her greatest inspiration, who herself had returned to university at the age of 49 in order to study Chinese literature. “My mother was the greatest influence in my life,” shared Dr. Mathen. “For her, you were never too young to follow the advice: Don’t just follow the crowd, have a mind of your own.”

Dr. Lucy Mathen

Making a Difference, One Eye at a Time by Chris Higginson

s with most things in her life, Dr. Lucy Mathen did not become an ophthalmologist and charity worker conventionally. Beginning her professional life as a print journalist for a local British newspaper in the 1970s, she quickly outgrew this small setting. In 1976, Dr. Mathen was hired by the BBC as the first female Asian news reporter on nationwide TV for the ground-breaking children’s news program, Newsround.

Afghanistan, that her life suddenly took an unexpected turn. "I felt like such a fraud,” she said. “I decided right then that if I was ever going back to a war zone, I wouldn't be there as a journalist. I would be there as a doctor, to make a difference. Within a year I was in medical school."

On blazing her own trail

For the next 12 years, Dr. Mathen would work in journalism. It wasn’t until 1988, when she was making a documentary about women in

At the age of 36, leaving a successful and trailblazing career in journalism and with a 3-year-old child, Dr. Mathen retrained as an ophthalmologist at St. George's Hospital Medical School in

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After completing her training and starting work in the NHS, she took time off from her job in 2000 to travel around rural North India. She discovered that although around 80% of India’s blind people live in rural areas, the vast majority of the country’s ophthalmologists were based in wealthier cities. Particularly in need were the northern states of Bihar and Orissa, which are two of India’s poorest states and make up part of what is known as India’s “cataract belt.” So, it was there that she chose to start her charity organization, Second Sight, with a goal to help deal with the epidemic of blindness plaguing the area.

Second Sight: From bedroom to Bihar Initially set up in her London bedroom, Second Sight was funded by her work as a locum ophthalmologist. Dr. Mathen traveled all over northern India, meeting people and volunteering her time. "I found that there were many eye hospitals with the required equipment in place. What was missing were the surgeons,” she noted. So, in order to fill the “specialist gap,” she persuaded not only ophthalmologists in the U.K. to go to India to volunteer, but also Indian professionals in private practice in the more developed and wealthier cities to travel to the countryside to do their bit to cure the rural blind. As well as bringing in specialists from outside the local community, Second Sight has also worked hard to train doctors on-site, not just in using the equipment but also in dealing with patients every day. This strategy means that once the volunteer-specialists return to their homes, the knowledge and skills they brought will stay in the countryside, where they’re most needed. A few years into her work, Dr. Mathen was invited to the state of Bihar, India’s poorest state, by legendary Indian ophthalmologist Dr. Helen Nirmala Rao. Dr. Rao had been running the most successful eye unit in the state at a Christian Mission Hospital when she had to stop performing surgery due to medical problems. At that time, one in every 100 people in Bihar’s over 100

million population was totally blind from cataract. Inspired by Dr. Rao’s total dedication to her patients, Second Sight decided to focus all its clinical and financial resources on Bihar. Mindful of the dire poverty of the area, the charity has no salaries, no expenses, no admin costs, and the office is still in the corner of Dr. Mathen’s bedroom. “Twenty years ago, we joined a few Indian eye surgeons and their teams who were willing to work in the areas of greatest need. We hoped that our example might encourage a reverse brain drain of eye surgeons,” Dr. Mathen shared. “This has happened and continues to happen in Bihar, and the main reason is that they know their skills are being used to the hilt. And that work is actually fun.”

Making a difference and inspiring others Since it started, the charity has paid the full cost of surgery of over 450,000 blind patients and helped countless others to avoid blindness. However, what Dr. Mathen believes to be the best news is that surgeries are no longer performed by strangers from abroad or the big cities. All surgeries are now performed by local, highly-skilled Indian surgeons at permanent hospitals providing comprehensive eye care. Second Sight clinicians still visit and

work alongside these teams, swapping clinical know-how, collaborating on research, and helping to train new generations of ophthalmic assistants who can be a village screener, scrub nurse and anaesthetist rolled in one. As they come from the local community, their on-site training is very important. According to Dr. Mathen, it is very rewarding to see skilled jobs passed down through generations of rural people. To date, Dr. Mathen has written two books about her work for Second Sight, both available on www.secondsight.org. uk. Every book sold for £20 (approx. USD$28) will restore sight to one more blind person. Dr. Mathen’s journey is truly an inspiration — not only for people to do more to support charitable institutions, but also for them to consider if the skills and abilities they have developed in their lives can be used to change the lives of others for the better. “If people are going to see me as inspiring, I don't want it to be just for happening to be the first Asian woman on the BBC. I want it to be because I am trying to put everything into a cause that really matters. I hope that inspires people to hold on to their ideals,” Dr. Mathen concluded.

Contributing Doctor Dr. Lucy Mathen was born in India in 1953 but has lived and trained as an ophthalmologist in the U.K. Her first career was as a journalist, making history as the first Asian woman to report for and host a TV program in the U.K. After being sent to Afghanistan in 1988 to make a documentary about the lives of women there, she had an abrupt change of heart, and within a year she was in medical school. She retrained as an ophthalmologist in London and a few years later set up her charity Second Sight to help restore sight to the poor of North India. The charity has been an amazing success, opening hospitals and paying the full cost of surgery for almost half a million Indians and helped countless others to avoid blindness. lucymathen@yahoo.com

Photo courtesy of Second Sight

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UDOS

WOMEN IN OPHTHALMOLOGY

Dr. Sanushka Moodley

On Gender Inequality in Ophthalmology by Brooke Herron

r. Sanushka Moodley is a general ophthalmologist in full-time private practice at Pretoria Eye Institute in South Africa. She manages glaucoma, cornea, medical and surgical retina, and cataract patients. Dr. Moodley is also the current chair of South Africa’s Young Ophthalmologists’ Society. As part of CAKE Magazine’s continued coverage of women in ophthalmology, we spoke with Dr. Moodley about some of the challenges she faced during her medical training, as well as the gender inequality that still exists today. She also provided tips for women entering ophthalmology and discussed how she balances work alongside her growing family.

CAKE: What inspired you to become an ophthalmologist?

CAKE: As a woman, can you

describe any hurdles you faced in your training?

Dr. Moodley: Traditionally,

surgical fields are male-dominated. I think as a female in this field, you really have to work hard to get recognized and to be taken seriously. Luckily for our generation, gender equality has made the road to specialization a lot less challenging. Having said that, I still encountered day-to-day problems with regard to being female — from older peers giving preference to male trainees for operations, to patients who

Dr. Moodley: I was first

exposed to ophthalmology in my third year of undergraduate medical school. The technology, micro-surgery, and the ability to restore sight are what attracted me to the speciality. I went on to do my undergraduate electives in ophthalmology — one in Guelph, Canada, and one in Port Elizabeth, South Africa — and I fell in love. After that, there was no turning back.

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“prefer” to be seen by or operated on by a male doctor.

CAKE: Were there

any opportunities, like scholarships, for women entering the field?

balance — I’m a new mom of a threemonth-old baby girl. I think the blessing is that I work in private practice, so for myself, I can dictate how I spend my time. On the other hand, no work means no pay, so I only took 10 weeks off for maternity leave. Luckily, I have an amazing partner and friend that I am in practice with and I trust, and who looked after my patients while I was away.

CAKE: How do you think gender

equality in South Africa compares with the rest of the world?

Dr. Moodley: We are still

Ophthalmology is definitely one of the easier specialties to maintain a good work-life balance. Before baby, I could end my day at the driving range with my husband. Since baby, we make time to bond with her and each other as a family … and still go to the driving range, only now we go with a pram.

lagging behind.

CAKE: What are the biggest challenges you face as a woman ophthalmologist today?

Dr. Moodley: In terms of our Dr. Moodley: Unfortunately, none.

CAKE: How would you describe

gender equality (or inequality) in the workplace in South Africa?

Dr. Moodley: Overall, I think

we still have a long way to go in terms of gender equality in the workplace in South Africa. In the medical field, however, the playing field has definitely started to even out. Medical school graduates are predominantly female. In ophthalmology, specifically, we celebrated our first female society president and vice president in the last elections, and our president-elect for the next term is also female. So, we are definitely making some progress. There’s still massive inequality in the corporate sector — the majority of top executive roles are still filled by men, and there’s a significant disparity in remuneration. Also, some of the benefits related to women in the workplace (e.g., maternity benefits) are not aligned to their needs.

peers, I think for the most part we are being taken seriously and are being given a seat at the table at these once upon a time “old boys clubs”. I think the discrimination still comes mostly from our patients — especially toward the younger female doctors. This is further exacerbated by racial bias associated with our history as a country.

CAKE: For women considering

entering ophthalmology, what tips can you provide? Is there anything you wish you knew then?

Dr. Moodley: I think

ophthalmology is a lovely speciality for women — it’s fine, delicate surgery, and it’s very rewarding. I don’t think I knew how long this road was going to be and I put getting married and having kids on the back burner until I was done with my training. If I could, I wouldn’t have done that — it’s definitely an easier specialty to establish some sort of work-life balance.

CAKE: Speaking of, how do you balance your home life?

Dr. Moodley: I’ll have to

admit that I have to remaster the art of

Contributing Doctor Dr. Sanushka Moodley is a general ophthalmologist in full-time private practice at Pretoria Eye Institute in South Africa where she manages glaucoma, cornea, medical and surgical retina, and cataract patients. She completed her Bachelor of Medicine and Bachelor of Surgery (MBChB) from the University of Stellenbosch, South Africa, in 2008; earned her Diploma of Ophthalmology (DipOphth) in 2013 and did her fellowship (FCOphth) in 2018, both at the Colleges of Medicine in South Africa; and finished her Master of Medicine (MMed) in 2019 at the University of the Witwatersrand, South Africa. Dr. Moodley was the winner of the South African Glaucoma Society resident case presentations in 2018 and had her MMed paper on “Visual outcomes in manual small incision cataract surgery vs phacoemulsification: a prospective comparative data analysis” published in South African Ophthalmology Journal. Previously, she was an ophthalmology registrar representative from 2016 to 2017 at the University of the Witwatersrand, a committee member of the Ophthalmological Society of South Africa Young Ophthalmologists from 2018-2019, and an ophthalmology representative at the South Africa Registrar’s Association (SARA) from 2018 to 2019. Dr. Moodley was in the class of 2019 of the African Ophthalmology Council LDP and has served as chair of the South Africa Young Ophthalmologists since 2019. drsanushkam@gmail.com

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NLIGHTENMENT

RESEARCH PAPER

9 Tips

for Writing

an Effective Research Paper Advice for Young Ophthalmologists

ongratulations, you’ve finished your studies! After years of commitment and hard work, it’s time to share what you learned with the world. Writing and publishing your research can be the icing on the cake, but getting there can be a challenge. After all, you are a skilled and brilliant ophthalmologist, not necessarily a gifted writer. To help you in your publishing journey, we asked some experts to share their pearls for writing an effective — and publishable — research paper.

by April Ingram

consultant ophthalmologist and corneal surgeon at the Oasis Eye Centre in Kuala Lumpur, Malaysia — shared their tips on how to write an effective research paper.

Know the importance of writing your research paper.

Two ophthalmologists who have numerous publications and have presented their work around the globe — Dr. Sheetal Brar, senior consultant in Phaco and Refractive Department and research director at Nethradhama Super Speciality Eye Hospital in Bangalore, India; and Dr. Vanitha Ratnalingam,

“Research is a great opportunity to explore a topic that is particularly interesting to you,” Dr. Ratnalingam shared. “While the research process helps you answer your research question, presenting what you have learned is as important as performing the research. Imagine a police officer solving a crime but then keeping the investigation results to himself! Writing also helps you organize your thoughts,

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craft narratives and share your newfound knowledge,” she added.

Distinguish a good research paper from a bad one.

According to Dr. Brar, a good research paper is based on well-designed experiments, robust methodology, logical rationale and is drafted with sincere intentions. “The concept discussed should be feasible, repeatable and addresses (directly or indirectly) some real problem being faced in a particular field,” she explained. “The study should be valid and verifiable, meaning that conclusions are correct and can be verified by others.” She added: “A bad research paper, on the other hand, is based upon poorly

designed experiments and methodology, plagiarizes other work, and falsifies data to prove a point. It misrepresents information and makes claims for which there is insufficient evidence.” Dr. Ratnalingam couldn’t agree more.“Good research aims to either develop or test a theory,” she said. “Therefore, a good paper should have a clear statement of the problem being investigated at the beginning with an argument that flows from one section to the next.” Good research utilizes welldesigned experiments with adequate control and sample size. “This allows for solid conclusions and accurate predictions made. If the study design is poor, results may be completely or partly invalid,” Dr. Ratnalingam pointed out.

Pick a relevant topic.

You’ve done all the work, but are your findings worth sharing with the world? Dr. Ratnalingam said: “You’ll need to decide if the topic is relevant. When contemplating the significance of the study to science or society, ask yourself — why should the research be published? How will this contribute to the development of ophthalmology?” Dr. Brar advised keeping your publication goals in mind at the beginning. “It is said that ‘writing a paper starts well in advance of the actual writing.’ You must always think about why you want to publish your work at the beginning,” she shared. “Personally, I ask myself the following questions: Is my research idea new and interesting? Is there anything challenging in my work? Is it related to a current hot topic of significant interest to the readers? Does it provide solutions to some ongoing/difficult problems? If all the answers are ‘yes,’

only then I start gearing up to draft my manuscript.”

Use the IMRaD format and take advantage of visuals.

You have an interesting and innovative topic, so how do you get started? Dr. Brar recommended using the tried-andtested IMRaD format: I - Introduction: What did you/others do? Why did you do it? M - Methods: How did you do it? R - Results: What did you find? And D Discussion: What does it all mean? Dr. Ratnalingam said she applies a similar strategy. “Many people may start with the methodology section since it’s the easiest to write and answers the ‘how’ question. But personally, I prefer to start with the introduction, answering the ‘why’ question, and the answer should matter! The introduction should explain how the work builds on previous work with references that are current and international,” Dr. Ratnalingam shared. When presenting your research paper, begin with what is well known and move deeper into the less well known. “This is where you get your reader interested,” she added. “Establish your research problem and specify your objective.” Another important thing to note is that in presenting results, a picture speaks a thousand words. So make use of visuals. “Figures and tables are the most efficient way to present results.”

Keep a relevant, concise, and well-documented discussion.

The discussion section can be the

most difficult to write. Dr. Ratnalingam explained: “It requires you to think about the meaning of the research. You should mention the major findings, the meaning of these findings, and how they relate to what others have done. One common mistake is mentioning all the literature references. Only results related to the study should be mentioned. Try to keep it relevant.” Dr. Brar added some key points to consider: “The discussion should be relevant, concise and well-documented, not mere repetition of results. Discuss both the ‘expected' as well as ‘unexpected’ results in the light of available past and present published literature,” explained Dr. Brar. “A good discussion should provide a balanced and unbiased view, rather than only highlighting ‘results of your interest’.” In addition, both strengths and potential limitations must be mentioned. “There should be some directions and suggestions towards future research for verification of results,” she noted.

Make sure to consult the ICMJE authorship criteria.

How do you know if you should include others as authors? Dr. Brar suggested consulting authorship criteria defined by ICMJE. “Deciding the author order can be challenging at times, especially when two or three authors have contributed almost equally,” she said. “In our system, the first author is the one who has either designed the concept of the research, performed the surgeries/procedures, or is in-charge of manuscript preparation. Other authors are usually listed according to their contribution or seniority. Last author is usually the supervisor or principal investigator who oversaw the project. This author receives much of the credit when the project is successful, or criticism when something goes wrong.” To avoid authorship issues, Dr. Brar said they decide the roles and discuss author order before the start of the project. “We also discuss authorship at regular intervals or major milestones to help reduce disagreements later.”

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NLIGHTENMENT

Carefully decide which journal is best suited to your research.

When deciding on the journal, you may want to consider the audience, impact factor, rejection rates and time from submission to publication. When making this choice, look at the articles you have referred to while preparing your manuscript. “Most are likely concentrated in four to five journals. With this background, you can narrow down to three journals or so, where your work can be potentially submitted,” Dr. Brar shared. She added her insight into the weight of impact factor on journal selection. “Only target journals with very high rejection rates (>90%) and very high impact factor ( >5) if you feel that your research is either very challenging, groundbreaking or has the potential to change current practice patterns. Otherwise, focus on submitting your research to more humble journals with slightly lower impact factors. This saves the time and energy required to revise the article for a new journal, in the unfortunate event of rejection. I don’t mind submitting my work to a journal with a relatively lower impact factor, as long as it is indexed in PubMed or PubMed Central. Eventually, my aim is to have good visibility of my work,” Dr. Brar shared.

To find the time to write, make it intentional and part of your daily routine.

Amid your clinic schedule, OR days and other administrative and family commitments, when do you find the time to write your paper?

RESEARCH PAPER

she tends to take research writing in small doses and tries to commit to it. “This maintains consistency, which eventually helps in achieving bigger goals without getting too stressed,” she said. Dr. Brar explained that finding the time has to be intentional and consistent, “I truly believe that when we love doing something, it is always possible to find time for it. For me, scientific writing is intentional and part of my daily routine rather than a chore. Irrespective of my schedule, I make it a point to open my laptop once daily and dedicate 30 to 60 minutes to research writing, without fail.”

Last but not least, stay focused, cherish your work, and learn to embrace rejection.

According to Dr. Brar, realize that the advantages of research extend beyond having an impressive degree certificate. “Through detailed research, students develop critical thinking, expertise, as well as effective analytical, research and communication skills that are globally sought-after and are incredibly beneficial,” shared Dr. Brar. “To become successful, stay focused, committed and cherish your work. It may take as long as one year or more for the final publication of your work. So, remain calm and patient and do not get too disheartened after a rejection. Rejections help to ignite critical and logical thinking, which eventually help you to grow and become better as a researcher and as a human being, overall.”

“Finding time can be a problem as we don’t have protected research time unlike in institutes of higher learning,” Dr. Ratnalingam shared. “Personally, I like to do a little per day, focusing on small chunks. However, others prefer to take a week off, check into a nice hotel, and finish the bulk of it in one go.”

Dr. Sheetal Brar is a senior consultant at Phaco and Refractive Department and research director at Nethradhama Super Speciality Eye Hospital in Bangalore, India. Dr. Brar has a special interest in cataract and refractive surgery and has trained over 75 national and international surgeons in refractive surgery, including SMILE. She has participated in over 70 master classes and instruction courses and performed live SMILE and phacoemulsification surgeries. Dr. Brar has over 40 publications in national and international peer-reviewed indexed journals and served as a peer reviewer for JRS, Cornea, BMC Ophthalmology, Open Journal of Ophthalmology and Indian Journal of Ophthalmology. She has received several prestigious accolades, including being the recipient of the “Young Physician” exchange program grant by the APACRS 2017 and APACRS Certified Educator(ACE) award at the APACRS 2019 in Kyoto, Japan. brar_sheetal@yahoo.co.in Dr. Vanitha Ratnalingam is a consultant ophthalmologist and corneal surgeon at the Oasis Eye Centre in Kuala Lumpur, Malaysia. Dr. Ratnalingam graduated from Universiti Sains Malaysia before completing her masters in O\ ophthalmology at University Kebangsaan Malaysia. She completed her fellowship in cornea and external eye disease at the Royal Victorian Eye and Ear Hospital in Melbourne, Australia. She is trained in the latest techniques of corneal transplant surgery, limbal stem cell transplant, collagen cross-linking, and managing diseases of the surface of the eye. In 2010, she won the Troutman Prize for best original article published by a young ophthalmologist in Cornea, a high impact journal focusing on diseases of the cornea and external eye surface. Since then, she has published further papers in numerous international journals and peerreviewed for many journals. Dr. Ratnalingam also enjoys teaching and has conducted Instructional courses at various national and international meetings. She is an honorary lecturer with Taylor’s School of Medicine, where she takes every opportunity to encourage young minds to push boundaries. v_ratnalingam@yahoo.com

Just like Dr. Ratnalingam, Dr. Brar said

Contributing Doctors

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Single-use I preloaded Capsular

Tension Ring Injector

Inside®CTR is an elegant & sophisticated single-use, preloaded Capsular Tension Ring Injector. An essential instrument to simplify the procedure. On-going surveillance of the ophthalmic market enables “O&O mdc” to develop and design highly efficient delivery systems, in line with market trends, that meet and exceed customer expectations. By using a combination of advanced Medical Grade Polymers and sophisticated, high-tech injection moulding techniques, we are able to offer innovative and high-quality single-use Injectors to our customers. The Delivery System is intuitive and user friendly and delivers uncompromising quality, efficiency, consistency and patient safety. The Delivery System has been developed specifically to simplify the safe implantation of a Capsular Tension Ring in order to stabilise the capsular bag before, during and after cataract surgery. •

The injector is equipped with a translucent guide, which allows the surgeon to visualise movement of the CTR in the cartridge funnel right up to the point of insertion.

•

The Inside®CTR, along with its anti-rotation system, guarantees optimum result through safe, consistent and efficient CTR insertion.

Inside®CTR Models: PRELOADED Inside®CTR 15 SERIES

Injector Packaging: TYPE 15

TYPE 15A

TYPE 15B

Size (Compressed)

10.0 mm

11.0 mm

12.0 mm

Size (open)

12.3 mm

13.0 mm

14.5 mm

Zonular Damage

Up to 4 hours (120°)

Incision

2.2 mm

Material

CLEAR PMMA (Compress Moulded)

Direction of Implantation Feature

The Inside®CTR is individually packed in a double blister, sealed with a Tyvek® lid, to ensure easy access and maintain perfect sterile conditions.

RIGHT (Clockwise) One bent eyelet, which reduces a possible puncturing (bulging) of the capsular bag when being dialled into the bag

Website: www.oo-mdc.com - www.ono-inside.com Email: int.sales@oo-mdc.com | March/April 2021

Four IOL Delivery Devices to Rule Them All by Brooke Herron

s surgical techniques evolve, instrumentation and devices must also adapt to meet those needs. In this sphere, one area that has seen remarkable progress is in intraocular lenses (IOLs). And it’s not just the lenses that have changed — the way they're delivered to the eye has evolved, too. Originally, IOLs were delivered via a reusable syringetype injector, which have become single-use to help ensure sterile conditions. Additionally, and based on surgeon requests, the size and design has progressed to cartridges with parallel end tips, which allow for smaller incisions than previous conical tips; and lateral rails that secure the lens position during butterfly flap closure. Further, based on demand from the lens industry, gliding agents have also been upgraded to sophisticated hydrophilic coatings. These technologies have been mastered by O&O MDC, which is recognized as one of the three world leaders in this regard, according to Director of International Sales Vasileios Skountis.

Developing delivery systems that reign supreme

lens loading under direct visualization — which reduces preparation time and enables a faster, safer and more efficient surgery. Presenting their court of products...

The O&O product catalog features IOL delivery devices, all of which are singleuse. Using an innovative cartridge design, each device provides easy

Inside SWING is a hydrophilic and hydrophobic delivery system. It can be used in micro-incision cataract surgery (dependent on the cartridge type) in either traditional or wound-assist surgical techniques.

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This helps stabilize the capsular bag throughout the surgical process. This injector is equipped with a translucent guide, which allows the surgeon to visualize movement of the CTR in the cartridge funnel, right up to the point of insertion. This CTR system ensures centration of the IOL, even with postoperative capsular bag shrinkage; it also replaces the need for a scleral IOL and simplifies potential IOL implantation.

Why O&O MDC? A subsidiary of He Vision Group, O&O MDC is an Italian ophthalmic medical device engineering company specializing in IOL manufacturing, delivery systems, polymers for IOLs and packaging accessories. The accumulation of nearly two decades of ophthalmic experience has allowed O&O MDC to extend the company’s core business and expand its range of products, resulting in groundbreaking manufacturing solutions for the production of IOLs and ancillary systems. Further, the company’s specially made, single-use products have attracted customers from around the world. CLOCKWISE: Inside SWING, Inside TWIN, Inside EASY, Inside CTR.

Inside TWIN is a single-use delivery system that enables simple, efficient and consistent IOL loading into the cartridge. In conjunction with the company’s Twin Glide cartridges, the device provides consistency and accuracy of IOL insertion during injection. Plus, the design allows surgeons to choose the preferred method of injection (push or screw).

Inside EASY is a hydraulic delivery system that can be used with any O&O butterfly-style cartridge. This ensures accuracy and precision of the IOL’s insertion during delivery, while the cartridge design ensures comfortable lens loading. The main difference between TWIN, SWING and EASY devices lies in the type of cartridges used – thus, making the loading methods of each injector different. For example, in the TWIN and SWING injectors, the lens is top loaded; meanwhile in the EASY injector, the lens is loaded in a butterfly cartridge.

According to O&O MDC, their innovative technologies are developed using trusted systems, products and expertise — making them the “One and Only” company capable of producing polymers with the qualities required for IOLs (e.g., a thick lens). Plus, their manufacturing experience allows them to make a polymer with both the optical and physical properties for a safe, easy and precise IOL injection — and these injection cartridges remain a major source of company revenue.

Inside CTR is a delivery system that was created to simplify and safely implant a capsular tension ring (CTR).

For more on O&O and its products, visit www.oo-mdc.com.

| March/April 2021

NLIGHTENMENT

EYE BANKING

A First-of-its-Kind Corneal Lenticule Banking Service by Jillian Webster

THINGS YOU NEED TO KNOW

Could lenticules correct presbyopia? Everyone over 40 is keen to find out...

ecently, the Ministry of Health gave Cordlife Group Limited a go-signal to launch OptiQ, a groundbreaking corneal lenticule banking service in Singapore. This simply means that patients who are undergoing refractive surgeries can store their corneal lenticules to treat ocular conditions that may arise in the future.

These lenticules are now being stored by Cordlife for future use. Here are five things you need to know about the new corneal lenticule banking service in Singapore.

According to Prof. Donald Tan, partner and senior consultant ophthalmic surgeon at Eye and Retina Surgeons, “a lenticule is a piece of the human cornea, which is shaped like a lens, taken from an individual.” These lenticules are removed during certain corrective refractive surgeries using the small incision lenticule extraction

(SMILE) procedure, a FDA-approved method for correcting refractive eye problems.

The concept was born to avoid throwing away the lenticules removed during SMILE surgery. Prof. Tan got the idea for lenticule storage while he was heading the Singapore Eye Research Institute

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(SERI) after receiving a grant from the National Research Foundation (NRF) in Singapore to study glaucoma and cornea in 2007. “Within the corneal field, we were really looking at new ways to perform corneal transplants, as well as new refractive procedures,” Prof. Tan shared. “A lot of these procedures, like laser-assisted in situ keratomileusis (LASIK), reshape the cornea. SMILE was a similar procedure to LASIK, but it had some advantages.” SMILE uses a single VisuMax (Carl Zeiss Meditec, Jena, Germany) femtosecond laser to remove a section of cornea, the lenticule. “We were doing SMILE surgery and all of these lenticules were being thrown away. I had the idea to store this tissue

and see what we can do with it,” Prof. Tan shared. He and his research team then established a series of experiments to see if they could store the material and reimplant it. Prof. Tan thought that they could use it to treat presbyopia, or the gradual loss of the eye’s ability to focus on near objects. “Everybody around the world will have presbyopia as long as you are alive and you hit your 40s,” Prof. Tan said. “You will have some problem with your reading and will need some form of correction.” Presbyopia is commonly treated with plus powered lenses, such as contacts or reading glasses. According to Prof. Tan, “This lenticule [removed from the cornea of a myopia patient] is plus powered.” The professor was inspired to see if it was possible to store lenticules for future treatments.

removed, the team then had to find a way to store them. “We did a sort of modified cryopreservation where we froze the lenticules and stored them for three or four months,” Prof. Mehta said. They then reimplanted the lenticlue in the animal. After publishing the results of the animal trials showing lenticular implantation to be safe, they were then ready to move on to patient clinical trials. As lenticule removal surgeries, such as SMILE, became more popular, Prof. Mehta and his team had opportunities to conduct such trials. “With collaboration with a group in Italy, we are able to do lenticule implantation on almost 70 patients under the European guidelines,” said Prof. Mehta.

4 2 Initial trials were conducted on monkeys.

Prof. Tan along with his colleague, Prof. Jod Mehta, head and senior consultant for the Corneal and External Eye Disease Department at the Singapore National Eye Center (SNEC), devised an experiment to test their hypothesis. They conducted their initial trials on monkeys. “We used research monkeys where we actually did the SMILE procedure, extracted the lenticule, stored it, waited a few months, and then reimplanted it back in,” shared Prof. Tan. Prof. Tan and Prof. Mehta had an idea for something new: additive technology. “We were putting something into the cornea now,” said Prof. Tan. “So when you implant a lenticule, firstly, you’re reversing what we did all those years ago. Secondly, you are also implanting something that can be removed, giving the surgeons ‘ultimate flexibility’ with this biological resource.”

Lenticules are stored through modified cryopreservation. Prof. Mehta described the first years of research: “The primary work we initially did on animals in Singapore at our research facility at SERI was focused on showing that it was safe to implant the lenticule.” Once the lenticules are

There are several indications for the use of lenticules. Prof. Mehta cited a clinical study of nine patients who showed absolute clarity when the lenticule was implanted inside the eye. “These are very similar results to what we saw when we were doing these studies in animals. But now this has been replicated in humans,” he shared. As more people choose lenticule removal surgery, like SMILE, there will be greater opportunities for more lenticule implantation clinical trials. Prof. Mehta explained that there are several indications for the use of lenticules. “Lenticule extraction procedure is currently being done for myopia, myoptic astigmatism and hyperopia. Lenticule implantation is mainly being done for hyperopia, which is longsightedness, and presbyopia, which is near vision correction,” he said. Once extracted, the lenticule can then be stored at the right temperature, indefinitely. Once Prof. Tan and Prof. Mehta were convinced that this tissue could be stored and then reimplanted, they needed a safe and tested means of cryopreservation. “Now we have this procedure as a clinical application, we are storing the cryopreservation with Cordlife for long-term storage,” shared Prof. Mehta.

Cordlife and OptiQ are the perfect partners in this important breakthrough in ophthalmology. Since 2012, Cordlife Group has been developing a sophisticated system of cryopreservation for the purposes of storing cord blood and tissue on the request of parents for disease prevention. “Cordlife owns the largest network of cord blood banks in Asia, with six internationally accredited storage cryogenic storage facilities in Singapore, Malaysia, Hong Kong, Indonesia, the Philippines and India,” shared Ms. Tan Poh Lan, group chief executive at Cordlife Group Limited. “OptiQ was a natural extension of our services,” Ms. Tan added. As well as a number of other diagnostic services, Cordlife Group’s expertise in the process of cryopreservation is the gold standard and the natural choice for the preservation of corneal lenticules. “This partnership with SERI fits perfectly with our commitment to providing innovative healthcare services,” she said. OptiQ is the first corneal lenticule storage facility in the world. The corneal lenticules are collected from clinics, upon request of the patient, where the extraction surgeries occur and are then brought to Cordlife facilities. They are then processed and then preserved. Dr. Tang Kin Fai, laboratory director at Cordlife Group, explained that lenticules are stored in at least -150 degrees celsius in a “vapor phase liquid nitrogen tank until the day it is needed by the patient.” “The results of the clinical trials provide an important breakthrough in the field of ophthalmology. We are excited to be part of this revolution,” Ms. Tan concluded. As more and more people choose lenticule extraction, the practicality of lenticule storage and implantation will become more and more apparent. The launch of OptiQ is an exciting step forward in the fight against blindness.

| March/April 2021

CONFERENCE HIGHLIGHTS

WEBINAR COVERAGE

Joint APGS-ISGS Webinar Top by Hazlin Hassan

s t h g i l H i gh

f you missed the virtual joint AsiaPacific Glaucoma Society (APGS) and International Society of Glaucoma Surgery (ISGS) Webinar on “Current Paradigms in Glaucoma Surgery” held in February 2021, fret not — because we’re here to give you the high points from the event.

Endoscopy-assisted vitrectomy provides good results when it comes to surgical management of malignant glaucoma. Scuba divers also know a thing or two about pressure…

Malignant glaucoma, characterized by a shallow or flat anterior chamber and high intraocular pressure (IOP) — usually after intraocular interventions — has an acute onset and is visually devastating. Medical management has a high rate of failure of between 85-100 percent and surgical intervention is normally challenging. “With endoscopy-assisted vitrectomy, the surgeon can obtain better visualization through the corneal edema and the non-dilated pupil, a common problem in malignant glaucoma eyes,” said Dr. Do Tan, chief of the Glaucoma Department, Vietnam National Institute of Ophthalmology, Vietnam. “Also with endoscopy-assisted vitrectomy, you can get better access to the far peripheral vitreous base,” he added. “You can preserve the posterior capsule easily, and it is easier for the surgeon to photocoagulate the ciliary processes, if needed, to control the IOP.”

Dr. Tan shared the results of a study of 53 eyes from 26 patients with malignant glaucoma, where endoscopyassisted vitrectomy was carried out to restore the anterior chamber (AC) and control IOP after failed medical and laser treatments. After one year follow-up, a total of 94.3% had improved best corrected visual acuity (BCVA); 100% saw AC reform; and 93% saw their IOP come under control. A total of 35.8% needed some additional IOP lowering meds, but there were no serious complications. The final success (complete and relative) ratio was 97.1%. “In conclusion, the endoscopy-assisted vitrectomy is a very good surgical method for malignant glaucoma,” said Dr. Tan.

| March/April 2021

Controlled hypotony can be used in filtering surgery to achieve low IOP with relatively small complications. “The use of devices or shunts, controlled short-term over-drainage or hypotony, wide application of mitomycin C (MMC), surgical technique modification, intensive post-op intervention and ocular massage, improve outcomes for patients,” said Prof. Prin Rojanapongpun, MD, consultant at the Bumrungrad International, Sukumvit Hospital and MedPark Hospital, Bangkok, Thailand.

Prof. Rojanapongpun shared a case of a 73-year-old male, followed over five years, with hypotony but with the AC maintained and without permanent visual loss. “Is hypotony a problem? Based on the consensus of the World Glaucoma Association, low IOP by itself should not necessarily be considered as a complication or a criterion for failure, if low IOP does not lead to maculopathy, choroidal effusions or worse vision,” he said. He added that there is no reliable way to control scar formation in filtering surgery, and Asian patients have the propensity for scarring. “A failed filtering bleb is common in Asian and African patients,” he continued. The key to a perfect filtering is to be able to control the aqueous flow and wound healing. MMC can improve the outcome of filtering surgery in Asians, who tend to have a higher risk of scarring compared to Caucasian patients. “We need a big change in filtering surgery,” Prof. Rojanapongpun added. What is needed are devices or shunts to control flow, a standardized lumen with less variables, a large flap area and a large bleb to control abrupt aqueous egress. A low IOP should be the target during early post-operative follow-up. In essence, what is needed, according to Prof. Rojanapongpun, is a system that creates a controlled hypotony, and can overcome wound healing for long-term success.

The PAUL Glaucoma Implant (PGI) regulates IOP in the patient’s eye and prevents further progression of the disease — a promising alternative to current aqueous shunts. Studies have shown that a new implant for the treatment of moderate to severe glaucoma demonstrates comparable efficacy with other currently available

Unfortunately, hiding from glaucoma is not an effective treatment.

implants. Almost three-quarters of enrolled patients with refractory glaucoma achieved complete surgical success after one year of follow-up.

length of 44.9mm, a width of 23mm and an extraocular plate surface area of 342.1mm2. It differentiates itself from other shunts by its small tube caliber.

Trabeculectomies with MMC (29%) have a higher rate of reoperation for glaucoma than tube-shunt surgery (9%), as well as a higher rate of failure. Thus, the mainstay of treatment has been tube implants. However, according to Prof. Paul Chew, senior consultant, Glaucoma Division, National University Hospital, Singapore, current-day implants still do not provide very good outcomes, with almost half failing by one year.

Results for the PGI’s efficacy and safety evidence show a promising outlook after one-year multicenter trials in the U.K. and Asia, and two-year trials in Singapore. “In one year, we had 4 failures, 69% were complete successes and 93% were considered qualified successes. This is quite a high level of success in the treatment group,” explained Prof. Chew.

“Is there a better glaucoma implant design? This has to do with making sure there is a better plate size, a better tube caliber, and whether a valve is really necessary,” said Prof. Chew. Prof. Chew’s PAUL Glaucoma Implant (PGI) was created as part of an effort to produce a better implant design and construction and to plug the gap for better treatments that address the needs of severe disease, which often do not respond to primary treatments and can cause vision loss. The PGI is a glaucoma drainage device designed to treat glaucoma by regulating IOP in the patient’s eye and preventing further progression of the disease. Constructed from medical implantable grade silicone, it has a

In conclusion, the PGI, with its lower caliber tube, appears to offer a promising alternative to current aqueous shunts, such as the Baerveldt Glaucoma Implant, in terms of safety, and efficacy in the treatment of refractory glaucoma.

Editor’s Note: The virtual joint Asia-Pacific Glaucoma Society (APGS) — International Society of Glaucoma Surgery (ISGS) Webinar on Current Paradigms in Glaucoma Surgery was held on February 6, 2021. Reporting for this story also took place during the APGSISGS Webinar.

| March/April 2021

WE’RE NO SOCIETY, WE’RE THE MEDIA.

e x p o . m e d i a m i c e . c o m 18-19 June 2021, 2-8 PM SGT

CAKE Issue 09: The ebook version (The Wild West Issue)

Articles inside

COVID-19 and the Great Cornea Bank Stickup

A First-of-its-Kind Corneal Lenticule Banking Service

Four IOL Delivery Devices to Rule Them All

The Jig is Up