CAKE Issue 10: The ebook version (The Side Show Issue, ASCRS 2021 Edition)

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Let’s Get Weird

Strange Cases in Anterior Segment Surgery


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


Stop! Collaborate and listen! If you're trying to make a breakthrough, you're probably thinking about things the wrong way


t’s difficult to understate how hard it is, in the words of Apple, to “Think Different”. Everything in life pushes against it, and the more you specialize in one topic of science or medicine, the harder it is to climb out of the rut you've dug for yourself and see what else is around you. But I think it's something that's seriously worth doing. I’m reminded of Richard Feynman, a Nobel prize winner for physics, who in the middle of prime career-building years, took a year off to live in Brazil and became a bongo drum-playing musician. It was certainly a change from the Cornell and Caltech physics departments, but the work he did in the years after that sabbatical is what earned him a trip to Sweden and a prize from their King. Could you do the same? Most people in your position have studied, studied and studied more. First to get in — and then to get through — med school. Then you work your asses off to make it through residencies (with a side order of studying your asses off to pass your specialty exams). At what point do you get to stop and take a deep breath? In your 40’s? Your 50’s? I bet none of you did something like joining a samba band in Rio de Janeiro to play bongos halfway through that process. It's even harder now than it was in Feynman's time. For the last 15 years, big tech has been narrowing your worldview in your free time. They make money by showing you adverts, so they need you to be staring at their offerings for as long as possible to maximize exposure. It's in their interest to present to you something that you're going to want to read. The algorithms see what you've read, and suggest more of the same. It digs a deeper rut for you every

single time you go online. Your horizons never broaden. My opinion is that if you want to change the game, you’re more likely to do so if you have something else to draw from. It’s interesting to see how many physics graduates go on to study medicine, and then bring so much more to the table in terms of advancing both treatment and diagnostics — and I’m not just talking about lasers in refractive surgery. Wherever you look in medicine: from oncology, cardiology, radiology — and pretty much any other “-ology” — it’s either physicians with a physics mindset or physicians working in tandem with physicists that have pushed the envelope. We’re now seeing the same with coding. If you're a young doctor, those that can code are those that are currently changing the game (although whether we like how the game is being changed is another discussion entirely). My point is, to make big changes, you need to embrace the cliché and think outside the box, and that almost always needs fresh perspectives. Not seeing the bigger picture extends to the many unintended biases there are in medicine. For example, what is "normal?” What is a normal weight, height or body fat percentage? Most "norms" in medicine were defined in studies performed on medical students in the U.S. in the 1950s. For most of the history of medicine, clinical trials involved Caucasian participants. That's great if you're a white European like me, as the data is more applicable to me than my fellow human beings from the rest of the world. But time after time, we've seen differences in drug efficacies in different racial groups, and it never seems to be my ethnic group that comes off worst.

Then there are the unconscious biases of those cultures that wrote the guidelines and set the rules, and the unintended consequences on other cultures that inevitably follow from that. I only truly became aware of this from having had a conversation a few years ago with Hugh Taylor, when he was the president of the International Council of Ophthalmology, where he was trying to battle the "pale, stale and male" state of so much in medicine to be something more inclusive of people of all ages, genders and backgrounds. And why not? They'll all have different experiences of life, and all will have something new to bring to the table: fresh perspectives. How can we open our minds? Steve Jobs espoused dropping acid occasionally to expand his. I won't go that far, but I'll suggest another mind-altering substance: tea. Or rather, the tea break. The most constructive meeting of minds I ever experienced was when I was an undergraduate doing some summer work in a laboratory in the University of Glasgow's West Medical Building in the pre-social media era 1999. At 10:30 a.m. every day, everyone in the building stopped work and went for a tea break in the same room, drank tea, and conversed. Ideas were exchanged, problems were solved and collaborations were forged. And ultimately, I think that's where you start to open your minds to more: eschew social media and simply be social. Talk to people. Who knows. The whole world might one day benefit from that conversation.


Mark Hillen

Dr. Mark Hillen

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


June/July 2021





Under the Big Top A peek into cataract surgery during the pandemic


A Novel Option? Nepafenac punctal plug reduces postop pain in cataract surgery patient


Tips from Experts on Congenital Cataract Surgery

Anterior Segment

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Addressing the Myopia Epidemic in Asia-Pacific


Understanding the Silent Thief Can we predict glaucoma before it begins?

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In the fight against AMR, are fluoroquinolones up to the task?

Class Act ARVO 2021 E-posters showcase latest advancements in glaucoma therapeutic

Improve Quality of Life with Early Surgical Intervention in Glaucoma Treatment

Cover Story Let’s Get Weird

Strange Cases in Anterior Segment Surgery

Matt Young CEO & Publisher

Hannah Nguyen COO & CFO

Robert Anderson Media Director

Gloria D. Gamat Chief Editor

Brooke Herron Editor

Mark Hillen Editor-At-Large International Business Development

Ruchi Mahajan Ranga Brandon Winkeler




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In the Spotlight Eye care heroes


Women in Ophthalmology ICO welcomes first female president

The IOL Dilemma Educating patients about their IOL options


Spotlight on 7 Industry Trendsetters Advancing ophthalmology through digital technologies


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

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Conference Highlights

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ARVO 2021 Coverage Changing the rules in glaucoma management with a novel rho-kinase inhibitor APGC 2021 Highlights What’s cool in glaucoma?


C&PE 2021 Coverage Tips and best-kept secrets in anterior segment

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Arunodaya Charitable Trust (ACT) Prof. Jodhbir S. Mehta

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.

ASEAN Ophthalmology Society

Asia-Pacific Academy of Ophthalmology

Dr. William B. Trattler

He Eye Specialist Hospital

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.

Ophthalmology Innovation Summit

Dr. Chelvin Sng

Orbis International

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.

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.

Russian Ophthalmology Society (ROS)

Young Ophthalmologists Society of India ( YOSI )

Dr. Harvey S. Uy


June/July 2021




Under the Big peek into cataract Top Asurgery during the pandemic

by Jillian Webster

Indeed, many patients were forced to consider the risk of exposure when seeking treatment, in addition to their own challenges with optical health.

Learning new acts: Not for the faint of heart Dr. Bhatia said the strangest thing he has had to do in terms of his practice during the pandemic is “telling patients not to come, unless absolutely necessary and they have to do COVID testing preoperatively.” This is a stark contrast to pre-pandemic conditions. Nowadays, doctors have less time with their patients. In a study* published in the Indian Journal of Ophthalmology by Reddy et. al., it was suggested that doctors needed to amend the ways patients are screened in order to minimize exposure.


ataracts are one of the leading causes of preventable blindness in the world today. And, as expected, there are many features to the complex world of cataract surgery. These facts did not change after the COVID-19 pandemic began. Doctors were faced with a dilemma: Their patients needed surgery and surgeons needed to find a safe way to provide treatment, without encouraging the spread of infection (coronavirus or otherwise) and continue the fight against preventable blindness.

Challenges in entering the tent Accessibility of care is key in this fight. Many people in need of surgery found their normal movements affected by the outbreak of COVID-19. Even simply traveling to the doctor became a risk. The means by which patients would normally access care were compromised, though the desire to receive care remained. Dr. Karan Bhatia, head of Cornea Services at Sitapur Eye Hospital in India, explained: “I work in a charitable hospital in North India where a majority of the patients are poor and from rural backgrounds. The pandemic has definitely affected the practice. This is not due to the fear of getting infected


with COVID, but due to lack of public transportation for these poor and needy patients. So, they travel by bus. Hence, every visit increases the risk of exposure to COVID.” However, many people still actively pursued medical treatment for cataract despite infection risks. Dr. Bhatia said that patients who require surgery have rarely turned down the service. The importance of surgery to cataract patients remained consistent even during the pandemic. On the other hand, Dr. Harvey Uy, a clinical associate professor of ophthalmology at the University of the Philippines and medical director at Peregrine Eye and Laser Institute in Makati, has had a different experience. “The pandemic has been an epic disaster for patients and practices,” Dr. Uy shared. “While many patients stayed away from clinics due to fear of contracting COVID-19 during their consultation or surgeries, others declined elective surgeries due to economic concerns and chose to save money for basic necessities, such as food. Lastly, mobility restrictions prevented even those patients desiring treatment from traveling to their doctor’s place of practice.”

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Dr. Uy couldn’t agree more. “The strangest adaptation I had to make as a medical director was to design health protocols from the ground up,” he said. “Previously, I concerned myself with assessing technologies needed to achieve best visual outcomes, patient satisfaction and workflow efficiency. All of a sudden, I had to learn infectious disease protocols, barrier efficiency, antibody/antigen testing/polymerase chain reaction (PCR), vaccination protocols and the like, in an effort to attain workplace protection. The show cannot continue unless staff and patient safety is assured.” In addition, many patients with an urgent need for surgery are still treated after appropriate precautions are taken. According to Dr. Bhatia, cases that are considered urgent enough for surgery include conditions which, without treatment, can permanently affect the patient’s vision and life in general. “A few examples would be lens-induced glaucoma, subluxed or dislocated lens or intraocular lens (IOL), an open globe injury, recent onset retinal detachment, among others,” Dr. Bhatia explained. To say the least, the pandemic has altered the way some doctors approach surgery, but not the need for it.

The art of ad-libbing Ophthalmologists have had to get creative with treatment options as well. Dr. Bhatia shared: “I am a cornea and cataract surgeon. We are currently seeing at least 50 cornea patients and 20 corneal ulcers per day during this pandemic lockdown. This pandemic has also halted eye donation. As a result, we cannot do keratoplasties when required. We do see about five cases requiring therapeutic keratoplasty every day. Due to the absence of donor corneal tissue, we are doing more temporary procedures like a Gundersen’s flap, Tenon patch graft, tissue adhesive (Cyanoacrylate glue) + BCL, and have saved many eyes, where an optical penetrating keratoplasty can be done later. The list of patients requiring elective keratoplasties (penetrating or lamellar) has greatly increased, though.” The effect the pandemic had on overall optical health played a large role in conducting cataract treatment. Ophthalmologists had to consider extra risks while still providing the best possible care. According to Dr. Uy: “Our philosophy is that all cases are doable with proper risk stratification and management. We continued to treat all patients. Some consults, including conjunctivitis, stye and skin lesions are done using telemedicine. Other procedures that do not require unmasking, such as intravitreal injections and laser treatments, are done as per usual routine to limit contact time to less than 30 minutes. Meanwhile, patients with procedures that require more than one hour contact time or potentially require unmasking, including surgeries, must undergo COVID-19 screening inclusive of antigen/antibody/PCR testing.” This way, Dr. Uy said they continue saving many eyes from blindness.

The show must go on As the global population embraces a “new normal” going into the second half of 2021, Dr. Bhatia and Dr. Uy remain hopeful, even with the many

new factors to take into consideration regarding their practice. “COVID testing (preferably RT PCR) should be done for all patients along with the routine preoperative investigations,” said Dr. Bhatia. “Any history of fever and sore throat should be considered COVID, and surgery to be deferred for a month (unless an emergency). A surgeon or nurse will have to take universal precautions and wear N95 masks for protection.” These preventative measures will hopefully only be necessary until the global response to the pandemic increases. Dr. Bhatia said he believes that in a year’s time, the situation will get better and we will return to normalcy. “As vaccinations increase, we expect COVID-19 transmission to decrease and surgical caseloads to gradually return to normal,” said Dr. Uy. “Overall, the lessons learned during the pandemic will greatly improve efficiency and safety in the post-pandemic era. For example, we instituted telemedicine protocols, enabled remote access of clinic databases, adopted contactless payments, and improved online training and marketing.” The notion that a return to normalcy is just around the corner is a sentiment that many ophthalmologists probably share. Dr. Bhatia expressed: “Cataract surgery is the breadwinner for ophthalmologists. One will have to continue to operate, despite the risks.” One silver lining we can note is that it is inspiring to see that the importance of their work is not diminishing despite global health concerns. Ophthalmologists continue to be dedicated to their patients and to the continuation of surgery and treatment in as normal a setting as possible. According to Dr. Uy: “The most important lesson of the pandemic is to value personal health and the wellbeing of people around you,” he said. “To spend time with family and friends, to exercise, to practice mindfulness. Ophthalmology is a great field to be in, but there is also life outside the clinic. Live long and prosper, everyone,” he concluded.

* Reddy JC, Vaddavalli PK, Sharma N, et. al. A new normal with cataract surgery during COVID-19 pandemic. Indian J Ophthalmol. 2020;68(7)1269-1276.

Contributing Doctors Dr. Karan Bhatia, MBBS, DOMS, DNB, FCPRS, MNAMS, is currently the head of Cornea Services in Sitapur Eye Hospital, Sitapur, UP, India. He is also head of Academics (MS & Fellowship) at the Regional Institute of Ophthalmology, Sitapur Eye Hospital, Sitapur, UP, India; as well as assistant professor and consultant at the same institution. In addition, he is also a joint secretary at Young Ophthalmologists Society of India (YOSI), as well as the editor-in-chief of YO Tube, the official YouTube Channel of YOSI. With special interests in challenging cataract surgeries, corneal ulcers, keratoplasty, keratoconus, ocular trauma, and teaching residents and fellows, Dr. Bhatia is also a chief and co-instructor with multiple presentations internationally and nationally. He has received many awards in his career, including the Dr. M. K. Mehray Award for best DOMS Student in 2011-2013 (Gold Medal Equivalent), the Dr. Madhav Honnatti Best Refractive Free Paper Award (KOSCON 2017), the Korean Ophthalmological Society Travel Grant 2019, and the Delhi Film Festival 2021, Best Video Award in Young Achievers session, among others. Dr. Harvey Uy, MD, is a clinical associate professor of ophthalmology at the University of the Philippines, and medical director at Peregrine Eye and Laser Institute in Makati, Philippines. He completed his ophthalmology residency at the Philippine General Hospital, retina fellowship at St. Luke’s Medical Center, and ocular immunology and uveitis at the Massachusetts Eye and Ear Infirmary. He has published over 50 peer-reviewed articles and book chapters and serves on the editorial board of the American Journal of Ophthalmology Case Reports. He has delivered more than 400 national and international presentations. He is a past president of the Philippine Academy of Ophthalmology and has been recognized by The Ophthalmologist magazine as a surgical pioneer in ophthalmology for being the first to perform femtosecond cataract surgery in Asia and for his work on accommodation restoration by laser lens softening and multicomponent IOL technologies. He is active in research involving intravitreal therapy, pars plana vitrectomy, macular hole surgery and ocular inflammation.


June/July 2021




A Novel Option? Nepafenac punctal plug reduces post-op pain in cataract surgery patients by Hazlin Hassan

“There was a significant improvement in postoperative inflammation in the nepafenac punctal plug arm as compared to placebo,” shared Dr. Donnenfeld. “Cell and flare were dramatically reduced in the treatment arm and visual acuity was significantly better.” He added that visual acuity was statistically significantly better in the nepafenac drug delivery arm due to less postoperative inflammation.


n cataract surgery, the use of a nepafenac punctal plug delivery system (N-PPDS) has proven to be effective in significantly reducing postoperative pain in patients. This is according to the findings of a recent study* published in the Journal of Cataract and Refractive Surgery. Researchers evaluated the safety and efficacy of the Evolute (Mati Therapeutics, Austin, Texas, USA) nepafenac punctal plug delivery system in controlling postoperative ocular pain and inflammation after cataract surgery as part of a phase 2 pilot clinical trial.

A safe and non-invasive punctal plug option The L-shaped punctal plug, also known as tear duct plug, is made of medicalgrade silicone. The device is placed and removed by the ophthalmologist, optometrist or supervised staff member as an in-office procedure and delivers a consistent level of medication for up to six weeks of sustained efficacy. During the first week, which corresponds to peak ocular pain and inflammation, more therapy is delivered with a gradually tapering drug dose delivered in the second week. The punctal plugs are noninvasive and easy to insert and remove. Once inserted, it is cosmetically invisible. However, its presence in the punctum can be easily confirmed with eversion of the lower lid. After the drug-eluting core is exhausted, the plug is removed.


The plugs were left in place for two weeks after cataract surgery. The results at 3 days showed that 69% of patients who received the N-PPDS were painfree compared with 38% of patients in the placebo group. A total of 52% of patients in the N-PPDS cohort were pain-free at all visits compared with 0% in the placebo group.

The plug retention rate in the overall group was 98% at 14 days. “There were no serious adverse events in the punctal plug arm and plug retention was excellent throughout the course of the study,” explained Dr. Donnenfeld. “Punctal plug drug retention was excellent and well-tolerated. Future trials are planned for corticosteroid punctal plug drug delivery,” he noted.

“The most important finding of the study was that a punctal plug drug delivery of nepafenac provided sustained release of the nonsteroidal anti-inflammatory drug (NSAID) and dramatically reduced postoperative cell and flare without the need for a topical NSAID drop,” shared study co-author Dr. Eric D. Donnenfeld.

Safety and efficacy of N-PPDS over placebo The prospective, multicenter, randomized, double-masked study involved 56 subjects over 22-years-old with expected post-cataract correctable distance vision of 20/30 or better. A total of 38 eyes received the nepafenac punctal plug delivery system (N-PPDS) compared with 18 eyes that received a placebo punctal plug delivery system. All eyes underwent routine unilateral cataract surgery with intraocular lens (IOL) implantation.

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In conclusion, the results of this phase 2 trial evaluating the safety and efficacy of N-PPDS over placebo for the management of ocular pain and inflammation are promising.

Heralding a new future in post-cataract surgery medications To the authors’ knowledge, this is the first punctal plug or sustained delivery system study to evaluate the use of an NSAID during cataract surgery, and it may herald a future change in the way medications are given to post-cataract surgery patients. N-PPDS was effective in reducing postoperative ocular pain and inflammation in the immediate postoperative period, with a safety profile and visual acuity outcomes superior to that of placebo. New surgical technologies and improved surgical techniques have made cataract surgery safer and less invasive by causing minimal trauma to the ocular tissue, raising patients’ expectations

for better safety, comfort and visual outcomes. However, postoperative pain and inflammation can produce ocular discomfort, and thereby reduce patient satisfaction with surgery. Meanwhile, prolonged inflammation can increase the risk for secondary ocular complications, such as increased intraocular pressure (IOP), posterior capsular opacification, cystoid macular edema, posterior synechiae, uveitis and secondary glaucoma. Outcomes of cataract surgery also partly depend on patient compliance. Poor patient compliance may be linked to burden of drop frequency, cost of medications, the complexity of the regimen, forgetfulness, or physical difficulty with eye drop administration. On the other hand, non-adherence to medication schedules leads to waste of medication, patients not benefitting from the prescribed treatment, more frequent hospital visits with an associated increase in healthcare costs, and increased morbidity for the patient with associated poor quality of life. NSAIDs and steroids have been the mainstay agents to minimize inflammation and pain after cataract surgery. However, topically administered eye drops have low compliance and ocular bioavailability, allowing less than 5% of the applied dosage to reach intraocular tissues. Furthermore, topical administration results in varying drug concentration over time with increased risk for side effects. Most topical eye drops contain preservatives (such as benzalkonium chloride) which have been associated with cytotoxic and inflammatory effects on corneal and conjunctival cells. With this novel punctal plug delivery system, surgeons and patients have an alternative option in simplifying postoperative management. The delivery of nepafenac through a punctal plug may lead to longer and a more constant retention of the drug in the target tissues, giving it a distinct advantage over topical drops. “Punctal plug drug delivery provides a low level of preservative-free medication that can replace the need for topical medications following cataract surgery,” explained Dr. Donnenfeld.

“This improves patient compliance and quality of life while reducing the toxicity of topical medications.”

Future studies needed to determine its long-term efficacy As the study was a short-term clinical trial of two weeks, the impact of the treatment on postoperative cystoid macular edema and iritis could not be determined. Given that the punctal plug used in this study can deliver sustained levels of medication for 6 weeks, future studies can be designed to evaluate the longer-term efficacy of N-PPDS in preventing the development of longer-term inflammatory complications. Good news to all, a phase 3 study to further evaluate punctal plug drug delivery is being planned. According to Dr. Mae-Lynn Catherine Bastion, professor of ophthalmology (vitreoretina) and senior consultant ophthalmologist at the National University of Malaysia, the study showed that the N-PPDS was safe and effective for the management of ocular pain and inflammation after cataract surgery. One of the advantages of a punctal plug is that it can be placed during cataract surgery, and compliance with steroids or NSAID eye drops become unnecessary. “It is useful in young or uncooperative children for whom putting eye drops can be a challenge for parents. Most adults are at least initially quite compliant in using drops,” Dr. Bastion said. “Cataract patients may also not need intensive eye drop therapy after their cataract operations. They can enjoy their postoperative period, only needing to apply antibiotic eye drops for two weeks instead of needing eye drop therapy for up to one month, especially diabetic patients.” Reducing one drop may mean less dry eye due to preservatives in eye drops. This may also result in better compliance for patients. However, Dr. Bastion noted that results were reported and analyzed up to 14 days only, with a relatively small sample

size of just 38 patients in the treatment group. “Therefore, further follow-up studies are needed,” she concluded.

* Donnefeld E, Holland E, Solomon K. Safety

and efficacy of nepafenac punctal plug delivery system in controlling postoperative ocular pain and inflammation after cataract surgery. J Cataract Refract Surg. 2021;47(2):158-164.

Contributing Doctors Dr. Eric Donnenfeld is a founding partner of Ophthalmic Consultants of Long Island and Connecticut, USA, and a clinical professor of ophthalmology at New York University. He has written over 180 peer-reviewed papers on cornea, external disease, cataract and refractive surgery. Dr. Donnenfeld is a past president of the American Society of Cataract and Refractive Surgery (ASCRS). During his nearly 30-year career, he has made significant advancements in the field. He was the first surgeon in the northeast U.S. to perform laser cataract surgery, he participated in the studies that led to FDA approval of the excimer laser technology, and he has been selected as an investigator for numerous other FDA clinical studies. He is on the editorial board of nine journals and has taken part in over 60 FDA studies. He was a primary investigator of both the excimer laser and femtosecond laser for cataract surgery. He is a Fellow of the American Academy of Ophthalmology and has received its Honor Award, Senior Honor Award, Lifetime Achievement Award, and Secretariat Award. Dr. Mae-Lynn Catherine Bastion received her medical degree from the University of Sydney, Australia, and graduated with First Class Honours in 1999. In 2003, she received a fellowship with the Royal College of Surgeons and Physicians of Glasgow, U.K., and in 2004, completed her Doctor of Ophthalmology post-graduate studies in ophthalmology with the National University of Malaysia (UKM). Following the completion of her clinical fellowship in vitreoretinal surgery at The Eye Institute, Tan Tock Seng Hospital, Singapore, she returned to UKM and served as Head of Vitreoretinal services from 2008 until now. She also served as Head of the Department of Ophthalmology at UKM from 2010 to 2015. A professor of ophthalmology at UKM, Dr. Bastion also has a private practice at the UKM Specialist Centre, Hospital UKM.


June/July 2021




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Tips from Experts on Congenital Cataract Surgery st

by Ankita Umapathy

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ongenital cataract is the clouding of the crystalline lens that occurs before a baby’s birth or at a very early age. Its treatment involves lensectomy and insertion of an intraocular lens (IOL) implant to prevent long-term damage, including amblyopia or vision loss. During a CyberSight Live Webinar held in April, Dr. Donny Suh, professor of ophthalmology at UCI School of Medicine, USA; Dr. Luis Javier Cárdenas Lamas, professor of ophthalmology and medical genetics at the University of Guadalajara, Mexico; Dr. Serena Wang, professor of ophthalmology at UT Southwestern Medical Center, USA; and Dr. Scott Larson, professor of ophthalmology and visual sciences at University of Iowa Health Care, USA; provided surgical pearls for congenital cataract surgery. All speakers highlighted the importance of surgical planning, anticipating surprise, and individualizing the procedure to both the surgeon and the patient.


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Tips and tricks for anterior capsulotomy Dr. Suh cautioned against performing anterior capsulorhexis (ideally 5mm) in patients with small pupils (<4mm). Troubleshooting the problem may involve breaking posterior synechiae, adding viscoelastic, using Graether hooks, or adding trypan blue to aid with visualization, particularly if microscope resolution is poor. Dr. Suh also announced that he was developing new pediatric anterior capsule micro-scissors that did not close completely but created a circular capsulorhexis without flaps, thereby reducing tearing. He emphasized complete epithelial removal as residual cells could generate severe inflammation, capsular opacities, recurring fibrosis, or, potentially, glaucoma from trabecular meshwork blockage.

As with anterior capsulotomies in the flatter adult lens, Dr. Suh explained: “There’s a pulling force and there’s a counter-traction, so as you are trying to do this on a flat surface, you can easily create a linear tear.” However, as the infant lens is biconvex, the same technique yields radial tears. Instead, pulling 45-90 degrees away from the intended direction of the tear counteracts the equatorially-directed force. A cohesive viscoelastic also helps flatten and tauten the capsule to counter vitreous upthrust and low scleral rigidity.

Management of the posterior capsule opacification Posterior capsule opacification (PCO) occurs on intact posterior capsules. An intense inflammatory response and fibrous membrane formation can cause visual axis opacification (VAO), necessitating posterior capsulotomy. Risk factors for PCO include the age at surgery, ocular anomalies, inadequate clean-up, IOL type and surgical trauma. Where possible, Dr. Luis Javier Cárdenas Lamas suggested using newer equipment for better visibility when performing manual posterior capsulorrhexis. “Management of the anterior vitreous also affects the outcome of pediatric cataract surgery specifically, central anterior vitreous removal,” advised Dr. Lamas. Indeed, patients undergoing both procedures have a reduced incidence of VAO, compared with posterior capsulotomy alone. “Even though primary posterior capsulotomy and anterior vitrectomy together are effective for PCO prevention, sometimes re-opacification is inevitable necessitating yttrium aluminum garnet (YAG) laser use,” added Dr. Lamas. Here, patient selection is key, with children older than 4-years-old demonstrating better cooperation, particularly if anesthesia is unavailable.

Dr. Lamas cautioned against IOL implantation in patients younger than 6-months with an anteriorposterior axis <19mm due to the risk of secondary glaucoma. By foregoing IOL insertion, using contact lenses, glasses, or patching for visual rehabilitation, and waiting until 2-years-of-age, the surgeon can perform more accurate secondary IOL calculations.

How to be a surgical minimalist Dr. Serena Wang showcased her minimalist approach to surgery and highlighted her equipment/settings through elegant videos. Key takeaways include fixating the eye manually, maintaining a stable anterior chamber, keeping a tight wound, minimizing ocular entry and exit, and ensuring adequate lens extraction and viscoelastic removal. The key to her technique is using a vitrector for lens extraction, posterior capsulotomy, anterior vitrectomy, and even anterior capsulorhexis. Due to the soft and bouncy nature of infant eyes, pairing a vitrector gauge with a similarly sized knife ensures a tight wound, which is also used for bag inflation prior to IOL injection. She begins lens aspiration at the peripheral cortex and works toward the nucleus, employing a swiping motion while ensuring the removal of all lenticular material. With this technique, she can also anticipate posterior abnormalities. As infant eyes are more elastic with a high risk of prolapse, wound sutures are strongly recommended. Her top tip for wound washout includes lifting the IOL and removing viscoelastic while lowering the infusion and irrigation.

IOL selection – when, what, and how

surgery is time-sensitive. As such, Dr. Scott Larson suggested using to perform IOL power calculations, specifically the SRK/T formula as it is well-studied in children. Unless amblyopia is a consideration, he recommended aiming for delayed emmetropia. Though partial coherence interferometry is useful for determining the axial length and performing keratometry, hand-held keratometers or A-scan ultrasounds are available for less cooperative patients. To choose IOL power, Dr. Larson said he relies on the suggested residual refraction table generated by Dr. M. Edward Wilson Jr. at the Medical University of South Carolina, USA, but urges consideration of amblyopia, fellow eye status, assumed compliance, and parental refractive error. He highlighted hydrophobic acrylic and polymethylmethacrylate (PMMA) as preferable lens materials and discussed the factors involved in choosing lens design. “Ideally you would have access to a lens you could put in the bag, a lens you can put in the sulcus, and a lens, if you had to, that you could fixate in some way,” Dr. Larson shared. He encouraged vigilance during IOL injection and being prepared for upside-down lenses, haptic and optic damage, and displaced lenses in the vitreous. Lastly, he recommended using an anterior chamber maintainer for secondary IOLs and complex cases, particularly with elastic infant eyes.

Editor’s Note: The CyberSight Live Webinar on Congenital Cataracts was held on April 30, 2021. Reporting for this story took place during the live webinar.

IOL selection during pediatric


June/July 2021




Addressing the Myopia Epidemic in Asia-Pacific by Brooke Herron


ye care practitioners in AsiaPacific are well aware of the myopia epidemic and its resulting impacts on society. Below, we explore some of these implications.

Myopia: A call to action “Myopia is one of the biggest health challenges in the 21st century,” began Dr. Monica Jong, executive director of the International Myopia Institute, BHVI, in Sydney, Australia. Uncorrected refractive error (URE) matters because people are pushed into poverty — they cannot work and they cannot get educated because they cannot see properly, she continued.

permanent blindness in China, Taiwan, Japan, Denmark and the Netherlands,” said Dr. Jong. High myopia is a risk factor for myopic macular degeneration — where every diopter of myopia increases the risk of vision impairment and blindness.

Myopia epidemic: Managing the long game “Quality of life is all about health, wealth and quality of life,” said Mr. Richard White, managing director of OCULUS Asia. “If we don’t have good health, we don’t have any money and we don’t have a good quality of life.”

“Today MMD is a major cause of

So, what can be done? “The governments have to get involved, mass screenings need to be done and we


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need to start managing these patients,” he continued, noting initiatives already underway by government leadership in China, Vietnam and the Philippines. “As we see throughout Asia, the governments are getting involved and this is what needs to continue.” Who should be screened? “As soon as they hit that school-level age of 6-years-old, this is really when we need to get them in. The more you screen, the earlier you can catch it and the more you can start working to fix these things,” said Mr. White.

Why eyeglasses? “My team has been working to achieve sustainable development goals (SDGs) for many years now,”

shared Prof. Nathan Cogdon with ORBIS International and Zhongshan Ophthalmic Center in Guangzhou, China.

and macular hole. He then showed how these complications appear in various imaging platforms, as well as their potential therapies.

His presentation focused on ENGINE: Eyecare Nurtures Good health, Innovation, driviNg safety and Education, which aims to assess the specific ways in which eye care delivered at crucial moments across the life-course can help achieve SDGs.

“You can see staphyloma in up to 50% of all eyes with high myopia,” he explained, adding that there are various causative factors and unfortunately there are still no specific treatments for this condition.

“As we talk about this, it’s important to ask ‘why glasses?’ when eyecare involves so many interventions,” he continued. This is because the majority of the target population needs either near or distance refractive care and doing trials for diabetic retinopathy (DR), glaucoma, or even cataract, would be impractical. Prof. Cogdon then provided details on frou ongoing trials: CLEVER in India, STABLE in Vietnam, THRIFT in Bangladesh and ZEAL in Zimbabwe (check out his presentation on demand for more!).

Pathologic myopia and its complications Dr. Wong Chee Wai, a consultant in surgical retina at Singapore National Eye Centre (SNEC), presented on complications of pathologic myopia. These can include posterior staphyloma, myopic macular degeneration (MMD), myopic CNV, and myopic foveoschisis

Regarding MMD, it is the main sightthreatening complication of high myopia; meanwhile myopic CNV can be treated with anti-VEGF. For patients with myopic foveoschisis, surgery is indicated when complicated by foveal detachment.

The future in optical management Australia-based optometrist Dr. Oliver Woo — who rocked an awesome panda costume during his talk — discussed optical options for myopia management in 2021 and beyond. One option? Contact lens correction, which includes orthokeratology and soft contact lenses. “When we look at orthokeratology lenses, they definitely require proper training and understanding in lens design and fitting procedures,” explained Dr. Woo. To fit these lenses, both a topographer and slit lamp are required.

“The main purpose of orthokeratology is the reduction of axial length and refractive error progression,” he continued. Results have shown that these lenses provide significant results in slowing down myopia progression — which can also prevent retinal and ocular health complications.

Working together for the greater good “I believe optometrists and ophthalmologists can really work together and learn from each other [in myopia management].” – Dr. Oliver Woo “It’s critical that optometrists, as well as ophthalmologists, work together to combat myopia. In Singapore, we’ve been working quite well synergistically in managing childhood myopia because orthokeratology has been practiced by our optometrists and then our ophthalmologists essentially focus more on the atropine aspect of therapy, so both sides focus on different aspects of myopia control,” shared Dr. Wong. “If optometrists and ophthalmologists work closely, then we can monitor patients for side effects and complications, particularly in regard to orthokeratology and atropine use.” “I believe optometrists and ophthalmologists can really work together and learn from each other [in myopia management],” concluded Dr. Woo.

Editor’s Note:

Ophthalmologists and optometrists need to work synergistically to manage childhood myopia.

A version of this article was first published in CAKE & PIE POST, C&PE Edition. The CAKE & PIE Expo 2021 was LIVE on June 1819. All sessions are available free on demand until July 19 at expo. upon login.


June/July 2021



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Class Act ARVO 2021 e-posters showcase latest advancements in glaucoma therapeutics by Olawale Salami


t the recent Association for Research in Vision and Ophthalmology (ARVO 2021) Virtual Meeting, experts presented some of the latest advancements in eye care, as well as valuable data from different research studies on various new intraocular pressure (IOP) lowering treatments.

Standing ovation: Bimatoprost implant extends the range of IOP lowering What if implants could sustain intraocular pressure (IOP) lowering for years without the need for rescue medications? At ARVO 2021, Dr. Felipe Medeiros from Duke Eye Center in North Carolina, shared results from a study that evaluated the duration of IOP control provided by the biodegradable, intracameral bimatoprost implant.

colleagues followed up with patients with open-angle glaucoma or ocular hypertension for 24 months after completing the ARTEMIS study.

”Our study demonstrated that patients treated with the bimatoprost implant have a sustained IOP lowering and require no IOP lowering treatment for more than two years after their last administration.” – Dr. Felipe Medeiros

This was a long-term safety and efficacy extension study. Dr. Medeiros and

“Our results showed that among the 181 implant-treated patients who completed ARTEMIS, 48 had not been rescued at the study extension and 32 did not require rescue for ≥2 years after their last implant administration,” shared Dr. Medeiros.


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oaches and

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Dr. Medeiros added: “For these 32 patients, 16 of whom were treated with 10 μg implant and 16 with the 15 μg implant. The mean time without rescue after the last implant administration was 2.6 ± 0.5 years. These patients had a mean IOP of 23.4 ± 1.9 mmHg at baseline and 18.1 ± 3.1 mmHg at the last recorded visit, still without rescue.” According to Dr. Medeiros, their study demonstrated that patients treated with the bimatoprost implant have a sustained IOP lowering and require no IOP lowering treatment for >2 years after their last administration. “The implant releases the drug for 3-4 months and the mechanism of action of the long duration of IOP reduction is under investigation,” he shared.

A peek into a crystal ball: Degradation of the bimatoprost biodegradable implant Bimatoprost 10 μg implant (DURYSTA; Allergan Inc., an Abbvie company), a biodegradable, intracameral implant, releases bimatoprost steadily, which lowers IOP and is eventually converted into water and carbon dioxide. In addition, the implant elutes bimatoprost for up to 4 months, and current data suggest that the implant matrix's polymers may last even longer. But how quickly does this degradation occur?

Can we peek into the crystal ball? Dr. Jacob Brubaker from Sacramento Eye Consultants, California, and collaborators didn’t have a crystal ball to look into. However, they evaluated the rate of biodegradation of the implant in two ongoing clinical trials in which patients received intracameral 10 or 15 μg bimatoprost implants administered on day 1, week 16 and 32, or topical timolol 0.5% BID.

after week 28 through week 52, and 2.4% per month after week 52 through month 20. “The estimated mean size of 10μg bimatoprost implant administered decreased according to an exponential function, allowing one to predict the size of a single or multiple implants in the AC (anterior chamber),” added Dr. Brubaker.

Ab-externo placement of

“The estimated mean the XEN Gel Stent: Tightrope size of 10 μg bimatoprost walker? implant administered The XEN Gel Stent (Allergan Inc., an decreased according to an Abbvie company) was approved for exponential function, which ab-interno implantation and has been used for more than 10 years. Recently, allows one to predict the surgeons worldwide have developed and adopted a novel approach, the absize of a single or multiple externo implantation of the Gel Stent. implants in the anterior chamber.” At the ARVO 2021, Dr. Natasha – Dr. Jacob Brubaker Dr. Brukaber shared: “We defined the rate of biodegradation as the decrease in implant size per month.” “We analyzed data from 230 eyes and found that implant size data were best fit to a model that considered interpatient variability and included an exponential function for the implant size decrease,” Dr. Brubaker explained. The estimated mean rate of implant biodegradation was 3.7% per month through week 28, 10.2% per month

Kolomeyer from Wills Eye Hospital in Philadelphia, Pennsylvania, and collaborators shared data on the first evaluation of real-world data of the Gel Stent when placed ab-externo. “Patients with elevated IOP requiring surgical intervention underwent abexterno placement of Gel Stent alone or combined with phacoemulsification, with or without opening of the conjunctiva,” explained Dr. Kolomeyer. “Mean IOP and number of topical IOP-lowering medications at baseline and 12 months were recorded, as well as ocular adverse events (AEs). Available preoperative, operative and

postoperative data were collected.” This retrospective analysis included 472 eyes from 412 patients and 382 (80.9%) eyes received the Gel Stent alone. The average age of patients was 75.1 years, and 54.7% were female. Month 12 follow-up data were available for 193 eyes. Dr. Kolomeyer noted that the mean (SD) IOP decreased from a medicated baseline of 20.8 (7.6) mmHg to 14.9 (5.1) mmHg at 12 months. “This represents a mean reduction of approximately 6 mmHg (~28%), 181 (93.8%) eyes required topical IOPlowering medications at baseline vs. 110 (57.0%) at 12 months,” added Dr. Kolomeyer.

“When placed via the novel ab-externo technique, the XEN Gel Stent effectively lowered IOP and the IOP lowering medication count, with a predictable and acceptable safety profile.” – Dr. Natasha Kolomeyer The most frequent adverse events observed were transient, self-resolving hypotony (<6mmHg, n=66, 22.8%), uncontrolled IOP requiring secondary surgical intervention (n=39, 13.5%), bleb leak (n=37, 12.8%), implant exposure/extrusion or conjunctival erosion (n=20, 6.9%), and choroidal effusion with or without hemorrhage (n=24, 5.9%). 'When placed via the novel abexterno technique, the XEN Gel Stent effectively lowered IOP and the IOP lowering medication count, with a predictable and acceptable safety profile,” concluded Dr. Kolomeyer.

Editor’s Note:

Clinical trials: Generally more reliable than fortune tellers when predicting ophthalmic outcomes.

The ARVO 2021 Virtual Meeting was held from May 1-7, 2021. Reporting for this story took place during the event.


June/July 2021




forward for further research.

Glaucoma: Multifactorial genetic risk factors Unlike some disorders — such as the singular RPE65 gene disorder that leads to retinitis pigmentosa and blindness — glaucoma has numerous genes associated with its presence. This is in large part due to the fact that glaucoma itself is a multifactorial condition — the symptoms may be familiar, but the causes can be many.



t e a l s i g ht .




Dr. MacGregor’s work helped identify genetic loci that can serve as risk factor indicators for glaucoma. As he explained, combining glaucoma and correlated risk factors dramatically expands gene discovery for glaucoma.

D on’



Understanding the Silent Thief Can we predict glaucoma before it begins? by Sam McCommon


f genes are the code behind all life, then a full understanding of which bits of genetic code are defective can help us prevent and treat diseases. That’s simple! Right…? Of course, it’s not simple. Even a fruit fly has an incredibly complex genetic structure, to say nothing of humans. And beginning to understand the genetic causes of something as complex as glaucoma is going to take a whole lot of time, effort and expertise.

That work is happening, though, and it’s wonderful. We were treated to a presentation on the genetic risk factors for glaucoma by Dr. Stuart MacGregor of the Queensland Institute for Medical Research (Brisbane, Australia). Dr. MacGregor presented his ideas at the Association for Research in Vision and Ophthalmology (ARVO 2021) virtual conference. His research points to some significant progress in identifying potential genetic causes and risk factors of glaucoma and indicates a way


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Glaucoma is one of the most heritable human diseases, but it’s a polygenic condition, meaning its causes can span a number of genes. The most recent case-controlled studies of genetic glaucoma have identified 127 individual loci that represent risk factors — but Dr. MacGregor pointed out that most glaucoma heritability is not explained by those 127 loci. So, there are many more genes at play here. How to identify more potential genetic risk factors, though? The answer is simple, but not easy — use a larger sample size.

Larger sample sizes mean more risk factors detected Dr. MacGregor noted that the larger the sample size, the more loci of genetic risk factors are discovered. Generally, a 2- to 3-time increase in sample size would lead to a similar increase in the number of loci detected. Being aware of as many genetic risk factors as possible can potentially lead to huge advances in determining who’s at risk for glaucoma. Similarly, it can lead to huge advances in how to treat the condition. Genes related to intraocular pressure (IOP) and vertical cup-disc ratio (VCDR) are strongly correlated with glaucoma. According to Dr. MacGregor, studying eight IOP patients generally leads to one glaucoma case. Similarly,

studying 14 VCDR patients leads to one glaucoma case. So, it’s all a numbers game, really. The output Dr. MacGregor would like to see is a patient’s risk factor for glaucoma in the form of odds. But what input can help result in such a number?

So, where are the big sample sizes? Fortunately, there are some gold mines for medical statistics out there — many of which Dr. MacGregor drew on to help identify additional risk-factor loci. The International Glaucoma Genetics Consort (IGGC), the UK Biobank, and the Canadian Longitudinal Study of Aging (CLSA) have all proven to be valuable in providing large data sets. We’re looking at tens of thousands of cases, which is a good place to start. As Dr. MacGregor said, a good sample size for this kind of research needs to be in the tens of thousands. So, that’s convenient.

By accessing these databases, Dr. MacGregor tripled his effective sample size. This led to discovering 263 independent genetic loci as glaucoma risk factors — 63 of which were novel.

synaptogenesis — and malfunctions are associated with IOP and AMD.

One of these novel loci is a fine example. The TCF7 gene can act as a transcriptional activator involved in T-cell lymphocyte differentiation. It may also act as a feedback transcriptional repressor of the CTNNB1 and TCF7L2 target genes.

There’s plenty more to do, but the research is moving in the right direction. Dr. MacGregor is currently waiting on datasets from 23andMe, which would produce more than 43,000 glaucoma cases and nearly 1.5 million control cases. That’s enormous, and like finding a treasure chest for a statistical geneticist.

Peak single-nucleotide polymorphism (SNP) of the TCF7 gene is associated with VCDR, and the same gene is also linked with cataracts. So, when there’s something wrong with the TCF7 gene, there’s a possibility of something wrong with the eye as well. The TCF7L2 gene is also associated with IOP and agerelated macular degeneration (AMD) at peak SNP. So, the research team is on to something here. Similarly, the SYN3 gene may be involved in the regulation of neurotransmitter release and

Much done, much more to do

In the past, the genome-wide association study (GWAS) showed that there were 145 significant pathways for glaucoma development. These included abnormal eye morphology, vasculature development, microphthalmia, cataracts and abnormal kidney morphology. Now, we’re seeing 652 genes significant to glaucoma on a small level, and 65 significant on a large level. A multitrait approach pushes the number of risk factor loci above 300 for glaucoma — more than double the 127 we were working with not long ago. Dr. MacGregor explained that combining case-control data with quantitative trait data dramatically improves our ability to identify novel risk loci. This is particularly true when using AI-derived phenotyping for VCDR. The goal here is to be able to accurately predict someone’s genetic risk of developing glaucoma based on their DNA profile. This can lead to preventive or maintenance treatments that may stop glaucoma before it even begins. That may sound futuristic, but the scientific community is making huge strides toward that goal every day — and bonanzas of data will only help drive it further forward.

Editor’s Note: The ARVO 2021 Virtual Meeting was held from May 1-7, 2021. Reporting for this story took place during the event. What seems futuristic now is not actually that far off.


June/July 2021




In the fight against AMR, are fluoroquinolones up to the task? by April Ingram

Bacteria might be tough … but are fluoroquinolones tougher?


t the 7th annual meeting of the Asia Cornea Society, Dr. Shigeru Kinoshita from the Kyoto Prefectural University of Medicine (Japan) and Dr. Donald Tan from Eye and Retina Surgeons of Camden Medical Centre (Singapore) co-chaired the virtual symposium, The Peaks and Valleys of Using Fluoroquinolones to Combat the Threat of AMR. Here are some of the highlights…

Overview of AMR and fluoroquinolones The first of three expert speakers was Dr. Prashant Garg, director of LV Prasad Eye Institute in Hyderabad, India, who presented Overview of Fluoroquinolones – Role Evolution in Light of AMR Challenges. Dr. Garg highlighted how antibiotic resistance


is a challenge for both systemic and ophthalmic physicians, and the mere mention of it fuels media frenzy, (e.g., Warning! Superbug!). Dr. Garg discussed questions surrounding the current panic: Are there no new molecules to be discovered that could help combat the increasing resistance to infections (such as methicillinresistant staph or carbapenem-resistant enterobacteriaceae)? Have we run out of options? Dr. Garg reviewed the WHO AMR surveillance results from 2015. Of particular note, five of six regions reported AMR in >50% of hospitalacquired infections and half reported resistance >25% in communityacquired infections. What does this mean in ophthalmology? Dr. Garg shared the findings from The

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Surveillance Network (TSN), which reported that MRSA caused 29.5% of ocular infections in 2000; this rose to 41.6% by 2005. What is more unsettling is that MRSA was resistant ≥3 classes of antibiotics, including fluoroquinolones. Ocular TRUST reported that most organisms were susceptible to fluoroquinolones at that time, but the ARMOR study found that fluoroquinolones demonstrated a significant increase in inactivity, or resistance, against all staph, and resistant organisms were far more common in the elderly. Dr. Garg shared insights from another multinational study, ACSIKS, which looked at the epidemiology of corneal infections, reporting AMR among pseudomonas aeruginosa from keratitis cases. In countries including India, the Philippines and China, the isolates were resistant to multiple classes of

antibiotics. When country data were combined, AMR was much higher for moxifloxacin at 25.6%, than for other agents, such as levofloxacin at 11.4%. Dr. Garg described the work being done at LV Prasad in AMR since the 1990s. When the fourth generation fluoroquinolones arrived on the scene, they were very effective for ciprofloxacin resistant gram-positive organisms. Then in 2009, they found that gatifloxacin and moxifloxacin had developed significant resistance to major classes of gram-positive organisms. This was a bit surprising to some, because it was believed that due to the dual mechanism of action, resistance was unlikely. Most recently, Dr. Garg and colleagues analyzed data from 32 isolates of pseudomonas aeruginosa, uncovering that 82% were resistant to moxifloxacin, but far lower to other fluoroquinolones. What is the way forward? “At the clinician level, we need to do more. We must look for options that will help to achieve and maintain higher concentrations, possibly by innovative drug delivery, to treat the susceptible organism and eradicate the drugresistance organisms to manage and

overcome the phenomenon of drug resistance,” Dr. Garg explained.

Nobody wants post-cataract surgery endophthalmitis The final expert speaker for the symposium was Dr. Tae-im Kim, a professor at Yonsei University in Seoul, South Korea, presenting Levofloxacin 1.5% as a Topical Prophylactic Agent for Cataract Surgery. Dr. Kim described post-cataract surgery endophthalmitis as the most daunting complication, with an incidence from 0.014% to 0.59%. She notes that although clear corneal phacoemulsification is a quick and easy procedure, it carries a 1.73x higher risk for endophthalmitis than ECCE. She shared the 2007 ESCRS study that reported a reduction from 34 to 7 endophthalmitis cases, per 10,000 with intracameral antibiotic agents. In follow-up, the ESCRS study delineated four infection-reducing interventions and found that perioperative levofloxacin 0.5% demonstrated satisfactory prophylactic outcomes, while intracameral cefuroxime resulted in only slightly less infection. Dr. Kim reminds us that fluoroquinolones are a strong weapon against bacterial

infection in ocular surgery, due to their broad spectrum of coverage and dual inhibition mechanism to reduce resistance. The water solubility of levofloxacin allows for formulation at high concentration, such as 1.5%, a favorite of Dr. Kim to boost potency and efficacy. Dr. Kim said: “To avoid topical antibiotic resistance, we need to use high concentrations of bactericidal drugs, with a high dose frequency for a short period, without a taper dose. I prefer to use 1.5% levofloxacin perioperatively.” Dr. Kim also shared results from animal studies that showed 1.5% levofloxacin demonstrated greater penetration and the fastest wound healing compared to other fluoroquinolones. In a clinical study of 1.5% levofloxacin used prophylactically in cataract surgery, the bacterial strains detected dropped from 83 to 4. Dr. Kim explained the two options for post-cataract surgery endophthalmitis prophylaxis — perioperative topical antibiotics and intracameral antibiotic injection — although, she added that there are still controversies regarding intracameral injections. “In my practice, we don’t use intracameral injection frequently, and prefer to use topical fluoroquinolone eye drops in the perioperative period. My strategy is 1.5% levofloxacin QID 3 days pre-op, 1 drop immediately postop and every 3 hours on surgery day, then QID for 2 weeks post-op, and we use the ‘keep the same bottle’ strategy as it improves their compliance. Since starting this regimen in 2018, in 2,000 cases, I have never experienced any infection related to cataract surgery or delayed wound healing,” concluded Dr. Kim.

Editor’s Note: The Asia Cornea Society 2020 Annual Meeting (ACS 2020) was held virtually on April 28-29, 2021. Reporting for this story took place during the event. Thanks, but no thanks: Nobody wants post-cataract surgery endophthalmitis.


June/July 2021




Improve Quality of Life with Early Surgical Intervention in Glaucoma Treatment by April Ingram


arly detection and early treatment lead to better outcomes.” This statement is the driving force behind so many screening and treatment programs in ophthalmology … except when it comes to surgical intervention. Indeed, surgery is often only considered after limited success with topicals and once all other treatments have been exhausted. But what if surgery was moved earlier in the treatment model? Thanks to recent advances, this shift is happening in glaucoma, and surgeons are now looking toward taking a more proactive — rather than reactive — approach to glaucoma management.

The battle against IOP reduction

the next visit. In this treatment pattern, the physician and patient had better enjoy each other’s company because the relationship is a long one. We’ve known for years (and have the studies to prove it) that outcomes are better with earlier, effective treatment and IOP reduction. For each mmHg of reduced IOP, there is a 10% reduced risk of disease progression.1 In 2008, Joseph Caprioli wrote an editorial in the American Journal of Ophthalmology describing the effect on visual disability of glaucoma patients as a function of the rate of progression and time of intervention — importantly noting that with earlier intervention in eyes with fast progression, visual function can be preserved.2

In glaucoma management, it’s a daily challenge for ophthalmologists to meet the patient’s desired intraocular pressure (IOP) goals and preserve optic nerve function. There are various (and important) things to consider, such as selecting the optimal therapy or combination of therapies to hit that IOP target. Other factors include: managing the delicate balance of patient compliance, adherence and side effects, as well as maintaining their quality of life.

The arrival of Minimally Invasive Glaucoma Surgery (MIGS) has provided an opportunity for early treatment in patients whose IOP reduction needs do not necessitate the plunge into a more invasive trabeculectomy or tube shunts. It has been established that MIGS delivers effective IOP reduction and reduces medication burden. And there are a growing number of options for MIGS devices; these can be divided by their approach or pathway: subconjunctival, suprachoroidal or Schlemm’s canal. Subconjunctival draining devices like the XEN Gel Implant (Allergan, an AbbVie company, Dublin, Ireland) or PRESERFLO® MicroShunt (Santen, Osaka, Japan) can be used in solo MIGS procedures and have better potential to achieve single digit IOP levels. Additionally, patients can combine their scheduled cataract surgery with MIGS — and who wouldn’t want the efficiency of getting two eye disorders treated at the same surgical appointment?

Could early surgical intervention (ESI) be the solution?

It goes on and on — and often, it can feel like going into battle. Pressure increases, we react, change the therapy, hope the patient is compliant and keep our fingers crossed until


So, if the surgical intervention can safely maintain acceptable IOP while reducing adherence issues and side effects, then why are we waiting and watching … and waiting again for other options to fail, or eventually become intolerable to our patients?

Dr. Chelvin Sng, from the National University Hospital in Singapore, supports MIGS options earlier for glaucoma patients. “The introduction of MIGS devices has improved surgical

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back to Peng Khaw’s 10/10/10 rule: A 10-minute technique that will reduce the IOP to 10 mmHg for at least 10 years.3

Slow Progression Earlier intervention Visual Function

Fast prograssion

We hope that with innovative devices and techniques which demonstrate safe, consistent and effective IOP lowering results — together with a more proactive attitude and earlier approach to surgical glaucoma management will get us closer to that “Holy Grail.”

Later intervention

Level of visual disability



Effect of timing of intervention on rate of progression. [Source: Caprioli J. The importance of rates in glaucoma. Am J Ophthalmol. 2008;145(2):191–192.]

DISCLAIMER: The Santen styrene-blockisobutylene-block-styrene (SIBS) Microshunt is CE-marked in The European Union and currently marketed under the brand name of PRESERFLO®. It is not yet approved for use in other countries except Canada and Australia. This educational article is based on Dr. Sng’s own clinical experience and has no financial interest to disclose.


safety, allowing us to offer glaucoma surgery to patients earlier in the treatment algorithm. In particular, cataract surgery provides an opportunity to have a glaucoma procedure performed at the same time, even if the glaucoma is medically controlled,” she said. Let’s consider the benefits of MIGS: These procedures reduce medication burden and adverse effects of topical treatments. They are safer, less tissueinvasive and are associated with a faster recovery than traditional filtering surgery, such as trabeculectomy or aqueous shunt implantation. As with any procedure or intervention, it’s critical to select the right patient for the correct procedure, based on treatment goals and the patient’s specific needs. So, what are some characteristics to consider with early MIGS intervention? In addition to the ultimate treatment goals, other key factors may include the patient’s age, progression rate, their response to other therapy, and their adherence and tolerance to topical treatment. Additionally, assessing the degree and cause of IOP increase and determining outflow impairment's location will help to decide which type of early intervention should be considered. (Think patient, disease type and target pressure.)

For example, a subconjunctival MIGS approach, like with the PRESERFLO® MicroShunt (Santen, Osaka, Japan), may be an ideal solution for a relatively young patient who has documented slow progression shown by visual fields. This approach is also a good fit for someone with modest IOP reduction requirements and who does not tolerate topical medication side effects very well. Plus, having to carry around several bottles of topical eye drops can be frustrating for younger patients — while older patients may find applying the drops difficult due to dementia, arthritis or other issues. These are further instances where MIGS may improve quality of life. This year, COVID-19 has been a new wrench in glaucoma practices. Of course, the goal remains to manage each patient’s IOP effectively, but this has been easier said than done — especially when trying to keep clinic visits to a minimum. The circumstances of the pandemic have forced physicians to adapt and evolve to a more proactive treatment approach. For many, this meant utilizing MIGS earlier in their treatment plan to achieve IOP control and reduce the need for frequent follow-ups. There are numerous challenges to managing glaucoma patients and glaucoma specialists are still searching for the “Holy Grail” solution. This harks

Leske MC, Heijl A, Hussein M, et al. Factors for glaucoma progression and the effect of treatment: the early manifest glaucoma trial. Arch Ophthalmol. 2003;121:48–56.


Caprioli J. The importance of rates in glaucoma. Am J Ophthalmol. 2008;145:191–192.


Thomas R, Billson F. The place of trabeculectomy in the management of primary open-angle glaucoma and factors favouring success. Aust N Z J Ophthalmol. 1989;17:217.

Contributing Doctor Associate Professor Chelvin Sng is a glaucoma consultant at the National University Hospital in Singapore. She completed her glaucoma fellowship at Moorfields Eye Hospital, and was named as one of the “Top 50 Rising Stars” in the global Ophthalmology Power List in 2017. A/Prof Sng has a special interest in glaucoma drainage devices, including minimally invasive glaucoma surgery (MIGS) devices. She is the Convenor of the Asia-Pacific Glaucoma Society (APGS)MIGS Interest Group, and has conducted training courses on MIGS at the ESCRS and APAO meetings. A/Prof Sng is also the co-inventor of the Paul Glaucoma Implant, which has attained CE mark and is currently undergoing international clinical trials. She has served in less fortunate communities which have little or no access to healthcare, and volunteers regularly in medical missions to the less accessible areas in South East Asia, India and Africa. In her leisure time, she enjoys traveling, reading and spending quality time with her two adorable sons.


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TECNIS Synergy™ IOL and the Digital Lifestyle With digitalization all around, we find ourselves increasingly using digital devices in our daily lives to the detriment of vision health. The prevalent use of mobile phones for example, is causing near working distance to be closer than before.1


recent study by Soler et al.1 on the working distance and mobile phone usage distance of 454 participants found that though working distance varies amongst individuals, mobile phone usage distance is around +/- 33 cm. This reinforces the need to have better visual acuity at 33 cm in order to achieve higher spectacle independence and patient satisfaction.

On the other hand, trifocals would demonstrate reduced visual acuity in low-contrast conditions.3,4 As such, the main objective of new IOL designs today is to provide the maximum level of range of focus in all lighting conditions. TECNIS Synergy™ IOL, the latest presbyopia-correcting lens developed by Johnson & Johnson Vision (Jacksonville, Florida, USA), is a new presbyopia correction approach that combines two diffractive technologies — the EDOF and multifocal diffractive technologies in the same lens, with the aim of delivering continuous highcontrast vision from far to near, even in low lighting conditions.

In recent years, a fast evolution of presbyopia-correcting intraocular lenses (IOLs) has occurred, from the popularization of extended depth of focus (EDOF) IOL designs to optimization of diffractive trifocal IOLs that are based on different optics principles. However, depending on the lens optical properties, light distribution with diffractive lens may not always be fully efficient, resulting to light loss.3

As a one-piece presbyopia-correcting IOL with a 6 mm optic and an overall length of 13 mm, the TECNIS SynergyTM IOL has C-loop haptics, offset from the optics and a continuous 360° posterior square edge. It is made of a hydrophobic acrylic material with ultraviolet and violet light absorber. It is an aspheric-correcting IOL and also reduces chromatic aberration.


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Clinical performance Range of vision A prospective, multicenter, bilateral implant, randomized (2:1) clinical study among 12 centers worldwide evaluated the clinical performance of TECNIS Synergy™ IOL compared to AcrySof® IQ PanOptix® Trifocal IOL (Alcon, Geneva, Switzerland).2 One hundred and seventeen (117) subjects were implanted with TECNIS Synergy™ IOL, while 60 subjects were implanted with PanOptix® Trifocal IOL. Interim 3-months study results show that TECNIS Synergy™ IOL provides superior visual performance across every distance and the widest range of continuous vision, from distance to 33 cm (Graph 1), with TECNIS Synergy™ IOL subjects achieving 0.8 LogMAR (0.16) and PanOptix® Trifocal IOL subjects achieving 1.5 LogMAR (0.032) at 33 cm. The TECNIS Synergy™ IOL is also shown to provide close to 0.5 to 1 line of visual acuity at very near distance.

Binocular Distance-corrected Defocus Curves†

Better performance across every distance

TECNIS Synergy™ IOL (111) PanOptix® Trifocal IOL (58)

Graph 1: TECNIS Synergy™ IOL provides wider range of continuous vision across every distance2§^

According to Dr. Fam Han Bor, senior consultant at the Department Of General Ophthalmology, Tan Tock Seng Hospital (Singapore), Asians tend to be myopic. “Anatomically, most Asians are of smaller physical stature and have shorter arms, thus typically have a closer working distance. Hence it is important that TECNIS Synergy is able to deliver good VA at very near distance,” he said.

Vision in low-light Moreover in low-light conditions, the TECNIS SynergyTM IOL was found to provide better visual acuity compared to PanOptix® Trifocal IOL (Graph 2). The TECNIS SynergyTM IOL subjects achieved higher far and near visual acuities under mesopic conditions – 0.09 vs 0.11 LogMAR for mesopic best corrected distance visual acuity (BCDVA), and 0.25 vs 0.31 LogMAR for mesopic distance corrected near visual acuity. In photopic low-contrast conditions, the BCDVA for TECNIS Synergy™ and PanOptix® lens groups was 0.13 and 0.17 LogMAR, respectively. Furthermore, results of the comparative study showed that patients reported more satisfaction with nighttime activities. Majority of TECNIS Synergy™ IOL subjects (90%) were able to see objects and read street signs in the evening or at night, compared to 87% of PanOptix® Trifocal IOL subjects.

lower lighting conditions (i.e. nighttime reading, driving, walking, etc.). TECNIS SynergyTM, with its chromatic aberration feature is able to better improve vision under mesopic or low contrast conditions as demonstrated by the comparative study results. Study findings suggest that compared to PanOptix® Trifocal IOL, TECNIS Synergy™ IOL provides a wider range of continuous vision, with superior near especially at close working distance of 33 cm and higher levels of binocular visual acuity from far to near.

Meanwhile, 96% of TECNIS Synergy™ IOL subjects were able to read the menu in a dimly lit restaurant (vs. 87% of PanOptix® Trifocal IOL subjects), and 97% were able to see steps or curbs in the evening or at night (vs. 94% of PanOptix® Trifocal IOL subjects). As diffractive lens usually spreads light over a range of distances, there is already light loss, making it harder for patients to read; even more so in

©Johnson & Johnson Surgical Vision, Inc 2021. PP2021CT5220


Soler F, Sánchez-García A , Molina-Martin A, et al. Differences in Visual Working and Mobile Phone Usage Distance according to the Job Profile. Curr Eye Res. 2021;1-7.


DOF2020CT4014 - Forte 1: A Comparative Clinical Evaluation of a New TECNIS® Presbyopia Correcting Intraocular Lens Against a PanOptix® Intraocular Lens- Defocus . Curves and Visual Acuity Results

^ Vs. PanOptix® Trifocal IOL based on headto-head post-market clinical study. Based on interim data collected at 3-months postoperative

§ Among leading PC IOLs – TECNIS Symfony® IOL, TECNIS Synergy™, PanOptix® Trifocal IOL.

† Based on interim data collected at 3-months post-operative


Portney V. Light distribution in diffractive multifocal optics and its optimization. J Cataract Refract Surg. 2011;37(11):2053-2059.


Kohnen T. First implantation of a diffractive quadrafocal (trifocal) intraocular lens. J Cataract Refract Surg. 2015;41(10):2330–2332

Binocular Distance-corrected Visual Acuities†

TECNIS Synergy™ IOL subjects achieved better near and far vision under mesopic and low contrast conditions

TECNIS Synergy™ IOL (n=111) PanOptix® Trifocal IOL (n=58) BCDVA- Best corrected distance visual acuity DCNVA- Distance corrected near visual acuity

Graph 2: TECNIS SynergyTM maintains better vision performance under different lighting conditions 2


June/July 2021



s ’ t Le Get Weird

Strange Cases in Anterior Segment Surgery by Brooke Herron


| June/July 2021


adies and gentlemen, step right up and prepare to be amazed: Welcome to CAKE’s Side Show of Ophthalmic Oddities! Hailing from faraway lands like Florida (USA) to the vast and diverse subcontinent of India, from “down under” in Australia and the ultramodern city-state of Singapore, we’ve scoured the globe to collect the most interesting (and the rarest) cases and conditions in anterior segment practice. Below, we’ve got corneal conundrums, unusual detachments, refractive rarities and a once-in-alifetime trauma — we hope you enjoy the “show!”

The devil’s in the (detachment) details Although cataract surgery is a routine procedure, complications can still occur in the blink of an eye (pun intended)… and certain adverse events might not be caught until outcomes are affected postoperatively. Based on sheer volume alone, Indian ophthalmologists encounter more unusual cases and rare complications than your average surgeon. One such case comes to us from Dr. Soosan Jacob, director at Dr. Agarwal’s Refractive and Cornea Foundation and senior consultant of Cataract and Glaucoma Services at Dr. Agarwal’s Group of Eye Hospitals in Chennai. Her rare case is a bullous Descemet’s detachment or BDD. “At any time during cataract surgery, due to complications or rough handling, the Descemet’s membrane (DM) can detach. The traditional treatment is to inject air from the opposite side and it reattaches,” explained Dr. Jacob. “But sometimes you don’t notice it during surgery — the Descemet’s is a transparent membrane — so, unless you’re looking for it, you might miss it. Then the next day, the patient has corneal edema and you can’t

see too clearly because visibility into the anterior chamber is reduced,” explained Dr. Jacob, adding that the easiest way to diagnose a Descemet’s detachment (DD) is with anterior segment OCT (AS-OCT). “If it’s a small DD, you can wait for it to attach spontaneously by itself. But if it’s a larger detachment or it’s on the pupil where it’s obstructing vision, you can push in air and it reattaches.” However, there is more than one type of DD. In fact, it was Dr. Jacob who proposed a classification for DD, which has since been published.1 The four categories of DD include rhegmatogenous DD (which is the most common), tractional DD, complex DD, and bullous DD, which we’ll discuss in more detail now. “This is a case that cataract surgeons come across once in a while — not frequently — but it’s important to identify it,” said Dr. Jacob. She is referring to a bullous Descemet’s detachment (BDD), a complication that she’s encountered fewer than 10 times in a high volume clinic. A BDD presents as a smooth bulge of Descemet’s membrane into the anterior chamber (AC), and it most commonly occurs when fluid or viscoelastic pools in the supra-Descemet’s space during viscocanalostomy or cataract surgery.2 “It’s something that most people don’t notice — and because there’s no tear, the fluid remains trapped,” explained Dr. Jacob. “This means when you put in air, it’s not actually draining the fluid out, so you have to intentionally create a controlled tear or break to let the fluid drain.” Once identified, the treatment is quite simple. Dr. Jacob then presented a case when the surgeon did notice a DD intraoperatively and injected air. But because it was a BDD, the DM did not reattach. Not realizing the pathology of the detachment, they tried to put in air again the next day with the same result — the cornea did not clear. The

patient was then referred to Dr. Jacob at her hospital. “We did an anterior segment OCT and it showed the classical appearance of a bullous Descemet’s detachment,” she said.

BDD causes and treatments So, what causes a BDD? According to Dr. Jacob, it generally occurs at the last step of phacoemulsification during stromal hydration if the cannula goes too close to the DM during fluid injection. “So now, instead of the fluid entering the stroma, it detaches part of, or even sometimes the entire Descemet’s membrane. It can be seen as a fluid wave going across the cornea if you’re observing carefully at that time. If you’re not observing but you recorded it, often you can go back and see it,” she shared. “Once the fluid wave has gone across, you might not be able to identify it unless you’re looking very closely, because now there’s nothing hanging freely in the anterior chamber. It’s just a detachment that’s like a trapped pool of water — and now if you’ve missed it completely, that’s when you see problems the next day.” Fortunately, the treatment is simple. “You use a keratome to make a controlled break (as an exit wound) for the fluid to drain out,” said Dr. Jacob. “You make a larger incision through the original paracentesis/ needle puncture wound and create a tear — then you can follow the classical approach and put in an air bubble and the DM reattaches. It’s basically an incision in the Descemet’s membrane — I call this a relaxing Descemetotomy. The final outcomes are very good because all you need to do is get the Descemet’s to reattach and the cornea is going to be clear,” she explained. Of course — and as with most things — prevention is the best tool. Dr. Jacob said there are two things to


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keep in mind to avoid BDD. First, don’t place the cannula too close to the posterior lip of the incision. Make sure that it’s always mid-stromal. It should also align with the curvature of the cornea rather than pointing downward. The second thing is that BDD can be more common in patients who have a weak endothelium or DM attachment, like patients with Fuchs’ dystrophy, where even a small misdirect of fluid could cause this to happen very easily. “So be even more careful in such patients when you are doing stromal hydration at the end of phaco,” she shared. If there is a suspicion this has occurred intraoperatively, BDDs can also be detected with an endoilluminator, or a vitrectomy light pipe. “Using this, you can throw light on the cornea from different angles and you can see reflections from the detached DM, which tells you it’s a BDD. If you’ve missed it during surgery, you’ll see corneal edema the next day and you can use AS-OCT to diagnose,” said Dr. Jacob. She added that BDD can also occur when injecting viscoelastic. This can be treated by making the cut again, washing away the viscoelastic and applying air. Trypan blue is another cause. To avoid BDD while injecting viscoelastic or Trypan blue, make sure the bevel is completely in the AC before injecting.

“If you’re injecting anything into the AC, make sure your bevel is fully in — otherwise it can go into this plane and get trapped,” said Dr. Jacob. “BDD is much rarer than RDD, but it’s an entity surgeons need to be aware of,” concluded Dr. Jacob.

Conundrums in corneal dystrophies According to Dr. William Trattler, although corneal dystrophies are rare, they can be successfully managed. Dr. Trattler is a refractive, corneal and cataract eye surgeon at the Center For Excellence In Eye Care in Miami, Florida, USA. Granular corneal dystrophy occurs when deposits slowly form in the middle layer of the cornea of both eyes with age. It’s an inherited genetic disease and can cause significant blurring of vision, as well as recurrent corneal erosions and discomfort. “One of the first challenges is diagnosing granular corneal dystrophy,” explained Dr. Trattler. “But now there is a simple test called AvaGen (Avellino, California, USA) that can determine the exact diagnosis of anterior corneal dystrophies associated with the TGFBI gene and the 70 TGFBI variants.” For such a rare condition, the test is easy, indeed. It’s performed by swabbing the inside of the cheek, and results are usually provided within a week. Today, there are varying treatment options. “In the past, corneal transplants were performed, but the challenge is that granular corneal dystrophy can recur in the graft,” said Dr. Trattler. “Thankfully, there are new procedures that can be performed that can help improve vision and avoid a corneal


| June/July 2021

transplant.” One effective treatment is phototherapeutic keratectomy (PTK), which involves smoothing the corneal surface with laser. Dr. Trattler emphasized that in PTK, the goal is not to laser deeply into the cornea and remove all opacities — rather, the goal is to smooth the cornea. “At the conclusion of the PTK procedure, it is expected that opacities will be visible in the anterior portion of the cornea. However, the new smooth surface will result in significant improvement in vision,” he shared. “In my experience, PTK may need to be repeated every five to 10 years — and because the procedure is performed superficially, that leaves plenty of room for additional treatments in the future,” he continued. Another advantage of superficial procedures (like PTK) is that they avoid a hyperopic shift. Of course, there is always room for improvement in regard to treatment. Dr. Trattler said that the future’s hope lies in genetic therapy to reverse the condition. However, this type of technology is still quite a ways off. “While granular corneal dystrophy can have its challenges, the ability to diagnose with a genetic test, and the ability to perform a safe and minimally invasive procedure (PTK) to restore vision provides significant promise to those patients,” he concluded.

A once in a lifetime adverse event “There are some cases that are never taught in textbooks — instead, they require use of every skill and principle of management that you learn while training,” said Dr. Sahil Thakur, a clinical research fellow for the Ocular Epidemiology Research Group at Singapore Eye Research Institute (SERI) in Singapore.

While completing his residency, Dr. Thakur encountered an elderly patient who illustrated this situation perfectly: The patient presented with an emergent case of trauma and subsequent vision loss; he also had cataract surgery (SICS) in the same eye a few years prior. “When the lid was everted on examination, it was noted that the lens (a posterior chamber intraocular lens, PCIOL) had been extruded from the eye from the trauma and was lying under the conjunctiva,” shared Dr. Thakur. “This was a once in a lifetime case and thus, I decided to document it with my phone camera — and it’s lucky that I did!” Because there is no precedent for these types of cases, Dr. Thakur said it’s crucial to be smart and flexible about management. In this scenario, he recommends meticulous documentation. “This can help in management, getting second opinions, preventing potential litigation (in the case of poor outcomes and unhappy patients), and publication later on. The basic principles of patient management are quite simple once you have figured out what the immediate underlying risks are,” said Dr. Thakur. For this particular case, he described the surgical management as similar to how penetrating eye injuries are managed, using exploration under general anesthesia and restoring the structural integrity of the eye. “The visual prognosis in such cases is especially poor if the presentation is late and initial visual acuity is only inaccurate perception of light,” he continued. “Later on, we found out that this clinical presentation

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

accommodating intraocular lens) and procedures like corneal collagen crosslinking (CXL). His involvement in the FDA-approval study for CXL led to its approval in 2016. In addition to his private practice, Dr. Trattler is on the volunteer faculty at the Florida International University Wertheim College of Medicine, as well as the University of Miami’s Bascom Palmer Eye Institute. He is board certified by the American Board of Ophthalmology and has been an author of several articles and abstracts. In 2016, Dr. Trattler received the Catalyst Award in Advancing Diversity in Leadership from the Ophthalmic World Leaders (OWL), an association of interdisciplinary ophthalmic professionals dedicated to driving innovation and patient care by advancing diversity in leadership. Dr. Sahil Thakur is a clinical research fellow for the Ocular Epidemiology Research Group in Singapore Eye Research Institute (SERI). He completed his residency at Government Medical College, Chandigarh, India, and has collaborated with his mentor Dr. Parul Ichhpujani on several projects, including a book on the usage of mobile phone applications in ophthalmology, called Smart Resources in Ophthalmology, by Springer. Dr. Thakur has special interest in bridging the advancement in mobile computing with practical applications in everyday ophthalmology practice. Dr. Anil Arora is the Medical Director of Laser Vision Clinic Central Coast in Erina, Australia. He graduated from the University of Sydney in 1985 and carried out his ophthalmology training at the Sydney Eye Hospital; he was also conferred with a Masters of Medicine degree in the same year for research in retinal electrophysiology. He holds particular interests in diseases and surgery of the vitreous and retina, cataract surgery, and refractive surgery, particularly laser vision correction.


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(pseudophacocele) is quite rare and decided to submit it as a case report.” Eye trauma is, of course, difficult to prepare for. However, as a cataract surgeon, Dr. Thakur recommends following up with patients at least once a year to help build rapport. “Giving them a card with your contact information in case of an emergency, injury or trauma is another good practice,” he continued. “If such cases do show up, meticulous documentation is of paramount importance. It’s also good practice to regularly read journals

and magazines so that you can learn from others' experiences,” said Dr. Thakur, adding that more often than not, a quick PubMed search can turn up a similar case. “I also recommend that while examining a patient, always evert the lids. I have seen patients with hair follicles or loose sutures causing chronic irritation for months before someone has a careful look at them.”


Well, let’s be clear, there are some truly ridiculous stories out there about the perils of refractive surgery. The outlandish ones should be ignored, but like any medical procedure, LASIK does carry risk. Common side effects like dry eye,



Jacob S, et al. A new clinico-tomographic classification and management algorithm for Descemet’s membrane detachment. Cont Lens Anterior Eye. 2015;38(5):327-33.


Thakur S, Ichhpujani P, Kumar, S. Pseudophacocele following a Bicycle Handle Injury: A Case Report. Nepal J Ophthalmol. 2018;10(19):94-97.


Hazin R, Daoud YJ, Khalifa YM. What is Central Toxic Keratopathy Syndrome if it is not Diffuse Lamellar Keratitis Grade IV? Middle East Afr J Ophthalmol. 2010;17(1):60–62.

As the curtain closes… Ladies and gents, we hope you’ve enjoyed this foray into these mysterious and strange cases in

The odd side of refractive surgery hen refractive surgery first appeared on the scene decades ago, stories abounded of horrible side effects and sometimes even instant blindness — and as such, the technique had many naysayers, especially in the lay community. We have come a long way since then and now LASIK is much more accepted by the general public. But venture into the depths of social media and there is still the odd meme or uneducated post about the horrors of refractive surgery. So, has there ever been any truth to these horror stories — or is it all ignorant fake news?

anterior segment practice. These oddities — although rare — do come to the surface on occasion… and we can all certainly learn something from the masterful handling by these renowned experts.

by Andrew Sweeney

flap problems, and keratoconus are well known, and less frequently encountered complications like halo starbursts and double-vision also exist.

central toxic keratopathy. It is so rare that I was not even entirely sure that was the correct diagnosis, and I had to do considerable research to ensure that I was correct,” he said.

Dr. Anil Arora, the medical director at Laser Vision Clinic Central Coast in Erina, Australia, shared with CAKE Magazine a few cases with rare complications in this area.

Dr. Arora's hesitancy in confirming the diagnosis is understandable as central toxic keratopathy (CTK) is often described as “exceedingly rare” by researchers. It is an acute, self-limited, non-inflammatory process that yields central corneal opacification and significant hyperopic shift after refractive surgery. To provide context about how infrequently it is encountered after refractive surgery, only 0.00760.016% of patients exhibit CTK postoperatively.3

“Personally, I have not had anything out of the ordinary. I do SMILE and LASIK surgery and I've had the rare epithelial ingrowth in a SMILE pocket or the occasional wrinkle in a LASIK flap, but these are wellrecognized,” Dr. Arora said. “However, I have had one case after a LASIK enhancement (following a previous SMILE procedure) where the patient developed a very rare condition in the flap interface called

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Thus, CTK is not something that your average patient should be overly concerned about, but it is a complication worth bearing in mind.




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LEARN MORE: | J u n e / J u l y 2 0 2 1 29

tage S w o h S e id S e h t n o t x Ne


a l u c O e r a s Disease e uncommon


As the name suggests, rare diseases ar — but that doesn’t mean they’re not encountered. According to a 2019 study¹:

1 10 1 2 350M

people are affected by rare diseases

patients diagnosed with a rare disease is a child

people suffer from a rare disease globally

8 10 rare diseases are caused by a faulty gene

8yrs is the average time it takes for rare disease patients to receive an accurate diagnosis


of the rare diseases lack an FDA approved treatment


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ered “rare” In the United States, a disease is consid if it affects less than 200,000 people. ogies less common pathol e th of e m so e ar e Her treated by ophthalmologists.²

Hemolacria (bloody tears)

Batten Disease

Tears tinged with blood usually signal another underlying problem.

There are different forms of the disease, but all are fatal — doctors are still working on a treatment



Retinitis Pigmentosa There’s no cure, but promising treatments like bionic eyes are in development.

25 100,000 in

Stargardt Disease

Stargardt disease can go undetected until adolescence or adulthood, when blurry or distorted vision develops.

12 100,000 in

Best Disease

There’s not yet a treatment, but gene therapies and stem cell therapies may alleviate or cure this condition in the future.

6 100,000 in

4 100,000 in

Bietti’s Crystalline Dystrophy

People of Asian descent are most likely to develop this condition. There is not yet a cure or treatment

1.5 100,000 in

Axenfeld-Rieger Syndrome

This syndrome causes various eye problems including a thin iris and an off-center pupil — and in some cases, extra holes in the iris can give the appearance of multiple pupils. In other cases, the cornea is affected.

<1 100,000 in

References: 1. 2.

Sburlan EA, Voinea LM, Alexandrescu C. Rare ophthalmology diseases. Rom J Ophthalmol. 2019; 63(1): 10–14.

Mukamal R. 20 Rare Eye Conditions That Ophthalmologists Treat. 2020 Oct. Accessed on June| 4, J 2021. une/July Available at:





In the Spotlight

Eye care heroes by Chris Higginson

As well as her medical work, Dr. Mustapha lectures at the University of Sierra Leone where she aims to be a role model (just as another ophthalmologist was for her as a medical graduate) and inspiration to medical students and even to other doctors who now see the potential of ophthalmology to change lives.


n light of the ongoing COVID-19 pandemic, it’s always good to hear positive stories to lift our spirits. In this regard, we want to shed light on some changemakers in ophthalmology, who are making a difference in eye care all over the world. We have selected two eye doctors and one optometrist who are making an impact in their communities and inspiring others to do the same.

Dr. Jalikatu Mustapha, Sierra Leone

She vividly recalled one of her patients’ reaction post-surgery. “As her eye pad was being removed the day after her cataract surgery, 74-year-old Amina, who was bilaterally blind for three years, happily shouted: ‘Doctor, I can see you clearly,’” shared Dr. Mustapha. “That look of pure joy and hope in her eyes is the reason why I love my job,” she added. “To be able to help people like Amina get back their sight, their dignity and livelihood, is an absolute blessing to me. Overseeing Sierra Leone’s Eye Care program means not only helping individuals like Amina but also developing policies that will protect present and future generations from avoidable blindness in our country.”


Dr. Indra Prasad Sharma, Bhutan

Not all heroes wear capes, but they often wear white coats.

Dr. Jalikatu Mustapha is one of only four ophthalmologists working in the whole of Sierra Leone, returning to the country as an adult after fleeing the civil war as a child. She was inspired to work in the field upon hearing another doctor’s passion for the subject and observing the life-changing effects that quick and simple surgeries could have. “Many of these people had been blind for years and after just 10 minutes of surgery, their whole lives were transformed,” said Dr. Mustapha.

For her work, Dr. Mustapha recently won an award from the International Agency for the Prevention of Blindness, and she even had the honor of meeting Queen Elizabeth II on World Sight Day, who congratulated her on her achievement.

Dr. Mustapha trained as an ophthalmologist abroad, then took a well-paid job in Kenya but left that role in order to take a much lower paying job in Sierra Leone when she saw the desperate need for eye care in her country. Since her arrival, Dr. Mustapha has been helping to make up for the country’s low number of eye doctors by working twice as hard as most people. In return, she has recently been appointed the head of Sierra Leone’s Eye Care program. Currently, she is completing a nationwide assessment of the eye health services available across Sierra Leone as well as the very first cataract audit research. In addition, Dr. Mustapha has been working to increase the rates of cataract surgeries and re-implementing a nationwide cataract surgical outreach campaign for hard-toreach populations. Working hard to raise awareness of the burden of glaucoma in Sierra Leone, Dr. Mustapha is also involved in a yearly event in the country, where for one week everyone is entitled to free glaucoma screening.

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Dr. Indra Prasad Sharma is an optometrist working in the tiny mountain kingdom of Bhutan — a unique, small and landlocked country nestled deep in the Himalayas between India and China. Filled with high mountains and deep valleys, the remote area has a population that is scattered across hard-to-access locations that can take days of hard travel to reach. Instead of working to promote its gross domestic product (as every other government in the world does), Bhutan is famous for its unique philosophy, prioritizing “gross national happiness,” which guides its development. Receiving the Royal Government Scholarship at a young age, Dr. Sharma went to university in India, finishing top of his class. While in India, he secured the prestigious Nehru-Wangchuck Scholarship to complete a Master’s Degree in Clinical Optometry, winning the university’s award for Academic Excellence and Best Emerging Researcher. When he returned to Bhutan in 2011, he left the capital city in order to work in a remote region — which had no ophthalmologists — and was soon assigned to lead all ophthalmic activities in six districts of eastern Bhutan for the next five years. Because the population of eastern Bhutan is so spread out, he conducted mobile eye clinics and coordinated mobile operative eye camps in order to service the thousands of people who needed help.

Today, one of Dr. Sharma’s many roles is working for the Ministry of Health, where he helps mould Bhutan’s eye health policies. He has been involved with many different initiatives, including leading the nationwide Bhutan School Sight Program which gave 20,000 children their first refractory diagnosis and first pair of glasses. He helped draft the National Eye Health Plan 2019-2023 and was instrumental in planning and conducting the national RAAB survey in 2018. His contribution was recognized by the National Eye Hospital with the Best Employee of the Year Award in 2018. He was also nominated for the International Award for Excellence, Eye Health Hero 2020, by the Bhutanese Ministry of Health. “Having been born and brought up in a small village in Bhutan, I experienced the reality of living in a remote community,” shared Dr. Sharma. “Since then, I was determined to pursue health and impact the lives of the community. Joining the Ministry of Health as the country’s first optometrist was an opportunity for me to make some contribution. Working in eye health for almost a decade, I realized that every effort in eye health can bring changes in improving the lives of the underprivileged population.”

Dr. Ingrid Yazmin Pita Ortiz, Mexico Dr. Ingrid Yazmin Pita Ortiz was born in Mexico. After completing her medical degree, she was inspired to study ophthalmology after seeing “the gratitude and happiness of the people after they received proper ophthalmologic attention.” To achieve her goals, she moved to Mexico City, away from friends and family, to study at the Fundación Hospital Nuestra Señora de la Luz. During her fellowship, she participated in a number of campaigns, including an extended trip to Mexico’s remote hinterland where she helped diagnose and treat children and adults with all kinds of eye health problems.

the retina and vitreous subspecialty fellowship, eventually achieving first place at the examination of the Mexican Board of Ophthalmology. Throughout her academic career, she has helped her fellow students and doctors and participated in teaching other medical specialties about the importance of ocular diagnoses, such as retinopathy of prematurity, giving lectures to pediatricians and neonatologists and raising awareness of the issue. Recently, Dr. Ortiz moved to Madrid, Spain, to take up an international fellowship in ocular oncology. However, she has continued to give virtual lectures, even though the difference of time zones often requires her to give them in the middle of the night. She is currently finishing her Master´s Degree in Direction of Healthcare Organizations, with the goal of becoming part of the Mexican National Research System. “What I love about my role is the feeling that everything I do helps others achieve a better life,” Dr. Ortiz shared. “It can be while helping patients save their vision or helping fellows understand the different pathologies or surgeries. The main thing in life is to be happy and being happy while doing ophthalmology reflects in every act and our attitude towards the rest of the world,” she concluded.


The Patriotic Vanguard. Available at dr-jalikatu-mustapha-of-sierra-leone. Accessed on July 11, 2021.


Life Care Hospital. Available at http:// Accessed on July 11, 2021.


Musings of a Lazy Geek. Available at http:// Accessed on July 11, 2021.


Optometrist Indra Prasad Sharma. Available at Accessed on July 11, 2021.


NeoVision Clinica Oftalmologica. Available at Accessed on July 11, 2021.


Doctoralia. Available at https://www. oftalmologo/ciudad-de-mexico. Accessed on July 11, 2021.


ResearchGate. Available at https://www. Accessed on July 11, 2021.

Contributing Doctors Dr. Jalikatu Mustapha fled Sierra Leone when she was less than 10 years old in order to avoid the destruction of a civil war. Inspired by seeing the transformative potential of simple surgeries, she trained as an ophthalmologist and chose to return to her country when she became aware of the desperate need for eye care. Since returning, she has helped make huge strides in eye care and has been appointed the head of Sierra Leone’s Eye Care program, where she has led a large number of different projects directed toward treating a variety of problems, but especially glaucoma and cataract. Dr. Mustapha lectures at the University of Sierra Leone where she aims to be a role model and inspiration to medical students and fellow doctors. Dr. Indra Prasad Sharma was born in a small and remote village in the Kingdom of Bhutan, set deep in the Himalayas. Recognized for his academic brilliance at an early age, he received a national scholarship to study Masters in Clinical Optometry. After completing his studies, he returned to Bhutan where he volunteered to work deep in the remote valleys of the east of the country. The Ministry of Health recognized his abilities and quickly appointed him to lead all ophthalmic activities in six districts of eastern Bhutan. Dr. Sharma now works in the Ministry of Health, helping to shape eye care in Bhutan, as well as working to lead a huge number of projects, bringing sight to people in remote corners of this almost forgotten kingdom. Dr. Ingrid Yazmin Pita Ortiz was born in Mexico and, inspired by the gratitude and happiness that fairly quick and simple ophthalmological procedures were able to give to people, chose to study ophthalmology at the Fundación Hospital Nuestra Señora de la Luz in Mexico City. Dr. Ortiz has always excelled academically, finishing top of her class and graduating with honors. Not content with simply doing well herself, she has always helped her fellow students and doctors and has participated in teaching other medical specialties about the importance of ocular diagnoses, such as retinopathy of prematurity. Even though she now lives in Spain, she still gives virtual lectures to Mexican students despite the difference in time zones.

After graduating with honors, she began


June/July 2021




ICO Welcomes First Female President by Brooke Herron


ndeed, ophthalmology is a forward-thinking specialty — and one that’s consistently riding the latest wave of innovation. Industry societies like the International Council of Ophthalmology (ICO) have also stepped up. ICO recently elected their first female president in history, Prof. Neeru Gupta, MD, PhD, MBA. Prof. Gupta officially began this role at the start of the year on January 1, 2021. Although the ICO was established nearly 100 years ago, Prof. Gupta is the sole female president.

I'm so pleased to share the news that once again this year, the ICO has been awarded Official Relation status with the World Health Organization,” Prof. shared. “This is an exceptional recognition that speaks to the vital role the ICO continues to play in representing, connecting and working with the world’s ophthalmologists and our international partners.” She also shared that the ICO is set to unveil its future direction: “Over the coming weeks, we will introduce our new strategic plan with a triple aim of priorities — education, membership and advocacy — that will guide our efforts to continue to build and lead a World Alliance for Sight,” continued Prof. Gupta. “I'm grateful to work alongside all of you and look forward to taking the work of the ICO to the next level together.”

“I’m honored to serve as the new president of the ICO," said Prof. Gupta in a press release. "It's a time of unprecedented courage, determination, and innovation as demonstrated by the work of our colleagues around the world.” Throughout her illustrious career, Prof. Gupta has held various roles. She is an internationally renowned ophthalmologist and surgeon-scientist at the Temerty Faculty of Medicine and the Dalla Lana School of Public Health at the University of Toronto in Canada. She is editor-in-chief of the Journal of Glaucoma, the official journal of the World Glaucoma

Association, for which she also serves as president-elect. Prof. Gupta has also dedicated herself to the ICO by holding several leadership roles, including chair of the ICO Advisory Committee, chair of ICO Society Relations and Leadership Development, interim chief executive officer, vice president, and interim president.


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“The ICO is committed to promoting eye health and ophthalmology, and

Prof. Peter Wiedemann, ICO immediate past president, shared his well-wishes for Prof. Gupta’s new leadership role: “Join me in welcoming Neeru to her new role. She is an exceptional and tireless advocate for our members and has been instrumental in expanding our reach over the last several years. We look forward to continuing to work with her as she builds on the ICO’s impressive legacy and advances our mission to improve access to eye care around the world.”


Oertli Introduces New Generation OS 4 Surgery Platform


ertli recently introduced the next generation of their OS 4 surgical platform for retinal, glaucoma, and cataract surgery. The new all-in-one surgical platform provides better speed, precision, and safety than its previous generation.

The fully automated user protection filter provides reliable eye protection during laser treatment. The filter glass is automatically inserted, making laser preparation faster and easier. The filter glass is only active during laser output, allowing consistently clear vision and uncompromised work. It has two Power LED light sources that offer 45% more light output for optimized illumination and visualisation during all maneuvres, extending as far as the periphery. The extended control range from high to low lumens enables increased patient and user safety through reduced phototoxic exposure. At low lumens, the new OS 4 is ideal in combination

with 3D microscopes. The Power LED Plus light source offers free colour selection on the high-quality touch glass screen. The associated highresolution contrast viewing visualises the finest tissue structures. Meanwhile, the high-performance multifunctional pedal navigates surgeons intuitively through all surgical steps. The wide range of pedal assignments, over 100 setting options, allows individual operation. As the endo laser can be controlled via the same pedal, the laser is ready for use without any delay. With the 70% shorter phaco test, surgery preparation is done in record time without compromising safety. The vacuum override function provides a selectable

reinforcement of holdability and optimum use of the occlusion. The voice confirmation offers focused and autonomous working throughout the entire surgery and full control of the settings. Language output is available in five languages: English, French, German, Italian, Spanish. As the inventor of the first dual pump system with Venturi as well as peristaltic pump in one surgical platform, Oertli established itself early as an innovative leader in the field of fluidics. With the unique 3-pump system, peristaltic, Venturi and SPEEP, the new OS 4 covers all applications in retinal, glaucoma and cataract surgery. For more information, visit www.oertli-instruments. com.


OPHTEC Announces New Presbyopia- and AstigmatismCorrecting IOL


PHTEC recently announced its introduction of the new Precizon Presbyopic Toric intraocular lens (IOL), a presbyopia- and astigmatismcorrecting IOL. The new lens is a spin-off of the Precizon Toric and Precizon Presbyopic, which offers patients the good qualities of both models with no limitations.

The Toric is unique because of its TCT (Transitional Conic Toric) optic, designed to tolerate misalignment and the Presbyopic through its

characteristic CTF (Continuous Transitional Focus) segments. CTF provides a smooth transition from far to near, offering a constant defocus between two sharp focal points, delivering excellent near, far and intermediate vision, with low halos and glare. TCT and CTF are unique patented technologies and are both provided by this new lens. “It sounds simple,” said Erik de Haas, Development Leader of OPHTEC’s R&D Department. “But,

that does not mean it is simple from a technical perspective. In terms of optics, it is a unique, advanced technological design. The lens is based on the TCT surface, upon which Precizon Presbyopic’s far/near segments are superimposed,” he continued. With this new advanced IOL design, OPHTEC ensures that patients with astigmatism can also benefit from CTF's Natural Vision. The new Precizon Presbyopic Toric IOL is available from May 2021. For more information, visit www.ophtec. com.


June/July 2021




The IOL Dilemma Educating Patients About Their IOL Options by Sam McCommon

advice given by Dr. Gemmy Cheung, PIE Magazine advisory board member and head of the medical retina department at Singapore National Eye Centre, and echoed by many others. “It is important to understand a patient's individual needs,” Dr. Cheung said. “This would require careful discussion of the patient's occupation, hobbies and daily visual needs. It is important to explain to patients that there is no ‘best’ option, but the goal is to find the most suitable option for the patient’s individual needs.” Though a retinal specialist herself, Dr. Cheung made some good points here. Watch out for pricing traps, too. In the consumer market, “expensive” is often associated with “best quality.” As Dr. Cheung advises, “The most expensive IOL may not always be the best either.” In this case, “best” simply depends on what the patient needs.


e’re going through a golden age of intraocular lenses (IOLs) with more tools, techniques and options available than ever before. That means more choices for doctors and better outcomes for patients — but it also means there’s much more for doctors to consider. Think of it this way — if you went to the shop a few decades ago, your selection of breakfast cereal might have been limited to Corn Flakes or Wheaties. But now that there are multiple varieties of each breakfast cereal — with or without marshmallows, brand name or generic, and so on — it’s hard to blame a person for experiencing a bit of a buyer's dilemma. How the heck do I choose what’s right? How can I be sure I’ll like what I get? If your minutes in the store — and ultimately your dollars — are your “Lucky Charms,” well, the manufacturers are out to get them. For would-be IOL users, the dilemma can be even more confusing and far more important than choosing a breakfast cereal. One can perhaps sympathize with someone who just wants to see and is hit by a barrage


of medical terminology they don’t understand — all about something that goes in their eye. It’s natural for patients to be a bit bewildered by all this information. This, of course, is where an ophthalmologist comes in. It’s an ophthalmologist’s job to help a patient navigate the ever-increasing complexity of IOLs and find the solution that’s right for them. After all, there’s no such thing as a one-size-fits-all IOL since everyone’s eyes and eye conditions are different. Perhaps above all, a doctor needs to fully understand their patient’s needs in order to make sure they get the IOL option that suits them best. That requires a holistic understanding of the patient’s life — not just their eye condition, but their lifestyle, expectations, habits and desires.

Guiding patients to smart IOL decisions The above idea isn’t our own, though we certainly agree with it. That’s the

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For example, someone who spends most of their time reading or dealing with electronic devices will need more near and intermediate vision. If they still need some vision distance as well, a trifocal may be the best option as it covers all three bases relatively well. Ophthalmologists will most likely be aware of IOL abilities, so we needn’t belabor the point of individual IOLs here. But mixing and matching can be its own interesting game that can be custom-tailored to patients for maximum effect.

Mixing and matching: Fun with IOL puzzles Mixing and matching isn’t always necessary, nor should it be the most common practice. Instead, it’s a valuable option in an ophthalmologist’s toolbox. As Dr. Jan Bond Chan, consultant ophthalmologist, cataract and refractive surgeon at International Specialist Eye Centre, Kuala Lumpur, Malaysia, noted in a recent virtual roundtable discussion hosted by CAKE Magazine, mixing and matching becomes an option when a patient isn’t fully satisfied with an IOL in their first eye. If they’re satisfied with their first IOL, why change it?

put it, “It is definitely important to involve patients in the discussion and explain the options upfront. However, as the medical professional in the discussion, we can help direct patients’ decisions by explaining the advantages and disadvantages of the IOL choices.”










Dr. Filip emphasized that doctors should make sure to explain the IOLs effects in a patient’s own language. Most patients don’t care about data points from clinical trials, and their eyes glaze over when they hear more than one acronym in a sentence. Speaking in layman’s terms can really help get your point across.





Essentially, mixing and matching ul allows each eye to specialize in a lo sw ut nt e certain distance of vision while the of i t yo pa ur h brain mixes the picture to produce full our y at is q , n ualit y visio depth of vision. Our brain is a pretty neat thing, and is capable of doing so. Doctors need to counsel their patients on the effects of these IOLs and help them manage their expectations, too. Dr. Andrei Filip, senior ophthalmologist at Ama Optimex Eye Clinic, Bucharest, Romania, also from the same virtual roundtable discussion, had some excellent insight as to that point. First, he jokingly noted that if he had one superpower, it would be to make patients forget they ever had surgery. Because they had the surgery, patients will forever be comparing their vision and thinking about it — rather than just enjoying it. Furthermore, he counseled patients to

not spend time comparing their eyes. Because patients may have different abilities in different eyes, they may find themselves frustrated or less satisfied with one eye than the other. That’s not how vision works, though — we’re born to have binocular vision and our brain is well suited to producing it.

How much should you let patients choose? Patients will always have some input when it comes to a medical procedure — at least, they should. However, it’s usually up to the doctor to help them make the right choice. As Dr. Cheung

Classic marketing techniques suggest you make a person think something is their own idea if you want them to like it. That’s this writer’s addition, not any doctor’s. But that advice is on the house.

Editor’s Note: CAKE Magazine's news roundtable style webinar, The Secrets to Happy Presbyopic Patients, was held on May 10, 2021. Reporting for this story took place during the event.

iCare IC200 200 degrees of positional freedom + Enables IOP measurement when the patient is standing, sitting, elevated or in a supine position + Easy and accurate measurement without calibration or anesthetic drops + Wireless printing and data transfer via Bluetooth



This is where a doctor’s guidance becomes of utmost importance to a patient since the doctor understands what an IOL is fully capable of. A patient may need a monofocal lens to help them with distance and an extended depth-of-field (EDoF) lens to help them with intermediate to distance vision — if their near vision is still solid.

With 200 degrees of positional freedom, iCare IC200 is a perfect tool for professional use in the clinic, eye surgery and emergency rooms.

More information: iCare is a registered trademark of Icare Finland Oy. Centervue S.p.A., Icare Finland Oy and Icare USA, Inc. are parts of Revenio Group and represent the brand iCare.


June/July 2021




Spotlight on 7 Industry Trendsetters Advancing Ophthalmology Through Digital Technologies


t the recent Ophthalmology Innovation Summit (OIS) Digital Innovation Showcase 2021, leading figures from seven trend-setting companies shared how their innovations are changing the industry and how digital technology can improve eye care for everyone.

1. Vivior AG

by Chris Higginson

attaches to the side of a pair of glasses and continually monitors distance, ambient light and color, as well as tracking movement with an attached accelerometer, gyroscope, and magnetometer.

(AI), and provided to the surgeon in the form of intuitive visuals, along with a patient report so that the surgeon can discuss options with the patient during the pre-op planning discussion. This allows the surgeon and patient to decide what kind of solution they should go for, whether it be spectacles, contact lenses, lens implants, surgery or something else based on the patient’s lifestyle.

When the testing period is finished, the data is uploaded to the cloud for analysis, analyzed using artificial intelligence

Mario Stark, CEO of Vivior AG (Zurich, Switzerland), spoke about the Vivior Monitor, which is designed to allow professionals to understand patient needs and visual behavior prior to making decisions about eye health. The monitor

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2. Oculo Connect Kate Taylor, CEO and co-founder of Oculo Connect (Melbourne, Australia), talked about the Oculo platform, which is designed to share clinical correspondence, such as imaging, test results and referrals securely and instantly between health care professionals. The intention is to bridge data silos in health by allowing physicians to share valuable patient information, regardless of location or type of electronic medical record (EMR). Oculo is designed to be a comprehensive tele-ophthalmology platform that centralizes patient medical histories, ocular examination results and clinical imagery, and moves health care decisions from single snapshots in time to a longitudinal, cloud-based, collaborative, and integrated patient care system. It has the ability to share high-quality digital imaging and communications in medicine (DICOM) images securely, do video conferencing — connecting providers with one another as well as the patient, and it even has remote monitoring with tools to objectively and subjectively measure vision and eye health at home.

3. Eyedaptic Jay Cormier, founder and CEO of Eyedaptic (California, USA), shared about how his company is improving the vision of those suffering from retinal disorders, including age-related macular degeneration (AMD) through the development of software-driven smart glasses, leveraging the power of augmented reality (AR) technology. Eyedaptic uses AR to simulate natural vision by capturing the image through cameras mounted on the front of the glasses, processing that image, and presenting it on the display in front of the user’s eyes. By using adaptive systems with image enhancement and pixel remapping, as well as an autonomous user interface (UI) with machine learning, it can adapt to the user — learning what they need and giving the best image possible. The Eyedaptic device does not need to go through clinical trials as it is Food

Clear the runway, new technologies are landing soon.

and Drug Administration (FDA) Class 1 exempt. But in tests, patients were able complete tasks five times better and visual acuity doubled in 75% of patients.

4. 2EyesVision Susanna Marcos, a co-founder of 2EyesVision (Madrid, Spain), spoke about their new product, the SimVis, which is designed to allow patients to experience the real world through multifocal correction before intraocular lens (IOL) implantation or contact lens fitting. It’s a mobile and wearable binocular system that a patient looks through in order to simulate presbyopic correction. Using periodic variations of optical power at high speed, the lens is able to give a static appearance of multifocal retinal images, and finetuning the variations allows SimVis to simulate any lens design. Multifocality is hard to explain and until now, there’s been no way for surgeons to be able to let patients experience IOLs before surgery. Giving patients SimVis to try out multifocal lenses in advance improves patient satisfaction and allows patients to compare different kinds of solutions. In addition, it reduces complaints and refunds and increases profitability by growing multifocal lens prescription.

5. Ocutrx Vision Technologies Linda Lamb, the chief scientific and strategic officer at Ocutrx (California, USA), shared about how her company

has developed the Oculenz AR Headset in order to treat AMD, which results in a scotoma (or a blind spot) in a patient’s vision. AMD is the most common cause of blindness in older Americans, and there are currently no products in the market to treat scotoma. By using visual field tests, the headset creates a map of the extent of the blind spot and sends it to the user’s doctor. Once the extent of the vision loss is ascertained, it tracks the user’s gaze to establish where they are looking, then uses pixel manipulation to allow the patient to see around the blind spot by moving images that are “hidden behind” the scotoma into the functioning part of the visual field. In addition, it uses Dynamic Opacity™ to handle the heightened contrast of indoor and outdoor use.

6. Lumio Health Aakash Agarwal, founder and CEO of Lumio Health (California, USA), discussed how proper medication adherence means patients are much more likely to get better or keep their symptoms under control. However, it can be difficult for patients to maintain their medication schedule. Lumio Health’s MyDrop app is designed to create a solution to medication adherence, starting with eye care. Lumio Health identified four points where adherence can go wrong and developed a solution for each. Receiving — rather than patients waiting until they run out, MyDrop delivers meds to the patients’ door, no pick-up needed. Remembering — the MyDrop app has


June/July 2021



customizable alarms and can handle variable schedules, so medications don’t get forgotten. Administering — MyDrop dispenses a consistent amount with the push of a button. Tracking — MyDrop measures the remaining volume and automatically refills. MyDrop also builds connections between doctors and pharmacies to make the ordering process easier and helps to educate patients about the medication they are taking.

7. Luminopia Scott Xiao, co-founder and CEO of Luminopia (Massachusetts, USA), shared about its new product, Luminopia One, which is a digital therapeutic for amblyopia, a pediatric eye disease that affects 1.8 million children in the U.S. alone. The Luminopia One has done very well in trials and is on track for launch in 2022. Amblyopia (also known as lazy eye) has a global prevalence of 3% and if left untreated can result in permanent sight loss. Current treatments, involving glasses and eye patches, still leave 74% of children with residual amblyopia when the treatment is finished. Luminopia One, on the other hand, is designed to be a treatment that children would actively want to have. Used with commercially available VR headsets, Luminopia displays children’s favorite TV shows, modifying the images in order to encourage weaker eye usage and forcing the brain to combine input from both eyes. This way, treatment becomes fun for the patient, and the stigma of having a patch over one eye is taken away.

Editor’s Note: The OIS Digital Innovation Showcase was held on 20 May 2021. Reporting for this story took place during the event.



How to Best Adapt to the EverChanging Digital World At the same digital event, a panel of industry experts from both the manufacturing and pharmaceutical sides discussed the future of ophthalmology and how best to adapt to the ever-changing digital world. Stephanie Ainscow from Alcon (Geneva, Switzerland), Daniella Ferrara from Genentech Roche (California, USA), Chuck Hess from Bausch & Lomb (New York, USA), Stephane Wolf from Novartis (Basel, Switzerland), and Rajesh Rajpal from Johnson & Johnson Vision (Florida, USA), came together to discuss how digital technologies will affect ophthalmology moving forward. Ainscow began by talking about how the COVID-19 pandemic has accelerated a lot of the trends that were already happening in the eye care sphere, like telehealth and remote monitoring and testing, with more consultations happening online and via video-conferencing. Alcon is developing digital technologies, such as their 3D head’s up microscope (Ngenuity 3D Visualization System), to make remote teaching easier and better, as well as working with IT providers to leverage some of the large amounts of data that are now being generated by the latest technology. Ferrara, whose work at Genentech Roche is directed toward pharmaceuticals rather than devices and durable goods, discussed how digital innovation can help shift eye care from a one-size-fits-all approach to a more individualized form of treatment. By using data and advanced analytics, in combination with AI and remote monitoring tools, she said it will be possible to treat every patient as an individual and create truly personalized healthcare, rather than applying the same cookie-cutter solution to every patient. Due to the fast-moving nature of the digital marketplace, it’s no longer possible for companies to innovate

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slowly and carefully. Rather than the cautious and risk-averse mindset drugs companies have historically had, they will now have to learn to move forward quickly, learning as they go, which is not at all how traditional drug development has gone in the past. The biggest threat for drug manufacturers moving into the future will not be about making mistakes and miscalculations, it will be failing to evolve as the world does. Slow-moving companies will get left behind as the world changes around them. Hess discussed how new pieces of technology are able to produce incredibly large amounts of data, so companies are going to have to understand not only how to get the data, but what to do with it — zooming in on the correct content to allow doctors and surgeons to make the best decisions. Rajpal gave an example of how things are changing in the digital space. With the next generation of femtosecond laser-assisted cataract laser surgery (FLACS), they want to develop a technology to the point where they can take the information from the office and input it directly to the hardware, which will reduce the chance of an error. Then, using AI that has been fed data from thousands of similar operations, plan the operation with the intention of personalizing the procedure for that particular patient. This way of using large quantities of data and direct input to the hardware will reduce the chance of error as much as possible, and increase the chances of getting the best possible outcome. Today, we have access to so much data. For example, Alcon has a database of over two million ocular images, and anyone working in the digital sphere has to find a way of harnessing and getting as much value out of that data as possible. Data and findings must be put together in a meaningful way — driving innovation and ideas and changing how companies interact with patients.

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June/July 2021




Changing the Rules in Glaucoma Management with a Novel Rho-Kinase Inhibitor by Olawale Salami

IOP reduction, respectively, and was generally well-tolerated,” added Dr. Kopczynski.

A novel therapy could change the rules of the game when it comes to glaucoma management.


s revealed at the recent Association for Research in Vision and Ophthalmology (ARVO 2021) Virtual Meeting, there is a new superhero in town. And, suddenly, the rules of intraocular pressure (IOP) management in glaucoma have changed. Netarsudil — a rho-kinase inhibitor that targets the trabecular outflow pathway — has been a gamechanger in reducing elevated IOP in patients with glaucoma or ocular hypertension (OHT).

Netarsudil: Setting new rules in glaucoma management “The clinical studies conducted to date show that netarsudil’s unique mechanism of action provides an equally impressive efficacy profile with several benefits for glaucoma patients.” — Dr. Casey Kopczynski, chief scientific officer at Aerie Pharmaceuticals


According to Dr. Casey Kopczynski, chief scientific officer at Aerie Pharmaceuticals: “Netarsudil represents the first new glaucoma drug class to be approved in the U.S. in over 20 years. In phase 3 trials, once-daily netarsudil demonstrated consistent and sustained IOP lowering, with tolerable ocular safety through 12 months.” Either alone or in a team, netarsudil gets the job done. “In 2019, netarsudil/ latanoprost 0.02%/0.005% fixeddose combination (FDC) received FDA approval for the same indication, becoming the first FDC in the U.S. to contain a prostaglandin analog,” shared Dr. Kopczynski. “In phase 3 trials, once-daily netarsudil/latanoprost FDC demonstrated significantly greater IOP lowering than both latanoprost and netarsudil as monotherapy at all time points over 3 months with tolerable ocular safety through 12 months.” Post-approval, netarsudil continues its trailblazing performance. “In the phase 4 MOST study, a prospective, randomized, multi-center, noncomparator study conducted in a realworld setting, use of netarsudil either as the first addition to prostaglandin therapy, or as a third or fourth addition to existing therapy provided an additional 4.3 and 4.5mmHg

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Dr. Kopczynski explained that netarsudil appears to lower IOP through a dual mechanism of action by reducing the profibrotic activity of rho kinase at the trabecular meshwork while simultaneously reducing episcleral venous pressure. “The clinical studies conducted to date show that netarsudil’s unique mechanism of action provides an equally impressive efficacy profile with several benefits for glaucoma patients,” he concluded.

Unraveling steroid-induced glaucoma “We observed that netarsudil effectively prevented and reversed ocular hypertension after long-term glucocorticoid treatment.” — Professor Daniel Stamer, Duke University A joint adverse event of glucocorticoid usage is ocular hypertension, which leads to vision loss if left untreated. Steroid-induced ocular hypertension is caused by decreased function of the conventional outflow pathway, which has not been specifically targeted therapeutically. Using an established animal model for steroid-induced ocular hypertension, Professor Daniel Stamer and colleagues at Duke University tested an FDA-approved rho-kinase inhibitor, netarsudil, targeting the conventional outflow pathway.

Prof. Stamer explained that their studies showed that early administration of netarsudil stops the fibrotic cycle, which is a critical factor in outflow obstruction in glaucoma. A retrospective study in humans supported findings in mice. Prof. Stamer described the study results. “We found that netarsudil reversed glucocorticoid-induced ocular hypertension in patients whose IOPs were uncontrolled by standard medications,” he shared. “These patients were all on almost three drugs before treatment with netarsudil. Following netarsudil treatment, we found an average of about 8mm reduction in IOP, and all patients’ IOPs are now within the normal range. These data suggest netarsudil is effective at preventing or modifying disease processes in the conventional outflow pathway responsible for steroid-induced ocular hypertension.” They found that netarsudil increases outflow facility in the human eye by increasing the active filtration area in the trabecular pathway. “In addition, morphologic correlations such as expanding the JCT (juxtacanalicular connective tissue) and dilation of the episcleral vein are associated with dynamic filtration area increase,” Prof. Stamer explained.

AHD of netarsudil in normal and glaucomatous patients “Netarsudil impacts both proximal and distal portions of the conventional outflow pathway. Its primary effect is increased outflow facility, but it has a secondary effect related to decreased episcleral venous pressure.” — Dr. Arthur Sit, Mayo Clinic According to Dr. Arthur Sit, professor of ophthalmology at the Mayo Clinic, measurement of aqueous humor dynamics (AHD) can be used to

elucidate the mechanism of action of glaucoma therapies. He described two randomized, controlled trials, which evaluated AHD in healthy subjects and patients with ocular hypertension or glaucoma before treatment and again after seven days of treatment with netarsudil 0.02% drops. “We measured IOP by pneumotonometry and outflow facility by a Schiøtz tomography on methods adopted in the study,” Dr. Sit shared. “In addition, episcleral venous pressure (EVP) was measured using an objective, computercontrolled venomanometer and image analysis software. The aqueous humor flow rate was measured by anterior segment fluorophotometry. Meanwhile, uveoscleral flow rate was calculated using the modified Goldmann equation and the other AHD parameters.” Dr. Sit said that in both healthy subjects and patients with ocular hypertension or glaucoma, the primary mechanism of IOP reduction for netarsudil was an improvement of outflow facility. A secondary effect was reducing EVP, which has not previously been demonstrated with commonly used glaucoma medications in humans. “This suggests that netarsudil acts on the conventional outflow pathway, including the distal outflow system, a unique combination of effects for glaucoma medications,” he explained.

Sick ganglion cells? Rhokinase inhibitors to the rescue Neuronal degeneration in glaucoma and other optic neuropathies lead to irreversible vision loss. But what if we could reverse this damage? What if damaged ganglion cells can be brought back to life? According to Professor Jeffrey Goldberg from the Byers Eye Institute at Stanford University: “The fundamental issue is that there is no retinal ganglion cell regeneration after optic nerve injury. A significant unmet need is to go beyond IOP and identify neuroprotective and regenerative therapies.” Prof. Goldberg presented recent experimental data on the use of rho-kinase inhibition as an approach to support retinal ganglion cell survival and axon growth after optic

nerve injury or degeneration. What is the clinical implication of this? “We can enhance the clinical trial design and study neuroprotection in glaucoma in a way that’s never been done before by studying the protection of sick, but not yet dead retinal ganglion cells,” Prof. Goldberg explained.

“We can enhance the clinical trial design and study neuroprotection in glaucoma in a way that’s never been done before by looking at the protection of sick, but not yet dead, retinal ganglion cells.” — Professor Jeffrey Goldberg, Byers Eye Institute at Stanford University Furthermore, in topical delivery systems, rho-kinase inhibition has been shown to promote axonal survival and regeneration and is a strong candidate for neuroprotection in glaucoma. “In our studies of topical delivery systems, we found that netarsudil increases retinal ganglion cell survival, regeneration and pharmacodynamic molecular response after optic nerve trauma,” Prof. Goldberg highlighted. “I would argue that rho-kinase inhibitors represent very strong candidates for neuroprotection in glaucoma. We have demonstrated that neuroprotection drug candidates can be studied in glaucoma patients by merging therapeutic testing with exploratory biomarker endpoints to cross-validate. The following steps will be to move these exciting drug candidates into human trials,” concluded Prof. Goldberg.

Editor’s Note: The ARVO 2021 Virtual Meeting was held on May 1-7, 2021. Reporting for this story took place during the event.


June/July 2021




APGC 2021 Highlights

What’s cool in glaucoma? by Ankita Umapathy

particularly when they are located at the macula,” Dr. Leung noted. Though the 10-2 and 24-2 test strategies, combined, achieve better structurefunction agreement, they can be tiring for patients. Instead, the relatively new 24-2C VF test includes 10 additional test locations over the central 10 degrees to better capture central VF loss.

OCT for improved diagnostic performance Next, Dr. Leopold Schmetterer from the Singapore Eye Research Institute, demonstrated how anatomical correction of OCT images improved their diagnostic performance, particularly in early glaucoma. Indeed, many reclassifications based on the corrections are due to anatomical particularities rather than RNFL thinning. Although machine learning algorithms could majorly revolutionize glaucoma care, Dr. Schmetterer urges critical analysis of studies that employ these methods. “Ask questions about age-, ethnicity- and gender-matching between control and glaucoma cases. Was the population separated in a training, validation and test dataset? What is the sample size? How good is the ground truth?”


he six speakers in the Hot Topics symposium at the recently held 5th Annual Asia-Pacific Glaucoma Congress continue to push the envelope in glaucoma imaging, diagnosis, surgery, and genetics. We enjoyed hearing about their exploits and how the field was progressing … Here's the inside scoop on what the cool kids are talking about!

Detecting RNFL defects

texture analysis (ROTA) integrated RNFL thickness and reflectance to enhance the optical texture and trajectories of individual axonal fiber bundles. As such, ROTA can detect RNFL defects, which go usually undetected by conventional optical coherence tomography (OCT) imaging or analysis of RNFL/ganglion cell-inner plexiform layer thickness, and provide better clarity on structure-function disagreements.

Kicking off the session, Dr. Christopher Leung from the Chinese University of Hong Kong, illustrated how retinal nerve fiber layer (RNFL) optical

"The structure-function discordance in early glaucoma can be attributed to the fact that test locations of the standard 24-2 visual field (VF) test may not be sufficient to cover focal RNFL defects,


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He demonstrated how algorithms developed and tested on a Singaporean population, for example, can perform very poorly when tested on a Caucasian European population, emphasizing the importance of validating algorithms on external datasets to understand the clinical value of the approach.

LC imaging for differential diagnosis Continuing in the thread of clinical imaging, Dr. Tae Woo Kim from the Seoul National University College of Medicine in South Korea explained how lamina cribrosa (LC) imaging could be used in clinical practice to make differential diagnoses, predict disease progression rate in glaucoma patients or suspects, and identify the pathogenesis of optic nerve damage.

For example, ischemic optic neuropathy may be confused with normal tension glaucoma (NTG) due to RNFL thinning and VF defects; however, the lamina tissue is relatively well preserved in the former. Similarly, although predicting disease progression can be difficult, particularly for patients with similar presentations, a steeply curved LC morphology could be indicative of faster progression, whereas relatively flat LC may imply a stable course. Lastly, Dr. Kim highlighted a study performed in NTG eyes, which showed that patients tended to have a steeply-curved LC when IOP-related stress was a major risk factor. In contrast, when non-IOPrelated factors were predominant, the LC was relatively flat.

The XEN advantage Dr. Michael Coote from Royal Victorian Eye and Ear Hospital, Australia, then showcased 10 XEN implantation videos with tips to optimize implantation. He emphasized the importance of needling the bleb both above and below the tip, with trypan blue dye serving as a good indicator of tip obstruction. The XEN (gel stent implant from Allergan, an AbbVie company) could also be implanted ab externo, particularly if the anterior chamber view were compromised, in acute and complicating circumstances, and

during significant intraocular surgery. Though it is easier to place nasally due to the temporal entrance wound when the conjunctiva is recessed, Dr. Coote suggests avoiding these areas by maneuvering the hand for a more anterior incision. An advantage of the XEN, over trabeculectomies, is that it can more easily traverse areas of anterior scarring, particularly in those eyes that have undergone multiple surgeries. Finally, he demonstrated how the XEN could be placed using a deep sclerotomy and in elderly patients with advanced disease. Given the complications of trabeculectomy caused by antimetabolites, anti-vascular endothelial growth factor (VEGF) agents were re-purposed in their stead; however, we need a better gauge for testing and comparing their efficacies.

The clue in bleb vascularity Dr. Tomasz Zarnowski from the Medical University, Poland, developed a model using ImageJ software to perform morphological analysis of bleb vascularity (i.e., calculating vessel area). In his 2020 study, this approach was used to evaluate the relationship between bleb vascularity and surgical outcomes after mitomycin C-augmented trabeculectomy.

Interestingly, bleb vascularity, during the early postoperative days, was not correlated with IOP or trabeculectomy success rates by the end of the 12-month follow-up. However, bleb vascularity was significantly higher at 1-, 3- and 12-months post-surgery in failed blebs. Therefore, postoperative bleb vascularity may predict trabeculectomy outcomes, potentially serving as a valuable model to assess anti-VEGF efficacy in future studies.

Don’t forget the genome! To close out the symposium, Dr. Tin Aung from the Singapore Eye Research Institute, made a strong case for genome-wide association studies (GWAS) in understanding disease biology and identifying therapy targets. So far, GWAS have provided >20 loci associated with primary open-angle glaucoma (POAG), 8 with angle-closure glaucoma (ACG), and 7 with exfoliation syndrome (XFS). In ACG and XFS, whole exome sequencing has also identified rare genetic mutations, missed by GWAS, which carry higher disease risks. Of the implicated POAG pathways, he singled out lipid metabolism as the most interesting, given the myriad of drugs currently used to reduce cholesterol. Of note, he explained: “Two of the 8 ACG loci may specifically confer greater susceptibility to a narrow angle configuration, with the others, potentially, involved in disease progression or disease severity.” One way to identify possible therapy targets from GWAS analyses may be to consider hits with lower odds ratios — their modulatory roles may be more “druggable” than hits with larger odds ratios, which could be more physiologically significant.

Editor’s Note: The 5th Annual Asia-Pacific Glaucoma Congress (APGC 2021) was held virtually from June 4 to 8, 2021. Reporting for this story took place during the event.


June/July 2021




Let’s Hear it from Experts

Tips and best-kept secrets in anterior segment by Chris Higginson


n the Piping Hot Anterior Segment Topics session of the CAKE & PIE Expo 2021, held on June 18 to 19, four ophthalmologists shared valuable tips and best-kept secrets in treating and managing anterior segment conditions. We cover the highlights below.

Dr. Sheetal Brar on presbyopia management During her presentation, Dr. Sheetal Brar from Nethradhama Eye Hospital in Bangalore, India, focused on how she manages presbyopia in her practice. Previously, Dr. Brar’s clinic used conductive keratoplasty, but they found that this technique had a high rate of regression, with an almost complete reversal in patients after 12-15 months. Today, Dr. Brar uses PRESBYOND® LBV (Carl Zeiss Meditec, Jena, Germany) to treat presbyopia. This therapy uses an increased depth of focus and a micro-monovision protocol where the dominant eye is targeted for


emmetropia, and the non-dominant eye is targeted for myopia of approx. -1.5 D. By correcting the depth of focus of the dominant eye (allowing it to focus nearer) and also correcting the depth of focus the non-dominant eye (allowing it to see distance), this technique creates an intermediate zone between the two eyes, known as a “blended zone”, where both eyes can see well. In addition, because the brain receives two images — one with good near vision and one with good distance vision — the brain is able to merge both images to provide a single, clear image overall.

Dr. George Beiko on managing unusual situations in cataract surgery During his presentation, Dr. George Beiko from the University of Toronto, Canada, shared six tips for managing unusual situations in cataract surgery. For example, to minimize induced

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astigmatism with an internal corneal incision, use a 6 mm L-Shaped scleral pocket incision. This allows for a stable anterior chamber (AC) and controlled wound management — and most importantly, does not cause significant postoperative astigmatism. When making a corneal incision there are three standard procedures: a 6 mm straight incision; a 6 mm frown incision; and a 6 mm inverted V incision — all of which cause around a diopter of astigmatism. However, it’s possible to make an L-shaped scleral pocket incision and avoid the risk of astigmatism. To do this, first, make a 3 mm incision at the limbus, then extend 3 mm to create the first L. Next, dissect into the cornea a further 3 mm, then laterally 6 mm, posteriorly 6 mm and medially 3 mm, creating a large L shape (or a square with one quarter missing). Fortunately, sutures are rarely needed to close this incision as it is fairly selfsealing. The result in closely followed cases showed no induced corneal

astigmatism with this technique. “Besides being safe, it allows for a stable anterior chamber and controlled wound management, as well as no significant induction of postoperative astigmatism,” continued Dr. Beiko. Another tip he covered was how to manage corneal astigmatism in patients with no access to toric intraocular lenses (IOLs). Dr. Beiko shared that corneal astigmatism is prevalent in the cataract population; however, not all patients can afford or have access to toric IOLs. Therefore, there are two strategies to employ depending on the amount of astigmatism. For the smaller amounts, Dr. Beiko recommends using opposite clear corneal incisions, which is a simple and effective technique that can deal with low levels of astigmatism. In patients with larger amounts of corneal astigmatism, he recommends using the Conoid of Sturm and targeting refraction so that the post-op sphere is 0.25 D greater than the cylinder. Using this approach, good distance and near vision can be achieved, with distance vision at 20/50 or better uncorrected. He continued that every year in the U.S. alone, approximately 250,000 radial keratotomy (RK) procedures are done, creating a lot of headaches for surgeons. RK is particularly challenging because it flattens both the anterior and posterior corneal surfaces in the small, central optical zone. Thus, the effective optical zone diameter is significantly smaller than the measurement zone of standard keratometry.

transient central flattening of the cornea and hyperopic error, he continued. Therefore, ophthalmologists should aim for myopic initial postoperative refraction. It’s important to remember that intraoperative aberrometry is not helpful, to use monofocal IOLs, and to do the non-dominant eye first, then adjust the dominant eye, depending on the outcome. In summary, use IOLmaster K’s (Alcon, Geneva, Switzerland) and enter the value into “average central power” on the ASCRS calculator. Target myopia should be based on the number of incisions and allow one week per incision for refractive stability — and be prepared for subsequent surgeries. Further, Dr. Beiko shared a quick way to extend the measurement range of manual keratometers. Simply tape a trial lens sphere in front of the aperture. By placing a +1.25 D sphere in front, the range can be increased from 52 to 59 — and by placing a –1 D sphere in front, we can increase the range from 36 to 31. Easy! “Occasionally we have patients who make it difficult to measure their K’s,” said Dr. Beiko. In order to deal with this problem, Dr. Beiko has created a formula using a mixture of population averages and measurements from the patient: 43.5 (the average pop K) – patient’s true refraction pre-cataract + measured axial length = patient’s keratotomy estimation. When Dr. Beiko checked his calculations, he found that in 75% of cases the calculated cases were within 2 D of measured K.

However, none of the standard calculations and formulas for RK is perfect, as they all involve taking averages from measurements surgeons are able to take. Dr. Beiko said that the OCT-based formula and True K were comparable to the Double-K Holladay 1 method on the ASCRS calculator, so all three can be used — although no formula was able to predict 80% of eyes within 1 D of target refraction at more than 3 months postoperatively.

Thanks to a recent study, we know that the keratoconus induces steeper corneas which create a greater hyperopic effect, so we need to target more myopia. For example, in a patient with a K of 53, we may need to target between 2.5 and 3 D of myopia in order to have a good outcome.

We should bear in mind that RK incisions tend to swell even after the gentlest of phaco surgeries; this causes

Dr. Harvey Uy, medical director at Peregrine Eye and Laser Institute in Makati, Philippines, spoke about the

Dr. Harvey Uy on exchanging IOLs

role of modular and exchangeable IOLs. He said that an IOL is needed that allows us to exchange the optic at any time after the primary procedure. This allows surgeons to correct premium IOL optic intolerance, visual disturbance or areas of refraction. The concept is a multi-piece design, where the refractive element can be exchanged for another with the correct power, or to a monofocal or multifocal lens, if necessary. By using an IOL with an exchangeable base, the lens can be swapped without removing the base component and therefore maintaining the same effective lens position.

Dr. Sahil Thakur on the importance of keeping a glaucoma diary Dr. Sahil Thakur from the Singapore Eye Research Institute (SERI) shared how glaucoma diaries can improve drug compliance and patient outcomes. He said that a physical glaucoma diary is a low-tech solution to recording glaucoma problems, treatment and medication, and often works well in the developing world where patients don’t always have access to a computer. Useful information, like a log, patient and physician information, as well as FAQs, and a guide to administer eye drops should be included; there are versions for both children and adults, as well. There is also an online diary, which has all the functions of a physical diary, but also includes prompts for appointments, informative videos that increase compliance, as well as links to more information.

Editor’s Note: A version of this article was first published in CAKE & PIE POST, C&PE Edition. The CAKE & PIE Expo 2021 was LIVE on June 1819. All sessions are available free on demand until July 19 at expo. upon login.


June/July 2021







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