CAKE Issue 11: The ebook version (The History Issue)

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A Revolution in Refractive Surgery P16

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History Repeating?

even then, nowhere near the 20D ablations of the past. Proper patient selection has been added into the equation too. The lasers themselves have gotten better: eye trackers, the move away from suction interfaces, better laser ablation algorithms, faster scanning patterns — everything has been engineered to almost eliminate any potential source of problems. In a suitable candidate patient, surgeons who know what they’re doing with an excimer laser can really pull off miracles. Excimer-based refractive surgery has never been safer, nor the outcomes better.

What can the past of refractive surgery tell us about the future?


h, the modern era of refractive surgery has come a long way since Barraquer was reshaping corneas with blades back in Bogotá in the late ‘50s and ‘60s and Fyodorov was performing radial keratotomies (the Russian way) in the 1970s. But then the excimer laser was born in the 1980s and everything changed. It offered a way of ablating organic tissues without causing too much in the way of thermal damage. And it meant that surgeons now had a super precise tool with which they could sculpt the cornea and correct refractive error at the touch of a button — and the pace of scientific development and clinical discovery was ferocious. Surgeons learned a few things along the way, like "how much ablation is too much?" and "oh no, some corneas are weaker than others." It’s incredible to look back and see pictures of laser ablation patterns being “painted” into a computer by hand, and the relatively primitive state of corneal topography. I mean, you hear "back in the day" stories of high myopes receiving corrections in the order of 20 diopters, and stories of revision surgery after decentered ablations where parts of the cornea were being masked with small pieces of metal held in place with tweezers. As is often the case, being a pioneer (whether it’s doctor or patient) can bring great rewards, but there’s always some level of risk. But my point is this: Now, the risks have almost entirely been engineered out of the system. Today, I’d hope that no surgeon offers laser refractive surgery to people with thin corneas — corneal topography/ tomography is de rigueur. Only the most experienced surgeons would even consider performing high ablations — only after exhaustive investigations, and

Then there are the femtosecond lasers. Their contribution to reshaping the cornea started with arcuate incisions and making LASIK flaps, and after a slow start, they’re now coming into their element in refractive surgery. Rather than ablate the stroma, they cut a lenticule from it, and the surgeon removes it from a small side port. The stroma above it sinks, and boom, the cornea is reshaped! Complications are rare, and most are to do with incomplete removal of the lenticule. Claims of biomechanical superiority over LASIK are warranted (although not over PRK — both procedures weaken the cornea to a similar extent). There’s also probably at least a short-term benefit in dry eyes compared with the excimer-based procedures, thanks to the fact that fewer corneal nerves are severed in small lenticule extraction procedures than LASIK or PRK — although for ultimate best visual outcomes, my feeling is the excimer laser still reigns. Is it enough for you to trade in your excimer? If I was a refractive surgeon, and I had already invested in an excimer laser, probably not. But if I was buying a laser for the first time? It's a possibility. And if I also did femtosecond laser-assisted cataract surgery, and the device could be used in both procedures … that could be a very tempting proposition. But the thing about reshaping the cornea is that it is surgery. Patients need to follow a post-surgical eye drop regimen (and frankly, many should follow a pre-surgery regimen to ensure

they don’t have dry eyes at the time of the procedure). Unfortunately, some patients don’t. Although most of the risks have been engineered out, surgery always carries risks. What interests me for the future is something called LIRIC (laser-induced refractive correction), which uses a 2-photon femtosecond laser to reshape the stroma. Rather than causing tissue ablation, it alters the density of stromal fibrils, at laser pulse intensities that are 2-3 orders of magnitude lower than those required to make a LASIK flap. This reduces the risk of inducing inflammation or wound healing responses. Rather than reshaping the cornea, the surgeon draws on a diffractive optical pattern much like you find in multifocal IOLs to alter the refractive properties of the cornea and correct the patients’ vision. The laser can also be used to draw similar patterns in IOLs as well, raising the possibility of “touch-ups” of lenses after surgery. Might this be the future of refractive surgery? Perhaps history has a lesson for us. Thermokeratoplasty never caught on, simply because as the years passed, the refractive, corneal reshaping effects of the heat treatment regressed. The average lifespan of the corneal stroma is six to eight years before it is entirely replaced (just like the rest of your body). Then again, if scars are permanent, then why not the refractive pattern? And if the procedure is a "light touch" one, even if the effects did start to dissolve away, would it be such a big deal to repeat it? Who knows? It's going to be fascinating to find out.

Mark Hillen


Dr. Mark Hillen

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


Sept/Oct 2021




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The Sequential Dilemma Is the jury still out for same day cataract surgery? Dry Eye Disease in Cataract Surgery Treat DED First

Anterior Segment


When Crossovers Occur Retina Essentials for the Anterior Segment Surgeon


Good News, Everyone! Talking IOLs with Dr. Mitchell Jackson

Matt Young CEO & Publisher

Hannah Nguyen COO & CFO


Selective Laser Trabeculoplasty A Safe and Effective First-line Therapy for Glaucoma

Robert Anderson Media Director

Gloria D. Gamat Chief Editor

Cover Story

Brooke Herron


Editor The History of Laser Vision Correction A Revolution in Refractive Surgery

Mark Hillen Editor-At-Large International Business Development

Ruchi Mahajan Ranga Brandon Winkeler Writers




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WIO: New Book Sheds Light on the Important Role of Women in Ophthalmology Coming Soon! The Next Big Things in Ophthalmic Innovation

The Impact of the COVID-19 Pandemic on Ophthalmology Residents Are You an Ophthalmology Influencer?

Andrew Sweeney April Ingram Corrina Lindkvist Jillian Webster Joanna Lee Joe Schreiber Nick Eustice Sam McCommon Maricel Salvador

30 Building a Successful Refractive Surgery: Targets Acquired

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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


Sept/Oct 2021




The Sequential Dilemma Is the Jury Still Out for Same Day Cataract Surgery? by April Ingram

procedures on the same day, but treating them as unique and isolated surgeries, may minimize the risk of complications. This means completely isolating the first eye from the second — including new gloves, gowns and drapes. This also goes as far as having different surgical staff and instruments from another sterilization batch, and drugs and materials from different manufacturers or batches. Many would argue these measures are excessive. Beyond the risk of complications, visual outcomes may not be optimized when bilateral procedures are performed on the same day. Ophthalmologists are now spoiled by choice when it comes to selecting IOLs, basing these choices on the patient preferences and lifestyle needs. This also comes with greater opportunity for patients to be dissatisfied with their outcomes, or experience undesirable dysphotopsia, particularly with diffractive optic IOLs. When only one IOL is delivered and the patient is unhappy, doctors still have the opportunity to consider a different IOL or alter the surgical approach. But if both have been done, that chance to adjust disappears. Is the patient with refractive surprises or bilateral symptomatic dysphotopsia twice as upset with their surgeon? Maybe.

And the benefits


t wasn’t very long ago that performing bilateral, same day cataract surgery was almost unheard of — or even considered reckless. More recently, the practice has become far more common, seeing an acceleration of acceptance during the last couple years with COVID-19. More surgeons are offering immediate sequential bilateral cataract surgery in order to meet COVID-19 health restrictions, as well as to minimize office and hospital visits and reduce the opportunity for nonessential exposure.

The risks bilateral, same day surgery This “one and done” technique sounds


like the ultimate in convenience for the patient — and there must be some economic benefit. So, what would be the argument against it? Well, the primary argument for maintaining same day surgery as the exception rather than the rule, is the small, yet potentially devastating, risk of bilateral blindness due to surgical complications. Although rare, cases of bilateral endophthalmitis following same day cataract surgery have been reported in the literature. Allowing for a period of time between surgeries would permit for management and resolution of any complications that arose in the first eye, and there would be a lower risk than both the eyes being involved. It has been suggested that performing

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That said, there seems to be a paradigm shift and bilateral same-day cataract surgery is becoming more the standard practice. Aside from patient convenience, healthcare providers have jumped on board as a result of the cost savings. In the United States, if both eyes are done the same day, the second eye is only paid at 50% of the first. A cost-saving for health insurance, but a financial hit for surgeons and surgical centers. What do the studies tell us? Neal H. Shorstein, MD, an ophthalmologist and researcher with Kaiser Permanente in California, has conducted several studies that compare the effectiveness and safety of immediate sequential versus delayed sequential bilateral cataract surgery in thousands of eyes. Dr. Shorstein said: “Our studies of bilateral same day cataract surgery at Kaiser Permanente have shown that it

is a safe and effective way to efficiently treat vision loss due to cataracts. Many of our patients appreciate the savings in time and money that same day surgery offers, with no trade-off in safety or in visual or refractive outcomes.”

“We did not find any statistically significant difference in the rate of postoperative endophthalmitis in patients who underwent immediately sequential and delayed sequential bilateral cataract surgery or unilateral cataract surgery.” — Cecilia S. Lee, MD, MS, Klorfine Family Endowed Chair, Associate Professor of Ophthalmology, University of Washington, Seattle

The American Academy of Ophthalmology Intelligent Research in Sight (IRIS) Registry is the first comprehensive eye disease clinical registry in the United States. It contains a wealth of data, including details from more than five million cataract surgeries. Cecilia S. Lee, MD, MS, is the Klorfine Family Endowed Chair and associate professor of ophthalmology at the University of Washington in Seattle. She and her colleagues analyzed data from the IRIS Registry, comparing the rate of postoperative endophthalmitis after immediate sequential (same day) and delayed sequential bilateral cataract surgery. The rate of endophthalmitis for those patients who had surgery on both eyes on the same day was 0.059%, which was very similar to those who had surgery on separate days (0.056%). There were seven cases of bilateral endophthalmitis — interestingly, all of which were in the delayed sequential group. Although this was a very large sample, bilateral endophthalmitis was extremely rare, and same day surgery is less commonly performed, so the lack of bilateral endophthalmitis in the same

day group may have been related to sample size. Dr. Lee shared: “We did not find any statistically significant difference in the rate of postoperative endophthalmitis in patients who underwent immediately sequential and delayed sequential bilateral cataract surgery or unilateral cataract surgery.” This was true even when they controlled for co-variates such as age, sex, race, insurance factors and other eye disease. So, has “big data” fully answered the question? Dr. Lee explained: “Big data studies have many limitations and caveats. But this is an example where big data studies can make a meaningful difference in our clinical practice. We would not have been able to study rare conditions such as postoperative endophthalmitis without big data. “Even though our study was the largest study that compared the rate of endophthalmitis between immediately sequential and delayed sequential bilateral cataract surgery to our best knowledge, we still had a much lower number of ISBCS (immediately sequential bilateral cataract surgery). Future studies that include more cases of ISBCS will be helpful,” added Dr. Lee.

Other factors to consider It would appear that the risk of endophthalmitis does not seem to be a significant consideration when deciding whether to have same day surgery versus delayed bilateral cataract surgery for most patients. However, beyond endophthalmitis, there remains many other factors to consider, including IOL performance and visual outcomes; comorbid conditions that may prohibit multiple surgeries for the patient; surgical flow and reimbursement. This means that the decision for or against same day bilateral cataract surgery needs to be a well-informed personal discussion between the patient and the surgeon. Dr. Lee agreed, noting that “the decision to proceed with ISBCS is primarily surgeon and patientdependent and likely involves many factors. I think it is helpful to know

that our study, the largest of its kind so far, did not find the rate of endophthalmitis as a major concern for either approach, which is especially helpful in the current setting of COVID-19 pandemic.”

Contributing Doctors Cecilia S. Lee, MD, MS, is the Klorfine Family Endowed Chair and associate professor of ophthalmology at the University of Washington, Seattle. Dr. Lee is a medical retina/uveitis specialist and serves as the director of Clinical Research at the Department of Ophthalmology. Dr. Lee is a clinicianscientist, and her research interests include big data, clinical epidemiology, retinal biomarkers of Alzheimer’s disease, and ophthalmic imaging. She is an active member of the American Academy of Ophthalmology IRIS® Registry Analytic Center Consortium. Dr. Lee has several NIH funded grants and is extensively published. Dr. Lee serves on the Editorial Board of the American Journal of Ophthalmology, Ophthalmology Science, the American Academy of Ophthalmology's Eyenet and Journal of Alzheimer’s Disease. Neal H. Shorstein, MD, has been in practice as an ophthalmologist and researcher with Kaiser Permanente (KP) since 1992. In addition to attending his ophthalmology clinic, he also serves as associate chief of quality for the Diablo Service Area. Dr. Shorstein has also been actively involved in KP research in the past three years, publishing papers related to cataract surgery. He was awarded a Morris Cullen award from his medical group of 8,000 physicians for his intracameral antibiotic paper. He presented the work at the annual conference for the American Academy of Ophthalmology in 2013 as one of the year’s best papers in cataract surgery. He serves on the American Society of Cataract and Refractive Surgery Cataract Clinical Committee. He has volunteered with Seva foundation since 2005, teaching phacoemulsification to ophthalmologists in Nepal, Tibet and China, and currently sits on Seva’s Board of Directors. In 2011, Seva awarded Dr. Shorstein the Lifetime of Service Award for the foundation.


Sept/Oct 2021




Dry Eye Disease in Cataract Surgery Treat DED First

by Sam McCommon

DED — will enhance postoperative outcomes for cataract surgeries as well as refractive surgeries. However, DED is a complicated, multifactorial condition, and what causes DED in one patient may not in another. So how should doctors proceed? A good start is taking a look at two of the main causes of DED and treating them before surgery begins: meibomian gland dysfunction and blepharitis.

Meibomian gland dysfunction: Meib-oh no! One good place to start is to suss out whether or not a patient has meibomian gland dysfunction (MGD) and begin treatment. MGD is the leading cause of DED — and, fortunately, treatments are becoming more widely available every year.

Our friend Dr. Laura Periman, founder of Periman Eye Institute in Seattle, Washington, has a great mnemonic acronym to help remember what supports MGD: BEISTO. In order, that stands for:

1. Bugs: bacteria, demodex 2. Enzymes: lipases, esterases, transferases, cytokine effects, and more

3. Inflammation 4. Stasis of meibum 5. Temperature: increased


any people are shocked by the number of patients scheduled for cataract surgery who present with dry eye disease. Why are they shocked? Well, it’s simple: That number is very high. According to a study by none other than our good friend Dr. William Trattler (and colleagues), some 87% of patients set to get cataract surgery are diagnosed with dry eye disease (DED).¹ As was noted in a panel discussion on treatment options for presbyopia by


melting temp of meibum CAKE magazine in May 2021, DED can significantly impact all sorts of other treatments. For one thing, DED can throw off biometry, giving poor readings. In the case of laser refractive surgery, this can lead to inaccurate refractive results. But what about cataract surgery? Cataract surgery can lead to an increased rate of DED in patients, so diagnosing and treating DED before surgery seems to be a solid bet. Treating ocular surface disorders — notably

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6. Obstruction/hyperkeratinization

But first let’s take a brief look at just why we should treat MGD besides DED. As Dr. Brandon D. Ayres of Willis Eye Hospital pointed out at ASCRS 2021, MGD impacts quality of vision, including increased ocular symptoms of dry eye and increased ocular surface staining. In short, MGD leads to lower

tear film quality, which leads to DED. MGD and DED often exist in a vicious circle relationship, with one worsening the other. Fortunately, treatments for MGD exist, some of which are quite simple. Antibiotics can play a role in treating MGD. For example, both doxycycline and topical azithromycin have both been shown to help with MGD, and topical azithromycin in addition to systemic may have additional benefits. However, the effectiveness of oral antibiotic usage overall is inconclusive in many studies. There are plenty of other treatments as well. Delivering heat to the eyelids — at around 45-45.5 Celsius — appears to be an effective and simple treatment to help reduce the symptoms of MGD.² Many devices are available on the market to deliver such heat. As CAKE magazine has previously reported, there is also an immunologic bridge between allergic conjunctivitis and MGD, as explained by Dr. Periman. Low-level allergies that lead to MGD and DED can be treated with topical anti-allergy or anti-inflammatory eye drops, like Zerviate (Eyevance, Fort Worth, Texas, USA) or FLAREX (also Eyevance).

Multiple devices exist to help treat MGD. These include: • Lipiflow® (Johnson & Johnson Vision, Jacksonville, Florida, USA) • TearCare® (Sight Sciences, Menlo Park, California, USA) • Intense pulsed light (IPL) • The Maskin Probe® (Katena, Parsnippany, New Jersey, USA) • Blephex® (Scope Ophthalmics, Crawley, U.K.) • MiBo ThermoFlo® (MiBo Medical, Dallas, Texas, USA)

Eighty-seven percent of patients set to to get cataract surgery are diagnosed with dry eye disease (DED)

We’d love to do a full breakdown on all of these devices, but those will have to be saved for another time. When imaging meibomian glands, look for duct dilation, gland constipation, curling and shortening, hazy appearance, and dropout. Sharing these images with patients can help encourage at-home treatment adherence with some of the devices mentioned above.

Blepharitis: it’s an ugly word, and an ugly condition Blepharitis symptoms often overlap with DED. Indeed, both play a significant role in ocular surface disorder that can have effects on surgical outcomes. One major cause of blepharitis is an infestation of Demodex folliculorum mites. Some 45% of blepharitis cases are caused by these mites, the infestation of which is also positively correlated with increasing age. For now, there is no treatment for Demodex, but one is in the pipeline: TP-03, an eyedrop treatment from Tarsus Pharmaceuticals (Irvine, California, USA). Watch for the FDA approval of this treatment, which began phase 3 trials in Q2 of 2021.

Overall goals for DED in cataract surgery Overall, ophthalmologists should seek to minimize the effects of DED before beginning either cataract or

refractive surgery to maximize the odds of a positive outcome. This includes addressing MGD, increasing tear production and controlling inflammation. Starting with questionnaires like the Ocular Surface Disease Index (OSDI) and Standard Patient Evaluation of Eye Dryness (SPEED) will catch some DED patients before surgery, but not all. Checking for MGD and blepharitis will help catch some others, leading to potentially improved outcomes postsurgery. That’s what this is all about anyway, isn’t it?


Trattler WB, Majmudar PA, Donnenfeld ED, McDonald MB, Stonecipher KG, Goldberg DF. The Prospective Health Assessment of Cataract Patients' Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430.


Borchman D. The optimum temperature for the heat therapy for meibomian gland dysfunction. Ocul Surf. 2019;17(2):360-364.

Editor’s Note: The annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS 2021) was held in Las Vegas, Nevada from July 23-27. Reporting for this story took place during the event.


Sept/Oct 2021




When Crossovers Occur Retina Essentials for the Anterior Segment Surgeon by Brooke Herron


lthough the anterior and posterior segments are two distinct entities, crossover events can occur. And while a cataract surgeon may not necessarily need to know the finer details of macular surgery, for example, there are a few retina “essentials” that can prove invaluable for those operating in the anterior. Some of these tips were highlighted by retina experts during a session at the recent annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS 2021)...

include posterior vitreous separation, pigmented cells from a retinal tear or detachment, among others.

On behalf of Dr. William Mieler from the University of Chicago (Illinois), Dr. Christina Weng shared his tips for managing those pesky vitreous floaters. First? Make sure to rule out diagnostics that may “produce” floaters; these can

Other than observation, surgical options for floaters include Nd:YAG vitreolysis and pars plana vitrectomy (PPV). However, data shows these procedures are not always efficacious — or worth the surgical risk. Recently, Katsanos (2020) revealed that Nd:YAG was only minimally effective at improving floaters. Meanwhile, Mason (2014) showed that 94% of patients deemed 25-gauge PPV a “complete success,” although complications can occur with vitrectomy. Importantly, Dr. Mieler noted that “a significant percentage of patients who seek PPV for floaters may have differing psychological profiles with unrealistic expectations … and they may be dissatisfied with the outcome of their surgery — especially with Nd: YAG vitreolysis.”


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Managing vitreous floaters

Posterior capsule rupture during cataract surgery Nowadays, cataract surgery is commonplace and a routine surgery for many ophthalmologists. However, there are times when complications transform a routine surgery into a more difficult one — and nowhere in ophthalmology is this “routine” more disrupted than with vitreous loss during phaco, said Dr. Keith Warren, founder of Warren Retina Associates (Overland Park, Kansas).

“Nowadays, cataract surgery is commonplace and a routine surgery for many ophthalmologists. However, there are times when complications transform a routine surgery into a more difficult one — and nowhere in ophthalmology is this 'routine' more disrupted than with vitreous loss during phaco.” — Dr. Keith Warren, founder of Warren Retina Associates, Kansas

Although this complication is unexpected, he said that with the right mental preparation and tools it can be managed effectively — and that despite vitreous loss, many patients can still expect good vision following surgery. To manage the vitreous, Dr. Warren covered some of the crucial steps. First, use viscoelastic to posteriorly displace the vitreous from the phaco tip — and then take a deep breath, inspect the anterior chamber (AC) and plan your approach. He continued that lens fragments can be “compartmentalized” anteriorly with viscoelastic and larger fragments can be removed with a lens loop. It’s also important to thoroughly clean the vitreous from the AC. And all easily accessible lens fragments should be removed and the angle and sulcus should be checked for retained fragments, he continued. Surgeons should also refer these patients to a retina specialist 1-2 weeks postoperatively. He also mentioned some big don’ts as well, which are worth mentioning here. These include: don’t cut what you can’t see; don’t withdraw the cutter without cutting; don’t follow lens fragments into the posterior segment; don’t cut the nucleus fragment with the cutter; don’t hydrate excessively — and finally, don’t try to be a hero.

Combining cataract and vitreoretinal surgery During her presentation, Dr. Christina Weng, associate professor of ophthalmology at Baylor College of Medicine (Houston, Texas), covered some of the important advantages and disadvantages of combined versus sequential phaco-vitrectomy surgery. Some of the major benefits are that it spares the patient from additional surgery; it can improve visualization for the retina surgeon; it provides greater eventual postoperative visual improvement and can help mitigate post-phaco floaters; there is a unidirectional visual improvement trajectory; it’s more cost-effective; and the higher complication rate of phaco in post-PPV eyes is avoided. Of course, combining these two

procedures has some drawbacks as well, such as: a slower recovery with more postoperative inflammation; visualization (for either surgeon) can be worsened; it violates the anteriorposterior barrier and can lead to IOL displacement if a tamponade is used; refractive outcomes are less predictable; reimbursement may be reduced for one co-surgeon; and finally, it can be logistically difficult to perform. Dr. Weng also shared her pre-, intraand postoperative pearls — but unfortunately, we don’t have the space to cover them all here. Instead, make sure to check out her on-demand presentation available on the ASCRS 2021 platform.

Vitreoretinal considerations in glaucoma management Sight-threatening complications in glaucoma management can require vitreoretinal intervention, began Dr. Basil Williams, from the University of Cincinnati (Ohio). He added that there can also be an increase in IOP following vitreoretinal surgery. During his presentation, he shared how anterior and posterior segment surgeons can work together to alleviate complications that arise. “Neovascular glaucoma is the first thing we think of from the retinal specialist’s perspective. We’re trying to give them anti-VEGF very early on and give them as much PRP as possible. Additionally, there are times where there is vitreous hemorrhage and it’s hard to see the posterior segment." “There are also situations where the tube needs to be placed in the pars plana and in these scenarios, we join in the operating room with the glaucoma specialist,” continued Dr. Williams, adding that it’s very important to make sure that all of the vitreous is removed and that there is no vitreous where the tube is going to be placed — this ensures that in future, vitreous does not clog the tube. “Aqueous misdirection is another scenario where vitreoretinal surgeons can help out … this happens when the aqueous goes behind the anterior

hyaloid surface and pushes the iris lens diaphragm forward and rotates the ciliary processes,” he explained.

“Neovascular glaucoma is the first thing we think of from the retinal specialist’s perspective. We’re trying to give them anti-VEGF very early on and give them as much PRP as possible. Additionally, there are times where there is vitreous hemorrhage and it’s hard to see the posterior segment." — Dr. Christina Weng, Associate Professor of Ophthalmology, Baylor College of Medicine, Texas Usually by the time a retinal specialist encounters such a case, Dr. Williams said that topical medications have already been tried. “The first thing you want to do from a surgical perspective, is to deepen the chamber — but when there’s a lot of posterior pressure, that can be pretty challenging to do,” he shared, before further describing the surgical process. These special considerations (and many more than space allows for here) were covered in depth — so make sure to check out Retina Essentials for the Anterior Segment Surgeon from ASCRS 2021 to learn more about managing these crossover complications.

Editor’s Note: The annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS 2021) was held in Las Vegas, Nevada from July 23-27. Reporting for this story took place during the event.


Sept/Oct 2021




Good News, Everyone!

Talking IOLs with Dr. Mitchell Jackson by Sam McCommon


he world of intraocular lenses (IOLs) has gone through extensive changes over the last several years. The term “change” itself is often a loaded term, as it doesn’t necessarily indicate positive or negative trends. However, the trends in the IOL sector have been overwhelmingly positive — especially in the last year-and-a-half in the U.S., for example. To get a better grasp on the current state and trajectory of IOLs, we spoke with Dr. Mitchell Jackson, a boardcertified ophthalmologist specializing in cataract and refractive surgery in Chicago, Illinois. Dr. Jackson is the founder and medical director of the aptly named Jacksoneye, and is also a clinical assistant at the University of Chicago hospitals. Dr. Jackson helped us understand how the IOL scene has changed recently, his criteria for determining which lens is right for a patient, and some insightful, uh … insights into IOL use, in general.

doing things now,” said Dr. Jackson in reference to recent IOL approvals in the U.S. The U.S. lagged behind the EU for many years in IOL availability, but the last few years have witnessed an explosion of new lenses available to U.S. practitioners and patients. These include AcrySof® PanOptix® trifocal and Vivity® extended depth of focus (EDoF) lenses (Alcon, Geneva, Switzerland), Tecnis® Synergy® multifocal (Johnson & Johnson Vision, Jacksonville, Florida, USA), Tecnis® Eyhance® (Johnson & Johnson Vision), and Tecnis® Symfony® (Abbott Medical Optics, Santa Ana, California, USA) — just for some examples. As Dr. Jackson noted, the U.S. is mostly caught up to the rest of the world now. Between all these lenses, a practitioner now has plenty of options for good coverage of the whole spectrum of lens needs.

“Everybody’s liking how the FDA is

What are the implications of all these new lenses? As Dr. Jackson told us, ophthalmologists don’t have to work as hard to find the right IOL for patients as they used to. Whereas mixing and matching used to be common, it’s not entirely necessary now. Having a


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A wave of approvals

broad spectrum of lenses helps match patients and their needs to the IOL that’s best for them. But how do you determine what’s right for a patient?

The IOL spectrum: Objective and subjective criteria and side effects Dr. Jackson uses a mental map of a left-right spectrum for IOLs. On the left are the safe play options with minimal side effect profile, and with less broad spectrum coverage. The further right you go, the more the lenses cover presbyopia and give a broad range of correction — but the more side effects there are, like glare, halo and starburst. On the far left of Dr. Jackson’s spectrum are monofocals like EnVista (Bausch + Lomb, Rochester, New York) — a zero-aberration aspherical lens with a little bit of EDoF. Continuing right he places Eyhance, Vivity, then Symfony, then Panoptix, and then Synergy. To determine just which lenses are correct for the given situation, though,

he starts by looking at objective data. If there’s a clean macula, no keratoconus, no corneal scarring, no prior LASIK or refractive keratoplasty (RK), then an ophthalmologist has a clean slate to work with. Any limiting factor will, well, limit choices. Dr. Jackson doesn’t like using any IOLs to the right of Vivity on his scale for patients with comorbidities, but will tolerate a little macular pathology up to Vivity. Once objective data has been collected, Dr. Jackson has patients fill out a thorough lifestyle questionnaire that helps determine which direction to go with IOLs. How important is it to the patient to be without glasses? How much time do they spend reading? How much do they need to drive at night? Dr. Jackson suggested that patients who like to read a lot and don’t have to drive at night will do well with Synergy lenses; those looking for more focus on intermediate vision may want to consider Vivity. But again, with all the individual variations and lenses available on the market, it’s down to matching the right patient with the right lens.

Light-adjustable lenses: The secret lens in the back pocket One of the secret weapons (well, not secret anymore) in Dr. Jackson’s IOL arsenal are light-adjustable lenses (LALs). He noted that he’s using these more and more for the “perfectionist personalities” he encounters — patients who expect everything to be just right. Light-adjustable lenses allow postoperative titrations in IOL power after the eye has healed, essentially allowing for customized IOLs based on patient experience. In this case, we’re talking about the RxSight Light Adjustable Lens and Light Delivery Device, approved by the FDA in 2017. Dr. Jackson told us that a doctor can perform about three to five adjustments with these lenses, with each treatment only taking 90-120 seconds. Doctors will see a patient anywhere between 3-7 days apart to dial in the adjustments — for example, these lenses can be used to treat up to about 3 diopters of astigmatism.

Managing expectations: You’ve got to be a psychologist, too?! Like in any medical field, a doctor has to set a patient’s expectations for the outcome of their procedure. Dr. Jackson has some valuable tips in this regard, which some parents may recognize. For example, he only offers two options to his patients: basic, insurancecovered IOL treatment that won’t free the patient from glasses — or the premium, “forever young” treatment. There’s no menu to choose from to overwhelm the patient like a shopper in the cereal aisle of a grocery store: either “legal to drive” or “forever young.” He also doesn’t tell patients what lens he’s using, as that may overload them with information. At the end of the day, a patient simply wants to see — most of them don’t really care how, and don’t have the expertise needed to make the right decision for themselves. That’s why we have eye specialists, after all. That’s this writer’s opinion, though it’s likely widely shared. Additionally, Dr. Jackson noted, some patients simply don’t qualify for an IOL. As he explained, “I spend a lot of time talking people out of options.” A patient with bad keratoconus, for example, wouldn’t qualify for any IOL options, nor would a patient with more advanced macular disease. A doctor that performed an IOL procedure would simply be taking their money while not improving their lives.

Solid progress Overall, our conversation with Dr. Jackson showed some overwhelmingly positive developments in the IOL world. Doctors have more options than ever, and can treat patients with increasingly customizable options. That’s good news.

in the near future — like the ongoing COVID-19 pandemic — ophthalmology is healing quickly. It’s not all over yet, though. Dr. Jackson mentioned that there was still a lot of concern over safety for his patients, especially those not vaccinated. If history has shown us anything, however, it’s that many of humanity’s best and brightest are in the medical field, and we’re happy to put Dr. Jackson in that category. We’re looking forward to checking in again to keep up to date on IOL advancements.

Contributing Doctor Mitchell A Jackson, MD, is the Founder and CEO of Jacksoneye, his private practice of 28 years located in Lake Villa, Illinois. He graduated from Pomona College, completed his medical training at FUHS/ The Chicago Medical School, and completed his Ophthalmology residency at the University of Chicago Hospitals. He serves on the editorial advisory boards of Cataract and Refractive Surgery Today, Ophthalmology Management, Presbyopia Physician, Advanced Ocular Care, Corneal Physician, Ocular Surgery News, and Ophthalmology 360. Dr. Jackson is also a board member of the American College of Eye Surgeons (ACES), founding member of the American College of Ophthalmic Surgeons (ACOS), and founding member and past 2018 President of the Cataract External Disease and Refractive Surgery Society (CEDARS/ASPENS). In addition to being selected to the top 250 PS250 Premier Surgeon list, OSN300 top 300 Refractive Surgeon list, and ASCRS clinical subcommittee for cataract and refractive surgery, Dr. Jackson has been involved in many FDA pharmaceutical and surgical clinical studies (Dry Eye, Viscoelastics, IOLs, Presbyopia, topical NSAIDs) over the tenure of his practice, including serving as the Global Medical Director of ACE Vision Group. He also has his own monthly column entitled “The Premium Channel” in Ocular Surgery News/Healio which launched in April 2013. He recently was the recipient of the 2018 Annual Millenial Award, the AAO Board of Trustees Achievement Award in August of 2018, the 2018 Innovation and Founders Award for Cedars Aspens, and the 2020 Albert Nelson Marquis Lifetime Achievement Award for Ophthalmology.

While there are still plenty of speed bumps


Sept/Oct 2021




Selective Laser Trabeculoplasty A Safe and Effective First-line Therapy for Glaucoma Laser therapy helps patients ditch the drops by Hazlin Hassan


n treating glaucoma, the typical route is often to prescribe medications.

If topical drops fail to achieve a reduction in intraocular pressure (IOP), then the alternative is to try laser trabeculoplasty, and finally surgery. With the advent of selective laser trabeculoplasty (SLT) however, many surgeons are now discovering that laser trabeculoplasty is a safe and effective option as a first-line treatment for glaucoma.

The patient compliance issue Paul Singh, MD, president of the Eye Centers of Racine and Kenosha (Wisconsin, USA), observed that one of the problems in medicating glaucoma patients is the rate of compliance, which depends on a long list of factors including dosing schedules, cost, side effects, busy schedules, forgetfulness, co-existing conditions, and many more.

“Just some 5% gets into the target tissues because of the number of barriers in the ocular surface,” he said.

of the pigment of the eyelashes or eyelid skin, and deposits forming on the cornea, among others.

This leads to drug companies increasing the concentration of the medications. But because of the chemicals used and other preservatives, this can then lead to cases of ocular surface disease among some patients.

All of these factors can lead to poor patient compliance which is a problem. Because when patients are not compliant, IOP can fluctuate. Large fluctuations (>5 mmHg) in IOP are a significant risk factor for disease progression in glaucoma patients.

“A number of studies have shown that between 50-60% of patients — and in my practice, probably 75-80% — have ocular surface disease, which causes symptoms such as tearing, burning pain, fluctuating vision, redness and photophobia — all symptoms that cause a lot of patients to have poor compliance or be less compliant. Then they blame the glaucoma drops on those symptoms as well,” shared Dr. Singh. Eye drops can also cause side effects such as darkening of the iris, darkening

“No matter how good we are, compliance really is difficult. How do we expect our patients to stay on medications long-term, to stay on a regimen that we prescribe, not complain and not forget, it's difficult … and that's one of the reasons why I think SLT is another option,” said Dr. Singh. Aside from getting around patient compliance, or the lack of, once the eye drops go into the eye, very little gets into the actual target, he noted.


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What SLT can offer On the other hand, SLT is a safe and effective treatment option to lower IOP in patients with early, mild and moderate glaucoma. SLT achieves its results by selective absorption of energy in the trabecular pigmented cells, sparing adjacent tissues from thermal damage, with minimal tissue alteration following treatment. It works by using a frequency-doubled

Q-switched Nd:YAG laser that provides four nanoseconds of pulse energy with a large 400µm laser beam diameter aimed at the trabecular meshwork. Another alternative, argon laser trabeculoplasty (ALT), causes coagulative damage that leads to scarring of the trabecular meshwork, said Dr. Singh. “SLT treatments do not cause the coagulative damage associated with ALT. Therefore, SLT is believed to improve aqueous outflow and regeneration of the trabecular meshwork. It is a significantly more benign procedure, at least from a traumatic perspective, than ALT,” he said.

Highlights from the LiGHT trial Studies comparing SLT with medication have shown similar efficacy and equivalent IOP reduction with less concern about side effects and patient compliance, highlighted Dr. Singh. Results of the LiGHT trial* which compared SLT and eye drops to treat patients with open-angle glaucoma, found SLT provided more robust IOP lowering and was more cost-efficient as a first-line treatment. A total of 718 patients were enrolled in the prospective, randomized controlled trial, with 356 treated with SLT and 362 were treated with eye drops. Overall, 95% percent of eyes in the SLT group, with and without IOP-lowering

medication, were at target IOP at 36 months, while 93.1% of eyes in the eye drop group were at target IOP. A total of 74% did not need drops for three years post-SLT. No SLT patients required glaucoma surgery to lower IOP compared with 11 patients who required surgery in the eye drop group. The use of SLT as first-line treatment resulted in reduced cost of surgery as well as medications, with an overall savings to the U.K.’s National Health Service of £451 per patient in specialist ophthalmology costs.

Longevity might be better as well in some patients,” he said. However, he noted there are slight limited risks with the use of SLT, including an IOP spike, inflammation, lack of efficacy, transient blurring of vision, headache, corneal edema and eye pain. But nevertheless, the data supports offering SLT earlier in the treatment plan for glaucoma, including as a primary therapy.

Primary SLT is a cost-effective alternative to drops and can be offered to patients with open-angle glaucoma who need treatment to lower IOP, in contrast to ALT.

“For me, there are a number of reasons why SLT is a great first-line therapy. Studies support the use of laser before medications. Doing SLT first may avoid the side effects of topical medications, including dry eye, and poor drop compliance puts the patient at risk. SLT is more effective when used the first time,” Dr. Singh concluded.

SLT may help patients skip the eye drops


Other studies have also shown that SLT therapy can help reduce patient dependence on topical medications. As adjunctive therapy, SLT delivers reduced and controlled IOP, said Dr. Singh. Studies showed that 70% of patients treated with SLT had an IOP reduction of at least ≥3mmHg, when performed after maximal medical therapy. “As an adjunct therapy, it works — but it doesn’t work as well as when it’s done as primary therapy. This is because when you start off with an eye with higher pressure, you see a significant reduction in pressure.

Gazzard G, Konstantakopoulou E, Garway-Heath D, et al; LiGHT Trial Study Group. Laser in Glaucoma and Ocular Hypertension (LiGHT) trial. A multicentre, randomised controlled trial: design and methodology. Br J Ophthalmol. 2018;102(5):593-598.

Contributing Doctor Dr. Paul Singh, MD, is a glaucoma specialist at the Eye Centers of Racine & Kenosha, USA, founded in 1981 by his father, Dr. Kanwar Singh. He is also a clinical professor at the Chicago Medical School. He completed his residency at Cook County Hospital Division of Ophthalmology, his internship at Michael Reese Hospital Department of Medicine, and his fellowship in glaucoma at Duke University. Dr. Singh is actively involved in clinical research and has published papers in many ophthalmology journals. He is a member of several societies and groups. He is the founder and president of the International Ophthalmic Floater Society (IOFS) and on the board of directors for the Glaucoma Forum. He was the first ophthalmologist in Wisconsin to implant the iStent, a device designed to treat glaucoma. He has also pioneered the use of in-office lasers to remove visually significant floaters. He enjoys giving lectures and teaching seminars around the globe to help other doctors adopt newer technologies and techniques. Dr. Singh balances his passion for music with his family and his career.


Sept/Oct 2021



A Revolution in Refractive Surgery by Brooke Herron ew will have the greatness to bend history itself; but each of us can work to change a small portion of events, and in the total; of all those acts will be written the history of this generation.” When Robert Kennedy made this statement, we’re pretty sure he wasn’t referring to the practice of medicine — but that doesn’t mean it can’t be applied to ophthalmology. Over the past few decades, the evolution of vision and eye care has made rapid progress as techniques and technologies advanced on the shoulders of both renowned experts, researchers and clinical ophthalmologists around the world. This progress is evident in the various subspecialties, like refractive surgery — and especially in laser vision correction (LVC), which combines not only surgical technique, but technological innovation in laser systems, too. So, in this CAKE


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magazine cover story, we take a look back at how laser vision correction has evolved: From PRK to LASIK, and finally SMILE — we explore how these techniques have revolutionized the way vision can be improved safely and effectively, as well as what’s still to come.

Prof. José Ignacio Barraquer is often regarded as the “father of modern refractive surgery,” as his research laid the groundwork for the field as we know it today. Importantly, he recognized myopia as a disease that could — and should — be treated, which wasn’t the common consensus at the time. According to a tribute written by his brother Dr. Joaquín Barraquer, it was Prof. José Barraquer’s lifelong desire to cure myopia so that people would not have to be spectacle- or contact lensdependent.1

Prof. José Barraquer’s continued research resulted in the introduction of two techniques: keratomileusis and keratophakia. These methods to adjust or modify corneal curvature would provide the foundation for modern refractive surgery. However, according to his brother, Prof. José Barraquer was well aware that these techniques — which he presented in 1989 — would soon be modified. He also anticipated the rise of laser vision correction in a speech from 1997: “With the newer techniques, there are still problems that are comparable to those experienced in the early stages of currently more established techniques. In its many and diversified forms, the laser promises to simplify and refine refractive surgery; however, the techniques and equipment involved still require more development and refinement.”

use has overhauled how refractive errors are corrected. The quote above from Mr. Kennedy again comes to mind when looking back at the excimer laser — and how it has indeed altered ophthalmic history. It began with Dr. Rangaswamy Srinivasan, who was an IBM researcher and found that excimer lasers could remove human tissue without collateral damage.2 Following this discovery, Dr. Srinivasan was approached by Dr. Stephen Trokel who queried if the excimer laser could be used to reshape corneas. This is often noted as the beginning of modernday laser eye surgery. And the rest (after quite a bit of work on cadavers) … is history.

Those advances in excimer laser We imagine that when the concept of laser was first introduced as a method of vision correction, there were a few naysayers (i.e., “You want to shoot a laser into my eye? That sounds horrible!”). However today, its

technology led to the development of photorefractive keratectomy (PRK), which uses laser to reshape the cornea. The procedure was first performed by Dr. Marguerite McDonald in 1988 and her research team (which included Dr. Trokel). The first patient was Alberta Cassady, a 62-year-old woman with orbital cancer requiring exenteration. Because the procedure already had a poor prognosis, the patient agreed to experimental PRK surgery. Dr. McDonald received permission from the FDA and the first laser vision


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correction procedure in the world was performed in Louisiana at the Delta Primate Center. Postoperatively, Mrs. Cassady’s progress was followed by the research team for 11 days, at which point she underwent exenteration. However, the healing pattern, postoperative evaluations and histology specimens laid the foundation for human trials and in 1995, PRK was approved by the FDA. “Looking back on the procedure we performed on Mrs. Cassady so many years ago, I am so proud and excited to see how far laser vision correction has come,” said Dr. McDonald, in a press release celebrating PRK’s 30th anniversary.3 Next came laser in situ keratomileusis (LASIK), which was first performed on a blind eye in 1989 by Prof. Ioannis Pallikaris from the University of Crete, Greece. Human studies followed in 1990.2 LASIK consists of two main parts: the creation of a corneal flap followed by excimer laser ablation to the

stromal bed. The flap can be created using either a microkeratome or femtosecond laser (FS-LASIK). The procedure was FDA approved in 1998, and remains the most popular LVC procedure today.4 Compared with PRK, LASIK patients have a faster and more comfortable recovery — and further, most have excellent vision one day postoperatively.

Meditec (Jena, Germany), the company behind the VisuMax Laser System used in SMILE, which is currently the only approved platform for the creation of an intrastromal refractive lenticule.

“It’s important to note that SMILE has superior biomechanics, but that only applies to the treatment of myopia, not hyperopia,” — Prof. Walter Sekundo, Philipps University of Marburg, Germany With 30 years of experience, Prof. Sekundo has seen the evolution of LVC from PRK to LASIK to SMILE. He said that SMILE is the first LVC procedure that uses one small incision; this not only makes it minimally invasive, but also eliminates the flap-related issues encountered with LASIK. Indeed, SMILE has similar safety, efficacy and predictability as FSLASIK and is associated with better patient satisfaction. The procedure involves docking, femtosecond laser application, lenticule dissection from

Following the rise and popularity of PRK and LASIK, small incision lenticule extraction — or SMILE — was next to make its grand entrance. Prof. Walter Sekundo, from the Philipps University of Marburg, Germany, was the first surgeon onboard with SMILE (read about his journey in the sidebar on page 19). Prof. Sekundo is also a consultant to Carl Zeiss


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the surrounding stroma, and extraction. And according to Titiyal et al., refractive lenticule extraction marks a paradigm shift in the field of refractive surgery from the conventional flap-based corneal ablative procedures to flap-less extraction of femtosecond laser-created intrastromal lenticules.5 “It’s important to note that SMILE has superior biomechanics, but that only applies to the treatment of myopia, not hyperopia,” Prof. Sekundo continued. Quick recovery and low-risk of infection are also added benefits. SMILE advantages aside, Prof. Sekundo shared that he would never say that FS-LASIK is a “bad procedure.” Rather, every procedure has its own place and some are interchangeable. “I never try to push a patient into one certain procedure. I try to tell them the pros and cons and let them decide.” Of course, cost can come into play and contribute to the patient’s decision, too. “When you go to premium, then obviously everyone would do SMILE,” said Prof. Sekundo. “On the other hand, low-cost chains do LASIK — and sometimes they don’t do FSLASIK, they just do microkeratome LASIK. However, I haven’t touched a

etting from idea to execution can be a long (and sometimes bumpy) road, especially when it comes to a new surgical procedure, like SMILE. Prof. Sekundo was the first surgeon to perform FLEx (femtosecond lenticule extraction) procedure and SMILE (using two incisions). Dr. Rupal Shah from India was the first surgeon to perform SMILE as we know it today with one small incision. To learn more, we spoke with Prof. Sekundo, a refractive and vitreoretinal surgeon, on the evolution and development of SMILE. CAKE: Can you provide some background on the development of SMILE? Prof. Sekundo: In 2004-2005 we began the first experiments. We started with postmortem pigs and it worked — however, we had to have clinical results, so we started working on rabbits … but it didn’t work very well. I looked at rabbits and realized that the rabbit’s cornea is no good. So, I suggested we use living pigs — and we decided on piglets because pigs are just too big. The problem we encountered was that piglets grow extremely fast. We had to have a three month followup, and by that time, they were huge pigs. I’ve got a sore back — and I can do everything else — but I’m not going to carry those pigs. They were huge animals. So, Zeiss hired two big guys who did nothing but carry those big pigs. There was

also a veterinarian who gave them general anesthesia because once they became so big you could not examine them. It’s quite a story. CAKE: When did you perform your first iteration of SMILE? Prof. Sekundo: I think it was 2005 when I did the first blind eyes, and 2006 when I did the first seeing eyes, which were amblyopic (20/40). In humans, it worked very well and it picked up very quickly. We started with femtosecond lenticule extraction (FLEx) because we wanted to see if the principle of femtosecond laser surgery alone was at all feasible — and, of course, it’s much easier to access the cornea with a flap. It’s like opening a lid. Then you peel off the lenticule and put the “lid” (flap) back. Once we did the first 10-15 eyes, we realized there was more potential because you can go through a smaller incision.

This is how we started to gradually reduce the cut. The first SMILE procedures I did were with two incisions: one at the top of the cornea and one below. My idea was that if I’m going to flush it, I wanted to have two incisions to go in and out, but that was wrong. When something new is developed, people tend to base it on what was done before — and this is how we used to do laser surgery in those days. In one of my recent papers, we published a large multicenter study and it showed that it doesn’t matter — you can flush or not — it doesn’t make any difference. All you have to do is remove the lenticule. CAKE: What happened next? Prof. Sekundo: I started working with Marcus Blum who was just starting out in refractive surgery and he was located near Zeiss in Jena, Germany. Once we started [performing] the procedure, we knew it worked well. In 2006, Dr. Blum and I went to Las Vegas for an American Academy of Ophthalmology (AAO) meeting. We presented our first 10 FLEx treated eyes with a reasonable follow-up of about six months, and people couldn’t believe it. For the next step, we needed to include many eyes — and we did not have that many people in Europe. So, this is why Zeiss decided to seek help outside of Europe and went to Dr. Shah. She treats large numbers of patients per day, so within three months, she came back with almost 500 eyes treated. Once the procedure is established, you need larger numbers in normal eyes — and that’s what Dr. Shah did. During her clinical research she also reduced the incision to one single cut and improved the performance of the laser cut by reversing the laser scan direction.


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microkeratome since 2008, because FS-LASIK gives much better safety and complications are almost nil. Whereas with the microkeratome, it’s different. I would say that more than 90% of premium surgeries are FS-LASIK and SMILE; however, these aren’t options for lower-cost clinics because the VisuMax laser is expensive.” For his part, Prof. Sekundo shared that about 60% of his total volume is SMILE and about 30% is FS-LASIK. He shared that he’s also aware of the advantages and disadvantages of both procedures due to his experience in biomechanics. “In terms of myopia treatment for a young patient, I will always go for SMILE, unless they want to have PRK,” said Prof. Sekundo. “PRK is a great procedure, but it hurts — and then it takes 10-15 days until the patient can see well. With SMILE, it’s the next day.” However, for older patients, Prof. Sekundo said he prefers FS-LASIK over SMILE. “When you do SMILE on people over 50, they need much longer time to recover because the cornea is stiff. This is a clinical experience and it’s based on our understanding of the biomechanics of the cornea and how it behaves,” he explained. “So, sometimes in older folks — and despite the advantages of SMILE producing less dry eye — I would still do FS-LASIK because they will recover faster and they will just have to use their drops. “In a younger patient, I strongly believe that SMILE is a much better procedure. This is based on all the experiments I did and published, which showed that the stiffness of the cornea is less influenced by the SMILE surgery compared to LASIK or FS-LASIK,”

continued Prof. Sekundo. According to Prof. Sekundo, the biomechanics of PRK and SMILE are similar — but due to PRK’s clinical disadvantages, patients are not keen to have the procedure. “About 5-6% of our laser volume is PRK. We do it for very thin and irregular corneas, or due financial issues as PRK is a cheaper surgery because it uses an excimer laser, which is about half the price of a VisuMax.”

Although this particular historical perspective focuses on the laser vision correction aspect of refractive surgery, there are other procedures gaining traction — and results — as well. Prof. Sekundo said that one of these rising stars comes in the form of implantable contact lenses (ICL), which have shown an increase in use for the past 5-6 years. “When I look at the entirety of refractive surgery in my clinic, I’d say about one-third would be lenses, and this includes refractive lens exchange (RLE). “We do a lot of presbyopia correction, particularly for hyperopes, and they fare very well with the new lenses like EDoF IOLs, which don’t have many problems with glare and halos,” he shared, adding that for myopic patients ranging from -8 to-9D, he would use ICL. So, what’s the next big thing? Dr. Sekundo said that it will be SMILE for hyperopia. “I’m not allowed to disclose the data, but I can say that the multicenter study has finished and I was the principal investigator, so I


Barraquer J. José Ignacio Barraquer: The Father of Refractive Surgery. CRST Europe. Sept. 2007. Available at: Accessed on August 21, 2021.


McAlinden C. Corneal refractive surgery: Past to present. Clin Exp Optom. 2012; 95: 386–398.


Ophthalmic Consultants of Long Island, a Spectrum Vision Partners partner. (2018 March 08). This March Marks The 30th Anniversary Of The First Laser Vision Correction Procedure Performed In the World. [Press release]. Retrieved from


Hatch K. SMall Incision Lenticule Extraction (SMILE): It’s what’s new in laser vision correction. Harvard Health Blog. Published on May 14, 2020. Accessed on Sept. 15, 2021. Available at: https://


Titiyal JS, Kaur M, Shaikh F, Gagrani M, Brar AS, Rathi A. Small incision lenticule extraction (SMILE) techniques: patient selection and perspectives. Clin Ophthalmol. 2018;12:1685-1699.


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know the data — and it’s great, at least as good as the last generation excimer lasers,” he shared. Further, he said that the new VisuMax laser which is extremely fast — the surgery for myopia is done in 8 seconds instead of 25. “So, hyperopia will probably take 12 seconds — it’s not just feasible, it will be there. And it will come with a new module for hyperopia treatment, which means you do not have to have an excimer laser any longer.”

Contributing Doctor Professor Walter Sekundo, MD, PhD, is medical director and chairman, Department of Ophthalmology, Philipps University of Marburg and University Eye Clinic Germany. In addition, he is the head surgeon of SMILEEYES Refractive Clinic Marburg. He is a comprehensive ophthalmic surgeon with special interest in cornea, cataract and refractive surgery. He studied Medicine in Frankfurt, Germany and New Orleans and Durham (USA). He received postgraduate training at the Department of Ophthalmology, University of Bonn, Germany. He also accomplished fellowships in Eye Pathology at Tennents Institute of Ophthalmology (Glasgow, U.K.), Corneal and Refractive Surgery at Moorfields Eye Hospital (London, U.K.) and Vitreoretinal Surgery at the University of Marburg (Germany). He is one of the inventors of Small Incision Lenticule Extraction (SMILE) and received several prestigious awards (Leonhard-Klein Award, etc.) for this and other microsurgical developments. Prof. Sekundo is a member in 11 national and international associations and a reviewer for several professional journals. He is an editorial board member of Der Ophthalmologe, the journal of the German Ophthalmological Society. He published 176 original papers, 45 book chapters and edited a book on SMILE. He presented over 700 papers at national and international meetings. Despite all these commitments, he remains a busy clinician with a total of over 30,000 anterior and posterior segment procedures performed to date. For this reason, since 2010, the independent Focus Magazine has regularly ranked him as one of the 30 top cataract and refractive surgeons in Germany with the exclusive highest overall ranking in 2020.

A Brief History of


here have been many historical corneal refractive techniques and procedures developed over the years. From early techniques of radial keratotomy to modern excimer laser techniques, the field of refractive surgery is one of the most rapidly developing in ophthalmology,” shared Dr. Colm McAlinden, from Flinders University in Adelaide, Australia, in a review titled Corneal refractive surgery: Past to present.*

Corneal Refractive Surgery

While we can’t cover all of the historic moments mentioned in Dr. McAlinden’s paper, let’s take a brief look at some of these early refractive milestones...



Clear lens extraction was first reported in the literature and the first cases of nonpenetrating astigmatic keratotomy occurred in the USA, the Netherlands and Italy

Radial keratotomy (RK) is introduced initially by Sato and later with Yenaliev, Fyodorov and Durnev in the former Soviet Union


Barraquer published the results of a study, which indicated refractive correction could be achieved with a procedure termed refractive keratoplasty



The first suggestions of corneal surgery to alter the refractive power of the eye by Dutch ophthalmologist Snellen

Yenaliev, from the Soviet Union, performed radial keratotomy using 4-24 anterior incisions


The first suggestion of refractive correction: Hermann Boerhaave proposed that high myopia could be corrected by couching the clear crystalline lens


Bores brought radial keratotomy to the USA



Ioannis Pallikaris from the University of Crete, Greece was the first to perform LASIK on a blind eye with human studies beginning in 1990


The first reports of the use of excimer lasers with the eye emerged from Taboada, Mikesell and Reed

The first large area excimer laser ablation procedure on a human living eye was performed by Theo Seiler in Germany to remove a corneal scar

… and the rest is history! * McAlinden C. Corneal refractive surgery: Past to present. Clin Exp Optom 2012; 95: 386–398.


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with offices in New Jersey and Pennsylvania (USA). She has taken time from her personal “juggling act” to contribute to a book to further this aim: Women in Ophthalmology (WIO).* The book is a guide for career and life and includes an assortment of stories and narratives contributed by female ophthalmology professionals for their associates. This book builds on Dr. Matossian’s already steady commitment to elevate women: She is also a founding member and a volunteer mentor of Ophthalmic World Leaders (OWL). Originally a women’s group, OWL has now expanded to include all diversity in ophthalmology. So, how are WIO and OWL promoting diversity and leadership among women? “It is wonderful to have two strong organizations with a mission of diversity, inclusivity, and leadership for women, by women,” said Dr. Matossian. “These organizations provide empowerment and mentorship by more experienced ophthalmologists in a supportive and nurturing manner to women who are starting their careers.”

New Book Sheds Light on the Important Role of Women in Ophthalmology by Corrina Lindkvist


lthough we all attempt to juggle life’s daily challenges, sometimes it’s not as successful as we hoped. Life can sometimes be entirely overwhelming and yet, it seems that some people breeze through their daily tasks and appear to have the perfect structure and balance. So, how do they do it? Do they have an ingenious fairy godmother who “bibbidi bobbidi boo’s” their time, life and work? (If so, I’ll take one!) One solution to all this multi-tasking would be a supportive network of like-minded people to lean on. Unfortunately, for many years, working women have long been expected to do it all — and do it well. Finding that perfect balance and being in control of


your career and life, well … truly, it’s not always that easy! Doctors are often called superheroes — and for good reason. They deal with the constant pressure of demanding days, a steady stream of patients, afterhour commitments, family time, meal preparation and most importantly, that precious “me time.”

Finding that balance in ophthalmology with WIO Fortunately in ophthalmology, and now more than ever, there is a growing network of support for women in the field. Dr. Cynthia Matossian is the founder of Matossian Eye Associates,

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And let’s face it, starting a new career can be daunting — but having an understanding and encouraging organization of people to lean on provides crucial support. Another key influencer is book Coeditor Dr. Christina Weng. She is an associate professor of ophthalmology and the Vitreoretinal Diseases & Surgery Fellowship program director at the Baylor College of Medicine in Houston, Texas (USA).

“The overriding goal of this book was to create a repository of amazing stories told primarily by women in the field of ophthalmology.” — Dr. Christina Weng, Associate Professor of Ophthalmology, Director of Vitreoretinal Diseases & Surgery Fellowship program, Baylor College of Medicine, Houston, Texas (USA)

“The overriding goal of this book was to create a repository of amazing stories told primarily by women in the field of ophthalmology,” shared Dr. Weng.“I have been fortunate enough to benefit from the wisdom, experience and advice of wonderful mentors over the course of my early career, and I wanted to somehow be able to share that across the community. So I was thrilled when Springer approached me about turning my vision into a reality. “The book — which I co-edited with Dr. Nina Berrocal — is truly a labor of love that spans a diverse variety of topics, including residency training, publishing research and work-life balance,” she added.

The advice within Dr. Matossian was invited to write the financial chapter in the WIO book. “There is a documented disparity between men and women about financial literacy. My chapter was filled with advice on finances and investments,” she shared. “The book was written for women ophthalmologists by women ophthalmologists, who have a lot of commonality and who have experienced similar hurdles and challenges. This book is filled with advice,” explained Dr. Matossian in regard to the need for the WIO book.

So, how have Dr. Matossian’s life experiences influenced her contributions to the book? She explained that life is the best teacher: “If we are open to learning from our mistakes and successes, then we grow from our life experiences. In this book, we shared those experiences with up-and-coming ophthalmologists.” In learning to achieve her worklife balance, Dr. Matossian said: “Learning to say ‘no’ was one of my biggest hurdles. I did not want to miss any opportunities, and therefore at times, over-committed. Now, I am much more comfortable saying ‘no’ in a kind manner or suggesting alternative ophthalmologists to fill that role.” Often, people have a hard time saying “no.” To say “no” could appear selfish or to show disinterest, so we often feel guilty in doing so. But in fact, it should be the opposite — we should be encouraged to acknowledge our own personal limitations. .

On managing personal lives Even today, women are often the main caretakers of the family and home — which is a full-time job in itself. How did Dr. Matossian manage early in her career, and now? “I always made time for my daughter when she was young, working around her sports activities and school events,” she shared. “I was totally devoted to her from the minute I got home from work, to when she went to bed. Then, I stayed up and did hours of work.” While that couldn’t have been easy, Dr. Matossian shows how both career and life can be managed with commitment, a splash of time management and a sprinkle of sync. Of course, we had to ask if she had any last advice to women seeking a career in ophthalmology. She said: “Be passionate about what you do and you will succeed.”

Contributing Doctors Dr. Cynthia Matossian, MD, FACS, is the founder and medical director of Matossian Eye Associates, a practice with three offices in Pennsylvania and New Jersey. She is a consultant to numerous pharmaceutical and medical device companies and is on the leadership team of the American College of Eye Surgeons, the NY IOL Implant Society and Women in Ophthalmology. She serves on multiple editorial boards, has published numerous articles, received the prestigious Ophthalmic World Leaders Visionary Award and was included in the Ocular Surgery News' Premier Surgeon 300 list. She is a clinical assistant professor of ophthalmology (adjunct) at Temple University School of Medicine. Dr. Christina Y. Weng, MD, MBA, is an associate professor of ophthalmology and the Vitreoretinal Diseases and Surgery Fellowship program director at the Baylor College of Medicine in Houston, Texas. She has a faculty appointment at the Level 1 trauma center, Ben Taub General Hospital. Dr. Weng graduated cum laude from Northwestern University and then went on to medical school at the University of Michigan where she was elected to the Alpha Omega Alpha (AOA) Medical Society. Dr. Weng completed her ophthalmology residency at the Wilmer Eye Institute-Johns Hopkins University and surgical retina fellowship at the Bascom Palmer Eye Institute-University of Miami. Dr. Weng is involved with multiple clinical trials; these include the DRCR Retina Network diabetic retinopathy trials and the AGTC Phase 1/2 subretinal gene therapy study for achromatopsia. She also leads numerous research studies in her areas of interest: clinical/surgical outcomes, medical economics, healthcare quality metrics, and telemedicine. Dr. Weng serves on the board of directors of the American Society of Retina Specialists, American Society of Cataract and Refractive Surgery, and Women in Ophthalmology.

* The book is available in print or e-book form through the Springer website.


Sept/Oct 2021




! Coming Soon

The Next Big Things in Ophthalmic Innovation by April Ingram


or a hot ticket to the future of ophthalmic care, look no further than Innovators General Session, held during the recent annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS 2021). Always a popular session, this year’s was led by Prof. Edward J. Holland, and the scope and brilliance of this year’s presenters did not disappoint.

An artificial cornea appears A highlight of the session was a presentation from Dr. Gilad Litvin, founder and chief medical officer at CorNeat Vision (Ra'anana, Israel). He described the development and application of the CorNeat KPro, a completely synthetic keratoprosthesis. Dr. Litvin’s talk included surgical video and outcomes from the first-in-human implantation, performed by Prof. Irit Bahar from the Rabin Medical Center in Israel, this past January. The CorNeat KPro includes an optical component and a nano fabric integrating skirt, fused together by a rim that has three sets of suturing


holes and four openings that provide future access to the anterior chamber. The nano fabric was developed to integrate the PMMA with the eye wall. The posterior surface has undercut segments to house the remnant cornea and there are phalanges to assist the surgeon with inserting the cornea into the undercuts intraoperatively. The nano fabric skirt is manufactured using an electrospinning process, which means that an electric force is used to draw charged polymer threads onto a target. It is a non-woven matrix that appears almost identical to a human tenon extracellular matrix.

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A unique feature of the CorNeat KPro is that it is anchored in the subconjunctival space, not the corneal tissue which is devoid of blood vessels. This takes advantage of the vigorous healing properties of this area, integrating the optics with the resident ocular tissue and allows for a completely synthetic material to integrate with the resident tissue. Following extensive viability and adherence testing of the nano fabric configurations in vitro with human fibroblasts and animal models, biocompatibility studies were conducted in rabbits. The animal trial

demonstrated that after 6 months there was a progressive and permanent biomechanical integration, meaning complete collagenation of the skirt material and no apparent inflammatory response. At the time of the presentation, two patients had received the CorNeat KPro implant. The first patient was a 78-year-old male, with only one functional eye that had undergone four previous corneal transplantations. Dr. Litvin shared the structural and functional outcomes six months after implantation of the CorNeat KPro. Despite having poor optic nerve function, the first patient is pleased with the outcome and has a visual acuity of 6/90, impressive for someone who has not been able to see in over a decade. The second is three months post-op and an ocular cicatricial pemphigoid (OCP) patient who had not been able to see in more than 30 years. At last follow-up, BCVA was 6/9 (20/30). Both implanted eyes have shown some conjunctival retraction within the initial few weeks but stopped once the tissue had adhered to the skirt material and has remained stable since.

Regenerative medicine for corneal conditions Dr. Jeffrey Goldberg, from Byers Eye Institute at Stanford University, shared the work of his group, using magnetic cell delivery as a platform of regenerative medicine, a method that has the potential to overcome many of the current challenges associated with cell therapy including delivery, retention and integration. The focus of Dr. Goldberg’s work is improving treatments for corneal edema. The Emmecell (Emmetrope Ophthalmics, California, USA) technology uses human corneal epithelial cells that are expanded in culture. And impressively, a single donor cornea has the potential to yield enough cells to treat hundreds of patients — marking a significant advancement in addressing current challenges with donor supply. The expanded donor cells are combined

with magnetic nanoparticles and are then injected into the anterior chamber. A magnetic patch is worn for one hour (or up to overnight) in order to facilitate the localization and integration of the magnetic human corneal epithelial cells into the endothelial layer. Dr. Goldberg outlined the magnetic cell delivery process, and highlighted key advantages of this treatment. He also addressed the critical challenge of too few human corneal epithelial cell donors and importantly, the ease of an injectable, non-surgical treatment with a rapid recovery. Additionally, this treatment is safe and repeatable, which means that corneal edema can be addressed at an earlier stage. Emmecell has completed proof-ofconcept and toxicology preclinical studies, as well as a first-in-human study, establishing safety and efficacy of the optimal dose and formulation. The first-in-human study was conducted at a single center in Mexico and included 21 patients with corneal edema as a consequence of endothelial dysfunction and a baseline visual acuity poorer than 20/200. Patients were followed for one year. The results demonstrated excellent safety and efficacy, with no serious adverse events, inflammation or vision loss associated with treatment: 9/21 gained 3 or more lines in BCVA, and 14/21 had significant reduction in corneal thickness. This magnetic cell delivery treatment delivers 500,000 human corneal epithelial cells, takes only 5

minutes, and is performed in the ophthalmologists’ office. Emmecell is currently conducting a Phase 1b, multi-site, dose ascending clinical trial in the United States. The trial dosed its first patient in July 2021 and will include 18 patients followed for 18 months.

Take off in the “surgeon’s cockpit” Sharon Bakalash, MD, PhD, presented the advancements in digitally enhanced visualization for surgeons, specifically innovations in headmounted displays. The Beyeonics’ (Haifa, Israel) platform is modeled after the view and functions used in aviation, but termed “the surgeon’s cockpit” allowing for an immersive natural 3D display. The presentation highlighted the features of the surgical visualization system and how it can be easily integrated with existing diagnostic and OR devices and platforms. The headset allows the surgeon to have both intuitive and natural control and views of multiple virtual screens. Plus, the wearable display is ergonomically friendly, takes up very little space in the OR, and allows for a unique teaching tool and training experience. If you are looking to stay at the forefront of inventions and innovations in ophthalmic care, check out all the virtual presentations from the Innovators General Session at ASCRS 2021.

Editor’s Note: The annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS 2021) was held in Las Vegas, Nevada from July 23-27. Reporting for this story took place during the event.


Sept/Oct 2021




The Impact of the COVID-19 Pandemic on Ophthalmology Residents by Jillian Webster


he scale of disruption of life caused by the COVID-19 pandemic is undeniably large. According to Bakshi et al.,* there were suspected to be 8 million cases of SARS-CoV-2 virus worldwide in just the first half of 2020. All aspects of life, work, education and social interaction have changed — and are continuing to change as people adapt to an uncertain world. The medical sector is one of the hardest hit by these disruptions. Those on the front lines are not only fighting for a healthier tomorrow, they have had to deal with astronomical hardships and heartbreaks. All of this while trying to reduce the spread of the virus — and still trying to treat patients.

field during the pandemic — or had their education disrupted by it — have endured a unique kind of emotional stress. New residents and medical students found themselves forced to reimagine their education. Despite the challenges of online instruction and the limited ability to bond in person with peers, the next generations of ophthalmologists have persevered during one of the most trying medical events of recent history.

Working within the pandemic

Individuals who entered the medical

Despite paperwork delays, Dr. Mohamed Bechir Hizem began his residency at the end of 2020. He is a first year ophthalmology resident


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at Precise Vision (Rheine, Germany), which is headed by Dr. Florian Kretz. Though the pandemic has been hard on the bureaucracy side, Dr. Hizem remained confident in his dedication to ophthalmology. When choosing a career path, ophthalmology was always the first choice for Dr. Hizem. He said: “I was always fascinated by this small organ which is the eye. The exciting combination of research, clinical practice and operative work has convinced me that I would like to specialize in ophthalmology and I am now really happy to work with an amazing team of ophthalmologists in Germany.” The pandemic slowed but did not deter Dr. Hizem’s education. Despite the challenges of the pandemic, he has found himself in a position to continue his career in ophthalmology. And he had a unique experience with learning that is indicative of a lasting change in academia.

Plugged in learning Some ophthalmic education has moved online. With restrictions regarding the gathering of people, educators have had no choice but to adapt. However, there is a silver lining to the Zoom calls and web conferences that appeared after the start of the pandemic. The implementation of online classes, lectures and webinars allowed for increased global communication among eye care professionals. “The COVID-19 pandemic has dramatically changed countless aspects of life around the world. As in every sector, it affected the ophthalmology department, as well as its doctors and patients,” said Dr. Hizem. “It also forced the rapid digitalization of learning in ophthalmology. Almost all of the congresses and lectures are now online.” Indeed, students and educators alike have adapted to online learning as the necessity for webinars increased. However, Dr. Hizem has made the best of the new system: “I actually made a lot of progress learning new information thanks to the webinars and the online meetings, in which you can find a lot of accessible information just after some mouse clicks.” Information was now — out of necessity — at the fingertips of students and professionals alike. And there are significant benefits to online webinars and lectures. “I can now have access to a congress on the other part of the planet while at home, which has made learning more accessible,” explained Dr. Hizem. It seems that the online open-world approach to education, though appearing through necessity, has also created a positive space for sharing knowledge.

Anxiety over engagement The pandemic forced many into their homes for extended periods of time, as work and study moved online. Many felt the emotional, social and professional toll of lockdowns and social distancing. Reflecting on these times, Dr. Hizem said: “I think that one of the most challenging parts of the COVID-19related new learning measures is

making professional relationships. Since everything is now online, it became very hard to meet other colleagues and to exchange ideas and knowledge.” This has limited the ability of eye care professionals to communicate and create meaningful relationships, which are necessary for continued development and knowledge sharing. However, Dr. Hizem explains that communication found a way: “Social media did help me a lot ... making new professional relationships and being professionally up to date.” The world of ophthalmology has transformed into an online exchange of ideas — and although direct contact would be preferred, it has still been possible for eye care professionals to connect and form relationships.

“The COVID-19 pandemic has dramatically changed countless aspects of life around the world. As in every sector, it affected the ophthalmology department, as well as its doctors and patients.” — Dr. Mohamed Bechir Hizem First Year Ophthalmology Resident, Precise Vision, Germany

globe. “Congresses and meetings that I normally don't attend because of lack of time to travel … I now have the opportunity to attend much more interesting events than ever before.”

“The pandemic has undoubtedly disrupted the well-established, traditional structure of medical education. The new measures of physical presence have accelerated the development of an online learning environment which have proven [up to this point] to be very effective.” The anxiety, frustration and isolation of the COVID-19 pandemic have clearly affected those in the medical community. Dr. Hizem, along with other residents and students, were forced to enter a world of intense restriction, online classes and conferences. Despite the stress and obstacles, ophthalmic educators have inadvertently created a stronger global community. Going forward, we can look at a greater sharing of information using the pathways forged during the pandemic.

What has been gained The loss of direct contact with peers during the pandemic has forced changes in the world of ophthalmology — but the desire and drive of these medical professionals is still as strong, if not stronger, than before COVID-19. “The pandemic has undoubtedly disrupted the well-established, traditional structure of medical education. The new measures of physical presence have accelerated the development of an online learning environment which have proven [up to this point] to be very effective,” said Dr. Hizem, adding that the creation of this online ophthalmology community has given him the opportunity to participate in events all around the

* Bakshi SK, Ho AC, Chodosh J, et al. Training in the year of the eye: the impact of the COVID-19 pandemic on ophthalmic education. Br J Ophthalmol. 2020 Sep;104(9):1181-1183.

Contributing Doctor Dr. Mohamed Bechir Hizem is a firstyear ophthalmology resident at the Precise Vision eye clinic in Rheine, Germany headed by Dr. med. Florian Kretz.


Sept/Oct 2021




Are You an Ophthalmology Influencer? by Nick Eustice


s your Instagram blowing up? Do you have millions of people following your outrageous lifestyle of high fashion and adventure? Or are you renowned for giving face-shaping makeup tips on Facebook, pulling hilarious public pranks on Tik-Tok, or just recording yourself playing video games on YouTube? In all likelihood, no. Chances are pretty slim that you’re that sort of “internet celebrity” who’s kicking back to read a publication for eye care professionals. But that doesn’t mean that you aren’t an influencer in your own field. Let’s scale it back a bit, and look at some more realistic questions: 1. Do people look to you for the latest trends in eye care? 2. Are you innovating in corrective procedures and preventative measures? 3. Or even if you’re not necessarily on the cutting-edge, are you interested


in sharing your experience and expertise with colleagues and potential patients alike? 4. And would you like to grow your network among both groups? Those latter questions probably hit a lot closer to home. Most of us use social media in some form these days in our personal lives. Whether it’s posting photos on Instagram, keeping in touch with friends and family on Facebook, or sharing opinions on Twitter, social media has become an undeniable aspect of daily life and interaction. Still, despite the fact that so many of us use social media frequently, plenty of people have difficulty bridging the gap between their personal use of social media and effectively using it to promote their professional lives. This is particularly true for ophthalmologists, for whom myriad concerns and hesitations may prevent them from making the most of social media in their practice.

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Reaching a network of new patients Ophthalmologists have plenty of reasons to want to grow their practices. Offering better and more robust services to patients, reaching out to those who aren’t getting the help they need, and making the most of one’s valuable time are just a few of the countless considerations that motivate doctors to open up their networks to a larger pool of patients. Social media is an effective and relatively simple way to do this. But it’s important to frame your engagement with potential patients appropriately. As with any profession, it should go without saying that a separate account is a necessity for addressing the public in your professional capacity. You don’t want pictures of your cat mixed in with ones of your treatment suite. Just as we all need to keep an appropriate distance between our professional and personal lives in the real world, the same is equally (if not more) true online. Sharing information on what treatments you can provide and how they can be of benefit to a patient will probably be the core of a social media presence aimed at the public. To that end, it’s essential to keep information general. Patient privacy is of course a big motivator for this, for a number of reasons. Compliance with the Health Insurance Portability and Accountability Act (HIPAA) and other medical laws is always a concern to be aware of. And furthermore, a potential patient will

want to enter into such a relationship with a good feeling of trust. Keeping this in mind, there are plenty of avenues to explore. Facebook is probably the first name that comes to most people’s minds, and with very good reason. With over 2.8 billion users worldwide, it is far and away the largest and best-known platform, and a relatively easy one to get started with. Existing groups dedicated to ophthalmology abound on Facebook. Broader groups like World of Ophthalmology cover a broad spectrum of issues across its 55,000 members, while the somewhat more lay-person friendly groups like Easy Ophthalmology have 13,000. These groups can be enormously useful in cultivating a social media presence reflective of your treatment goals and the possibilities available to prospective patients. Instagram, quite a distance behind with a “mere” billion users, is owned by the same company as Facebook and is probably another very familiar name. Oriented toward sharing photos and videos, it is often much shorter on words, and a profile can be easily generated from the template of your Facebook page. Sometimes images can have a powerful impact all on their own, as can be seen on the American Academy of Ophthalmology’s Instagram Page. Twitter is a good deal smaller, but is designed for the express purpose of reaching out to an ever-expanding audience. In an article for the American Academy of Ophthalmology's EyeNet Magazine, Dr. Steven Christiansen writes1: "An official, practice-based Twitter feed can be a great marketing tool to brand your practice and connect with patients.” So, putting out an occasional 280-character factual tidbit or word of advice can end up paying dividends in expanding your network. While these and other networking opportunities abound, a valid question to ask is how much time an ophthalmologist wants or needs to spend on marketing and patient outreach. After all, while reaching out to new patients is a goal plenty of doctors have, treating patients is the most important aspect of their work.

To this end, many services large and small exist to handle this aspect of an ophthalmology practice. Depending on how deep your interest in patient outreach goes, and how much time you are willing to spend on doing so, it may very well be worth your while to engage a professional for this responsibility.

Networking with other doctors While patients are of course a vital part of a doctor’s professional network, they are only one side of the coin. Usually when talking about professional networking, the subject has much more to do with building peer relationships with fellow ophthalmologists and other eye care professionals. It comes as no surprise that social networking has a substantial role to play in this, and it’s probably one that you’re already doing, even if you haven’t looked very much into patient outreach. Before last year, an increasing amount of dialogue within the ophthalmological community was already moving online, due to the ease and convenience of the medium, and the truly global scope of the industry which had never been possible before. Due to the outbreak of COVID-19 and the resulting travel restrictions and distance mandates, this has been boosted to even higher levels, to a point where attending online conferences and participating in discussions via text boxes has started to feel much more like the norm than ever before. Certainly, the major networks mentioned above are every bit as useful for interacting with an audience of peers as they are with the general public. Another often overlooked networking site is LinkedIn. While typically thought of as a site for job-seekers, an increasing number of ophthalmologists have found it to be an invaluable nexus for interacting with fellow eye care professionals. Writing about her experiences in Optometry Times, Dr. Leslie O’Dell shares2: “Through LinkedIn, I have connected to industry leaders, giving me the opportunity to learn about cutting-edge technology before I read it in print.” Also of note on the subject of

professionally-focused networks are the medically-specific networks. While these networks are aimed at doctors in all medical fields, ophthalmologists make up a sizable percentage of those already active in these communities. While they do not offer the opportunities for crossover networking between doctors and patients as the mainstream networks do, medical communities such as Sermo and Doximity do offer the advantage of networking in a space strictly for professionals, and offering the possibility to exchange experiences with doctors in other fields. Whether you’re already quite adept at social networking with regard to your practice, or you’re relatively new to the notion of taking ophthalmology online, the resources available to you are varied, ample and growing. Whether your interests lie in expanding your network of fellow doctors, or in reaching out to those who could use medical help, social networks are a massive part of our communicative world. Whatever your focus audience may be, there’s always room to become more of an influencer in your own right.

Editor’s Note: Media MICE is naming its 50 KOL Influencers for 2022. They are ophthalmologists with considerable social media presence and/or digital influence worldwide, and are actively interviewed by and involved with our media. Stay tuned, check out the list, and get in touch if you'd like to be considered for our 2023 KOL Influencers! Send an email to for more details.


Christiansen SM. Twitter as a Tool to JumpStart Your Career. EyeNet Magazine. Available at: Accessed on Sept. 14, 2021.


O’Dell L. 3 tips to use LinkedIn to advance your career. Optometry Times. Published on March 10, 2016. Available at: https://www. Accessed on Sept. 14, 2021.


Sept/Oct 2021




Building a Successful Refractive Surgery

Targets Acquired by Sam McCommon


edical school and business school are two very different things, but running a clinic is by definition running a business. So, while the things doctors learn in med school are crucial to the understanding of their work, they’re only half the battle in many cases. And although most doctors don’t set out on their career journey thinking they’ll be businesspeople, that’s often where they end up.

Get investments and know your value-add What do you do when you don’t have money and you’re starting a clinic? This is a common problem, but Dr. Andrea Russo, medical director of the Centro Oculistico Bresciano in Brescia, Italy, shared how he got started from scratch.

Thus, understandably, many doctors could use some business advice, and that’s why we’re here today. Media MICE CEO Matt Young hosted a discussion entitled “How to Build a Successful Refractive Practice,” with some actionable takeaways and nuggets of insight.

Dr. Russo started a collective with two colleagues who invested in him, allowing him to pay a small amount to begin. A doctorate is a valuable investment draw, so reaching out to financial institutions, colleagues, or even venture capitalists can be a solid move. Whatever the case, getting the start-up cash you need to begin is the first step to a successful practice.


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But how on Earth do you operate a private practice when your country offers free nationalized health care? That’s the case for Dr. Russo, whose main competitor is Italy’s national health system. To stand out, he said, you have to have the absolute best tech and provide serious added value over what patients can get from the free system. For Dr. Russo, that means reinvesting to upgrade equipment. As he put it, “The best technology is now here in my practice because I want to be sure to offer the best to my patients. The best for your patients is the best for you as a doctor. Patients will refer more patients and you may become a key opinion leader.”

Breaking into markets and allying with optometrists Dr. Anton van Heerden, director of Armadale Eye Clinic in Australia, shared that his clinic had an interesting beginning. As he explained, the status quo in Melbourne was firmly entrenched — ancient and well-established practices dominated the market. So, they had to offer something different. In his case, the clinic decided to offer both SMILE (small incision lenticule extraction) and Presbyond, which gave them a definite leg up on the competition. Marketing SMILE was built in, and Dr. van Heerden took good advantage of what was available. Additionally, working closely with optometrists and forming a pleasant working relationship has helped his practice considerably. He’s had many referrals from more rural areas of Victoria

thanks to his optometrist contacts, and he encourages patients to go back to referring optometrists for further checkups. He also suggested offering SMILE surgery to optometrists — at a very discounted rate. Those same optometrists will likely further refer patients your way, making everyone happy.

Building a clinic in the UK: Working with the NHS The NHS is a big deal in the U.K. As Dr. Maghizh Anandan, refractive surgeon at Optegra Eye Health Care in Derby, U.K., noted, around 90% of all medical treatments in the U.K. are performed by the NHS. Dr. Anandan began working with the NHS as a cataract surgeon in 2010 before beginning his refractive practice. Working with the NHS helped Dr.

Dr. Pang’s Rules for Building a Practice Looking for a well-thought-out bullet list of rules for building a practice? Look no further. Dr. Claudine Pang, consultant ophthalmologist and medical director at Asia Retina in Singapore, is all over this one.

1. Talent.

You need to attract talented people in their respective fields — and there’s a simple way to do this: good remuneration. Pay well to attract top talent and ensure their personal development.


Team. As she said, “I

believe that a doctor is only as good as his or her team. If the doctor rolls out really good treatment but there’s poor supporting staff and poor customer service then the entire patient experience is compromised.”


Technology. Dr. Pang

concurs with Dr. Russo that technology is the key to a good practice.


Training. Dr.

Pang trains her team regularly in equipment use, maintenance and customer service to ensure a consistent high standard of care.


Customer service.

Simply put, when patients feel like they’re the most important person in the clinic, they’ll be happy.

6. Value-add.

Look for ways to add value to patients’ lives. Dr. Pang recently created a mobile app to help people conduct self eye assessments, make reminders and more. Such an app really helps with marketing and helps separate her from her competitors.

Anandan build trust with optometrists who felt confident in further referring patients his way. Like Dr. van Heerden, most of Dr. Anandan’s patients are referred by optometrists. So, a good working relationship is key. When it came to equipment, Dr. Anandan didn’t have to overthink it. “It was fairly straightforward to go with Zeiss for most of the equipment. Zeiss probably has the broadest vision portfolio amongst all the other providers.” Having SMILE and Presbyond helped Dr. Anandan offer significantly more than many other ophthalmologists in his area, and the broad range of IOLs didn’t hurt either.

How ophthalmic surgical tools broaden the market Dr. Vardhaman Kankariya, refractive and cataract surgeon at Asian Eye Hospital and Laser Institute in Pune, India, brought up an excellent point — one of patient psychology. As he pointed out, there’s a huge untapped market of potential refractive patients who have been sitting on the fence for many years. SMILE offers them an opportunity to help them off the fence and get the refractive surgery they have been unsure about. Compared to LASIK, Dr. Kankariya sees a big difference in the way patients view SMILE. The short recovery time combined with the lack of a flap makes reluctant patients much more willing to get laser surgery. Dr. Kankariya also suggested there are millions of untapped presbyopia patients that can be treated by refractive practice. He’s absolutely right: Being able to successfully dig into this market would be an absolute goldmine for any refractive practice.

Editor’s Note: This article was published on CAKE online on Sept. 24, 2021. Read the full version at:


Sept/Oct 2021




ASCRS 2021 E-Poster Highlights by Joe Schreiber


he annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS 2021) was held in person from July 23-27 at the Mandalay Bay Convention Center in Las Vegas, Nevada, USA. Below, we detail some of the most interesting posters from the prestigious meeting.

Evolution of glaucoma surgery from ancient Egypt In keeping with this issue’s focus on history, we’ll begin with Ashika Angirkeula’s fascinating presentation on early Egyptian identification and treatment of glaucoma. Although glaucoma was properly identified during the Renaissance by Richard Bannister, the earliest known research and identification happened over 4 millennia ago alongside the construction of the great pyramids. The most notable text was the Papyrus Ebers, dating back to 1500 B.C., but the Edwin Smith papyrus from 1800 B.C., Kahun Papyrus from 1800 B.C. and Hearst papyrus from 1450 B.C. were also examined. All of them fail to directly name glaucoma, but accurately describe the condition’s symptoms. In the Ebers Papyrus, the ancient Egyptians examined 20 eye conditions, which they treated with incantations and natural ointments. It also provides evidence that the Egyptians were aware of the benefits of a healthy lifestyle, such as diet and supplements. It was a far cry from MIGS, and they had no surgical component at all, but we continue to use similar dietary treatments for glaucoma to this day.

Real world experience of a novel glaucoma drug delivery implant Inder P. Singh presented a study examining the bimatoprost implant, Durysta (Allergan, an AbbVie company,


Dublin, Ireland), a tiny dissolvable bimatoprost eye implant that lasts 4-6 months, but has reports of relief for 1-2 years. The analysis was a retrospective of the first 30 implantations in history. It analyzed demographics and characteristics including severity, IOP lowering medications, adverse events, technique and IOP reduction. Since the product is new there was only a 3-month follow-up included, but longerterm data was available if you caught the presentation. Zero adverse effects were reported, with patient satisfaction at 98%. Of the cases evaluated, 16 eyes were considered mild, 10 were moderate and 4 had advanced open-angle glaucoma (OAG). The study noted that the slit lamp seemed to be a more effective method of implantation, taking over half the time to settle as in the supine position. The Durysta implant seems to be a resoundingly worthwhile solution for glaucoma.

New presbyopia implant promises VA Improvement Presbyopia treatments continue to be on the forefront of innovation. One study by Dr. Frank A. Bucci evaluated VisAbility Micro Inserts for stability and effect on distance corrected near visual acuity (DCNVA) at 48 and 60 months post-op as part of the VIS-2014 FDA multicenter prospective clinical trial. Uncorrected distance visual acuity (UCDVA) and adverse ocular events were also monitored for long-term safety results. The study found that at the latest

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postoperative visit (at 48 or 60 months), 90% (52/58) of all eyes maintained 20/40 or better DCNVA, with 67% (39/58) achieving 20/32 and 52% (30/58) achieving 20/25 or better. Further, distance vision remained stable in all enrolled eyes with 97% (60/62) of the eyes achieving uncorrected distance visual acuity (UCDVA) of 20/20 or better. The remaining 3% (2 eyes) achieved UCDVA of 20/25. No serious ocular adverse events were reported. These results suggest that the VisAbility Micro Inserts may provide clinically significant improvement and stability with distance corrected and uncorrected near visual acuity.

Safety and efficacy of KPI121 for DED Based on the insight from seven U.S. clinicians, Steven R. Sarkisian Jr. and colleagues carried out a study to demonstrate the safety of a new ophthalmic solution as a remedy for presbyopia. Features were measured, statistical analysis was carried out, and subjective measurements for everyday things like driving and reading were performed. The solution was found to provide significant improvements for patients and recorded very mild side effects. Distance vision remained stable and most patients maintained 2 lines of improvement in photopic BCNDVA on day 30, with many having 3 lines or more. A small decrease of pupil size in scotopic and photopic light was recorded, with only mild stinging and burning after administration. Dr. Sarkisian recommended that further investigation into the benefits of the compound should be performed.

Editor’s Note: The American Society of Cataract and Refractive Surgery (ASCRS 2021) was held in Las Vegas, Nevada, USA, from July 23-27. Reporting for this story also took place during the annual meeting.

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Triaging by Telemedicine


Highlights from APAO 2021 Virtual


s the official media partner of APAO 2021, CAKE magazine publisher Media MICE covered the Virtual Congress from Day 1 to 7 in its digital Show Daily. In case you missed it, we’ve compiled a sampling of highlights right here...


r. Renata Puertas, a glaucoma specialist at Moorfields Eye Hospital, presented the Effect of Telemedicine on the Glaucoma Service at Moorfields. Her report shed light on the telemedicine system the U.K.’s National Health Service (NHS) had in place before COVID-19, and how the institution adapted to the pandemic. She revealed that by splitting patients into three telemedicine consultation categories — namely consultant-led, technician delivered and optometristdriven — the triage process for patients could be optimized. This, she pointed out, was absolutely essential given that there are only 1,500 ophthalmologists working in the U.K. at present, and this move also led to a quicker road to treatment and diagnosis, thus improving patient outcomes. Indeed, Dr. Puertas said that under this system, 97% of patients reported that they were satisfied with the quality of care they received. — Andrew Sweeney

Consider Cycloplegic Refraction

“T COVID-19 and Changing Practice Patterns


o capture a worldwide view of how ophthalmology has been practiced during the pandemic, Dr. Tien En Tan shared findings from Global Ophthalmology Practice Patterns in COVID-19: What Has Changed in 2021? The study traced the development of COVID-19 discoveries related to the eye; how centers from about 50 countries worldwide protected their ophthalmologists and patients; and the digital health solutions they used. “We saw there was a general de-escalation of measures in 2021, particularly in PPE requirements, and many centers have ceased routine temperature


monitoring for ophthalmologists and patients,” he said. However, certain measures remained universal like the masks and use of slit-lamp shields. Beyond 2021, Dr. Tan said significant challenges are ahead with resurgent infection waves, unequal access to vaccines, and emergent new variants. To provide high quality ophthalmic care while safely mitigating risks related to COVID-19, Dr. Tan said: “The best way to do this is to greater international collaboration, sharing of best practices between institutes, as well as continued innovation primarily in the digital health sphere.” — Joanna Lee

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here’s lots of new data, but most of it has been taken without cycloplegia … which is the gold standard for myopia measurement,” began Prof. Ian Morgan, from the Australian National University in Canberra, during his presentation during the 2nd Asia-Pacific Myopia Society Congress. “These methods overestimate the prevalence of myopia and emmetropia and underestimate the prevalence of hyperopia.” Although there are many gaps in the evidence, Prof. Morgan says this doesn’t change the myopia and high myopia epidemic in East and Southeast Asia. That said, there have also been some positive developments in the understanding of myopia. “Despite non-cycloplegic refractions, another thing we’ve discovered especially in data from China, is that the increase of myopia during the school years is due to educational exposures almost exclusively — and not due to increasing age,” said Prof. Morgan.— Brooke Herron

AI: Advocating for Change


rtificial intelligence (AI) and big data are part of the world now, and will become a larger part of the future. So, what can organizations like the APAO and AAO do to advocate not just for change, but for the right kind of change? Dr. J. Peter Campbell, the chair of the AAO’s AI Committee, noted three specific areas of change that AI can help target and will hugely influence: research, education and patient care. In research, for example, AI can play a huge role in image classification, image segmentation, disease prediction and federated learning. As Dr. Campbell pointed out, AI is simply a very powerful tool — and like all tools, it has great potential for both benefit or harm depending on how it is implemented. He suggested that professional organizations like his advocate for AI reimbursement and research funding, and for improved interoperability in medical imaging. Additionally, doctors need to demonstrate added value for patients and not just added cost, while ensuring ethical and effective implementation everywhere. — Sam McCommon

Measuring Success in Dry Eye


he OptiLight from Lumenis is the first FDA-approved IPL (intense pulsed light) solution for the management of dry eye due to meibomian gland dysfunction (MGD). Dr. Laura Periman, from the Periman Eye Institute in Washington, USA, was asked how she measures success in patients with MGD who receive IPL treatment. “[How we define success is] very multifactorial. There’s improvement in the physical metrics of the tears, whether it’s osmolarity or tear break-up time — or maybe it’s the patient and their speed scores, and their ability to wear contacts and have clear vision … so, there’s multiple ways to measure it,” she replied. “I think there’s a lot we can’t measure as clinicians and the temptation is to think ‘well, it’s not working.’ But you have to remember, there’s all this amazing stuff happening on an ultrastructural level, on an inflammation reduction level … there’s a lot going on and there’s multiple ways to measure success.” — Brooke Herron

Surgical Options for Angle Closure Eyes


ncontrolled IOP, progression of angle-closure, optic nerve damage or visual field defects, poor compliance, and economic barriers should be considered as trabeculectomy indicators, said Dr. Norman A. Aquino, an ophthalmologist at the University of the Philippines in Quezon City. Speaking strongly in favor of the procedure, he said that trabeculectomy “still has an important and relevant role in decreasing the burden of angle-closure.” He summarized by emphasizing preoperative preparation, intraoperative diligence, and postoperative vigilance.

Meanwhile, Prof. Prin Rojanapongpun, an ophthalmologist at Bumrungrad International Hospital in Bangkok, Thailand spoke against trabeculectomies, instead making the case for phacoemulsification. He said his position was explained by the fact that phacoemulsification offers better vision, lower complications, it’s quicker and easier, and involves simple postoperative care. He also said that lens removal is notable for modifying angle configuration and reduces the patient’s IOP, and while trabeculectomies achieve the same result, they also involve a higher risk of complications. — Andrew Sweeney

Move Over for MIGS


ne of the reasons glaucoma still causes blindness (among many reasons) is that we still treat glaucoma improperly. This can be due to difficulty in assessment, difficulty in addressing adherence and underdiagnosis,” said Dr. Ike Ahmed. He noted that although topical eye drops are still the mainstay, they pose both adherence and quality of life issues. “Surgery, while the gold standard, is a reasonable option but it’s not something that most glaucoma specialists or ophthalmologists are willing to expose their patients to in all spectrums of glaucoma,” he said. “If the only surgery you do is trabeculectomy, I will submit my hypothesis that in 2021, I would think again. If you’re not doing some MIGS, then you’re missing out on an important option for some patients — not for every patient.”

Dr. Ahmed explained that interventional glaucoma is predicated on safer options, addressing adherence, doing things earlier, and balancing safety and efficacy — and this is why MIGS was developed. — Brooke Herron

Editor’s Note: The 36th Asia-Pacific Academy of Ophthalmology Virtual Congress (APAO 2021) took place from Sept. 5-11, 2021. This story is a selection of highlights from the APAO Show Daily published by Media MICE.


Sept/Oct 2021







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