CAKE Issue 13: The ebook version (The Sustainability Issue)

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t y l u i s S tainabi gy

o l o in Ophthalm

reen practices g t a k o A lo c e a r o u n d t h e wo a l p n i rld



Cut costs, cut carbon?


read an eye-opening statistic in a paper recently: One cataract surgery in the U.K. produces as much carbon emissions as driving a car for 500 km (or 310 miles). About a third of that comes from the energy required to run the hospital infrastructure. But another third comes from the supply chains and the operation of the medical equipment required to perform the surgery. Remarkably, the supply chains involved in supplying even the pharmaceuticals accounted for nearly a fifth of the 130 kg per surgery carbon footprint, and the remaining 10% came from staff and patient travel. That’s two “average” people’s worth of kilograms! However, the paper that described this was published back in 2013, and I think several trends are changing this situation. First of all, there’s been a trend for pushing any procedure that can be performed outside of the operating theater, to be performed somewhere with lower running costs — everything from intravitreal injections, corneal cross-linking, and even cataract surgery — are now being performed in procedure rooms and doctors’ offices. There’s now a plethora of data, some of which are from very large studies, showing that with sensible precautions, this change of scenery isn’t associated with increases in infection or other adverse event rates. When you can bring procedures out of an operating theater, you can start bringing them out of a hospital setting and into a community setting. This not only increases access to sight-restoring and saving procedures (particularly in low-tomiddle income countries) but I'm going to argue that this will also cut the carbon footprint. The COVID-19 pandemic forced a rethink of how a lot of eye care is delivered to patients, in terms of not only check-ups and screening but also how the treatment is delivered. Much like Zoom and Microsoft Teams have done more to cut people’s carbon footprint in the last two years than pretty much anything else tried this decade, teleophthalmology in terms of screening and consultations is modern medicine’s eyecare equivalent. It’s more efficient, and even if your motivation isn’t to save the polar bears, it’s clear to me that shrinking the costs cuts carbon. This trend will only continue to grow. For example, I work in the same office as two engineers, Daniel Eckert and Christian Funck (the man, not the musical genre) on a project managed by the innovation powerhouse that is Nikki Hafezi to make smartphone-based keratography a reality. Imagine clipping a device onto your old Samsung Galaxy phone and getting corneal topographic maps out of it. The screening can easily come to you (or in this case, which is intended for


keratoconus screening, your children), rather than you and your kids going to the clinic to get screened. Convenient and cost-saving, yes, but hopefully kinder to Canadian permafrost too. A lot has been said about the use of machine learning, how it can automate the reading of much of medical imaging, and how this will revolutionize not just ophthalmology, but also radiology, pathology, and beyond. I guess, sooner or later, that will be the reality for most of us. This has the potential to relieve doctors of some of their workload, and, as is the case with Moorfields/ DeepMind retina collaboration led by Pearse Keane, can be used to triage patients into the right care pathway. When screening is easily available for all, then a heck of a lot of diagnoses are going to be needed for all of these eyes, and sending all but the most obviously healthy ones over to the nearest hospital eye clinic isn't sustainable — in terms of the specialists available to deal with this, or the increased carbon emissions in the meantime. But actually, there's one thing you can do, as practitioners of medicine, that can save even more carbon: Don't accept bitcoin payments. In 2020, it was estimated that one transaction cost 402 kg of carbon dioxide, and as the blockchains become more complex, this number continues to rise. If you want to save the polar bears and several Pacific islands from the effects of global warming, don't be a crypto bro, bro. Cheers,

Mark Hillen

Mark Hillen, PhD

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

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Matt Young CEO & Publisher


Anterior Segment



Collagen Crosslinking Possible LongTerm Keratoconus Treatment: Study Shows CXL Could Help Patients Avoid Corneal Transplant


Rare, But Significant: A Review of Corneal Dystrophy


The New Wave in Simplifying Cataract Surgery Workflow

Hannah Nguyen COO & CFO

Robert Anderson Media Director

Gloria D. Gamat Chief Editor

Brooke Herron Editor

Cataract and Corneal Surgical Challenges

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The Debate Continues in Combined Versus Sequential Surgeries Could Research in Key Proteins Unlock the Secrets of Age-related Cataracts?

Cover Story ty Sustainabili y

Mark Hillen Editor-At-Large International Business Development

Ruchi Mahajan Ranga Brandon Winkeler Writers

Ben Collins Elisa DeMartino Hazlin Hassan Joanna Lee Leon Ash Nick Eustice Sam McCommon Tan Sher Lynn


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Maricel Salvador

How to Succeed in 2022 as a Female Ophthalmologist eLos: The Cream of the e-Learning Crop Accessible Eye Care for All: Measures for Improving Eye Health Among Aboriginal and Torres Strait Islanders


Paradigm Shift: Taking a Proactive Approach to Glaucoma Management The Dawn of Gene Editing: Is Asia-Pacific Ready for Precision Ophthalmology? Yoga and Glaucoma: Can Holistic Approaches Lower IOP?

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Dr. Boris Malyugin is a professor of ophthalmology and is the deputy director general (R&D, Edu) of the S. Fyodorov Eye Microsurgery Institution in Moscow, Russia. He is also the president of the Russian Ophthalmology Society (RSO). Dr. Malyugin is a world-renowned authority and expert in the field of anterior segment surgery. He has established himself at the forefront of advanced cataract surgery by pioneering numerous techniques and technologies. He is well known for his development of the Malyugin Ring, for use in small pupil cataract surgery. Dr. Malyugin has received multiple international awards and was invited to participate with named and keynote lectures and live surgery sessions during several national and international meetings. He is a member of the ESCRS Program Committee, Academia Ophthalmologica Internationalis (member since 2012), International Intraocular Implant Club (member since 2009), as well as the ICO and AAO Advisory Committees. Dr. Boris Malyugin

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 the Singapore Eye Research Institute (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. Chelvin Sng

Dr. George H.H. Beiko


Dr. George H.H. Beiko is a lecturer at University of Toronto and an assistant clinical professor at McMaster University in Canada. Dr. Beiko is a medical graduate of Oxford University and completed ophthalmology specialty training at Queens University in Canada. After his residency, he worked for one year at the St. John Ophthalmic Hospital in Jerusalem. He is currently a cataract, anterior segment and refractive surgeon practicing in St. Catharines, Ontario. His research interests include development of advanced cataract techniques and new intraocular implants. He has been an investigator in a number of Phase 1 FDA trials on intraocular lenses and he has done extensive work investigating multifocal, accommodating and aspheric IOLs. Dr. Beiko has published numerous peerreviewed articles in Ophthalmology, Journal of Cataract and Refractive Surgery and the Canadian Journal of Ophthalmology. He has also authored 10 book chapters. He has given over 500 scientific presentations at meetings throughout the world, including the annual meetings of the AAO, ASCRS, COS, CSCRS, ESCRS, WOC and ISRS.

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. Dr. Harvey S. Uy


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Prof. Jodhbir S. Mehta

Prof. Jodhbir S. Mehta, MBBS, FRCOphth, FRCS(Ed), FAMS, PhD(UK), is the executive director and head of the Tissue Engineering and Cell Group at the Singapore Eye Research Institute (SERI), 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 full tenured professor with Duke-NUS Medical School in Singapore. With a main interest in corneal transplantation, he completed a corneal external disease and refractive fellowship at Moorfields Eye Hospital in London and at SNEC. He has co-authored nearly 20 textbooks and 333 citations, and holds 16 patents, six of which have been licensed. Prof. Mehta has won several awards from the AAO and ARVO, among others, the latest of which was from the ASCRS in 2018. Prof. Mehta is also a favorite keynote speaker and presenter in several international conferences.

Dr. William B. Trattler

Dr. William B. Trattler, MD, is a refractive, corneal and cataract eye surgeon at the Center For Excellence In Eye Care in Miami, Florida, USA. He performs a wide variety of cataract and refractive surgeries, including PRK; all laser LASIK; no injection sutureless cataract surgery; as well as laser cataract surgery. He has been an investigator for next generation technologies (like the Tetraflex accommodating intraocular lens) and procedures like corneal collagen crosslinking (CXL). His involvement in the FDA-approval study for CXL led to its approval in 2016. In addition to his private practice, Dr. Trattler is on the Volunteer Faculty at the Florida International University Wertheim College of Medicine, as well as the University of Miami’s Bascom Palmer Eye Institute. He is board certified by the American Board of Ophthalmology and has been an author of several articles and abstracts. In 2016, Dr. Trattler received the Catalyst Award in Advancing Diversity in Leadership from the Ophthalmic World Leaders (OWL), an association of interdisciplinary ophthalmic professionals dedicated to driving innovation and patient care by advancing diversity in leadership.


Arunodaya Charitable Trust (ACT)

ASEAN Ophthalmology Society

Asia-Pacific Academy of Ophthalmology

He Eye Specialist Hospital

Ophthalmology Innovation Summit

Orbis Singapore

Russian Ophthalmology Society (ROS)

Young Ophthalmologists Society of India ( YOSI )

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g n i k Ma the Cataract and corneal surgical challenges by Joanna Lee


uring symposiums, and thanks to distinguished physicians and educators, ophthalmologists can find avenues to continue learning (and thus, practicing) the latest cataract and corneal surgery techniques for difficult cases.

cataract, phacodonesis and a peripheral corneal scar after a traumatic corneal perforation. The left eye had no light perception due to end-stage glaucoma. They went ahead with cataract surgery despite a zonular instability in the right eye.

Even with COVID-19 restrictions in place, learning from live surgeries still must continue, like at the recently held 26th European Society of Cataract & Refractive Surgeons Winter Meeting (Winter ESCRS 2022). Chaired by Prof. Dr. Oliver Findl (Austria) and Prof. Dr. Andreia Rosa (Portugal), the lively symposium and discussions on difficult cataract and cornea procedures was divided into two segments. Here, they began by showcasing complicated cataract surgeries, followed by challenging corneal cases.

To save the bag throughout the surgery, they used the Ahmed capsular tension segment (CTS) where the instability was greater. For this type of cataract, Dr. Maduro said the CTS offers a good and safe option in managing the cataract with profound zonular instability. CTS can be placed atraumatically within the capsular bag as it is a flexible device and can be inserted any time after capsulorhexis. It also doubly functions as intraoperative support as well as a postoperative fixation implant (capsular bag).

The first segment included panelists Dr. Joaquim Net-Murta (Portugal), Prof. Dr. Rudy Nuijts (the Netherlands), Dr. Ramon Lorente (Spain) and Dr. Sorcha Ni Dhubhghaill (Belgium). Meanwhile, the second segment on corneal challenges included Dr. Nuno Alves (Portugal), Dr. Nino Hirnschall (Austria) and Dr. Beatrice Cochener-Lamard (France).

“The sutures may be passed either before or after lens extraction and can be combined with a capsular tension ring if needed or iris hooks, too,” said Dr. Maduro.

Surgical options for subluxated cataract Dr. Vitor Maduro (Portugal) presented the case of a patient who had bilateral ocular trauma 20 years ago. His right eye had a BCVA of 20/60, a nuclear


DMEK in an eye with a Dubroff anterior chamber IOL In the next case, Dr. Victoria de Rojas (Spain) shared about a 71-year-old patient with congenital cataract. He had a Dubroff lens implanted in the anterior chamber of his left eye and a posterior chamber lens in his right eye. He also had a history of pupillary block in his left eye which resulted in an iridotomy and treatment using timolol (0.5%) in

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both eyes. He came for an endothelial keratoplasty due to bullous keratopathy, wearing a therapeutic contact lens in the left eye. Considering that they had to perform an EK, they kept the lens in place and performed a DMEK procedure. A month after the operation, the eye saw a 28.07% endothelial cell loss. His final visual acuity after four months was at DCVA 0.7 with an IOP of 12 mmHg (with timolol). Prof. Neto-Murta said he agreed with Dr. de Rojas’ method as it would have been very difficult to do the bubbling without the lens. She opted to keep the lens due to the synechiae in the lens which would have caused bleeding.

Lens coloboma The third case involved a 47-year-old male patient who was referred to Dr. Miguel Raimundo’s practice in Portugal for progressive, yet painless, decreasing visual acuity in the right eye which had undergone a pars plana vitrectomy (PPV) and scleral indentation for retinal detachment. Unfortunately, his left eye had undergone an enucleation for blinding and painful eye following a trauma. He could see hand motions due to the cataract and a fundoscopy showed inferior retina coloboma. Once they had decided to do a phacoemulsification, the question was how does one support the bag during phacoemulsification? Dr. Raimundo chose to insert capsule retractors (or iris retractors). “The trick was to do a small hydro dissection to create some space in order to insert the segments,” he said. Then, he did a standard hydraulic dissection and delineation. “It’s important in these cases to not let the AC collapse,” he said, advising to keep the zone with tamponade or viscoelastics. To support the bag long-term, he opted to insert a capsular tension ring (CTR)

for which he used a Sinskey hook to avoid damaging the interior zone. The patient was reported to be very satisfied and had UDVA of 20/80 and CDVA of 20/50 six weeks postoperatively. It was not a true coloboma but rather a lens contraction or notching due to the absence of the zonular apparatus. “You must support the bag as much as needed,” Dr. Raimundo advised for this type of challenging cataract case with difficult biometry.

Irregular cornea and decentered multifocal IOL In Portugal, Dr. Tiago Monteiro’s case was a 67-year-old female patient who had corneal haze with paracentral and central corneal scars, irregular astigmatism and the decentered bifocal IOL in a compromised capsular bag. With a contact lens trial using a rigid lens, she could achieve 20/30. She had a history of adenoviral keratitis, having done PRK and refractive lensectomy, and subsequently another PRK and CXL in the right eye. They suggested the patient undergo six months of ocular surface optimization. Then, a multifocal IOL removal, possibly with a monofocal IOL implantation. Dr. Monteiro's message was that multiple/sequential corneal procedures must respect the minimum intervals to allow for proper corneal healing. An irregular or non-transparent cornea is a contra-indication to a multifocal IOL. “Intraocular surgical complications without conditions for a proper centration of the IOL in the capsular bag should also be a contraindication for implanting a multifocal IOL,” he said. Dr. Cochener-Lamard reiterated the key point that the multifocals need to be put in when all the conditions are well in place, but she said with the kinds of infection the patient had had before, a high level of dryness was to be expected.

Hypermature intumescent pseudoexfoliation cataract and other surprises One could use the RAO technique for

performing the rexis in intumescent cataract safely, according to Dr. Ramon Lorente (Spain). When it comes to emulsifying a morgagnian cataract, he suggested the F. Martinez Technique, but he opted for the chop. It’s almost impossible to do a divide-and-conquer in this case, he said, so he first adjusted the parameters and attempted to fix the nucleus. Then only later did he perform a horizontal chop. “It’s very important to use some longitudinal power because we want to occlude and maintain the occlusion while we’re working with the chopper,” said Dr. Lorente. To stabilize the capsular bag, a CTR was used. Prof. Findl reminded the audience that when putting the CTR in, it’s important to have a “safety line” by placing an intraoperative suture at the beginning before the implant to enable the ring can be removed in case of any issues during the procedure.

Macular ‘star’ following trauma surgery A 24-year-old male was rushed to the emergency department with an inferior corneoscleral laceration with an iris prolapse. Dr. Rafael Barao (Portugal) shared that the patient was fine but two months later, he had decreased visual acuity and optic disc edema and a starshaped macular wrinkling appeared. They thought it was a cyclodialysis cleft at first, except that the IOP was average. They investigated further and found his injured eye to have a hypermetropic shift of about 2 mm with a reduced axial length of 21 mm. There was entrapment of the peripheral iris, and an ultrasound biomicroscopy showed a valved cyclodialysis cleft and an inferior structuring bleb behind the iris. They eventually did an ab externo cyclopexy to resolve the issue.

Keeping your cool with complex cataract A 65-year-old female patient came to Dr. Sorcha Ni Dhubhghaill (Belgium) with black cataracts and amblyopic left eye. She was told many years ago that there was no point in operating but had noticed her vision was now

worsening. Dr. Ni Dhubhghaill said she chose to do an extracapsular cataract extraction (ECCE), partly inspired by Dr. Nuijts’ session at the last ESCRS in Amsterdam. She deemed that the majorly amblyopic patients won’t have significant benefits visually in that eye, so she might not mind the potential astigmatism. The only challenge that got her “hot under the collar” was she had not done an ECCE in nine years and had never been formally trained to do this procedure. What made it nerve-wracking was while performing the ECCE, she started to lose control over the rhexis edge, causing the rhexis to grow wider. But she figured one would need to just prolapse the lense into the anterior chamber for removal (using lots of dispersed OVD underneath the endothelium and cohesive OVD under the lens). With a cystotome approach, (and having watched “tons of videos” by Indian surgeons doing ECCE prior to this surgery), she managed to remove the cataract. With a larger capsular bag, she chose an Alcon MA60 3-piece lens. They tied a “1, 2, 4, 3” suture tied as 1 type of suture as it is very neutral for astigmatism. The patient reported visual field improvement, more color and light, and had more confidence with her peripheral vision with overall satisfaction. Not doing too many new things at once was one of the lessons she learned from this case, she admitted before inviting the panel for their opinions on what could have been done differently in this case. Smiling, she added: “Online videos are wonderful and those of us who don’t have these opportunities to see these very crucial skills can always go back to learn as much as we can from all these different platforms.”

Editor’s Note: The 26th Winter ESCRS Meeting was held virtually on February 18-20, 2022. Reporting for this story took place during the event.

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The Debate Continues in Combined Versus Sequential Surgeries

by Nick Eustice


hile many procedures in the world of eye surgery are complex, involved and prone to potential side effects, cataract surgery is typically quite the opposite. Cataract procedures are among the most commonly performed surgeries — they are quick to perform and specialists frequently do hundreds (if not more) of these procedures in a year. Patients usually have a rapid recovery, with improved vision and pain typically subsiding within a few days of the surgery. As cataract occurs quite frequently, and particularly in older patients, they often accompany a variety of comorbid conditions. They also happen most often in both of a patient’s eyes at once. Due to the simplicity of cataract removal procedures, and their relatively quick turnaround time, it begs the question: Should cataract procedures be performed at the same time as other surgeries, or even in both of a patient’s eyes at once?

Cataract surgery 101 The process of performing cataract surgery is quite well understood in the


world of eyecare. Cataract occurs when the eye’s lens becomes cloudy over time and causes diminished vision. An incision is made in the cornea above the lens, which is removed and replaced with an artificial one, restoring the patient’s visual acuity. Within this basic scheme, a number of variations are common. The use of lasers in order to create the required incision (and in some cases to avoid the need for sutures) is increasingly common. While the original procedure for cataract surgery, now known as extracapsular cataract extraction, involved removing the entire lens in one piece, this is no longer the most common method. Nowadays, surgeons usually use a procedure called phacoemulsification to break up the original lens in order to remove it through a much smaller incision. In either case, a synthetic lens is usually inserted afterward. In almost all variations of standalone cataract surgery, the procedure takes well under an hour. Patients are commonly treated without the need of general anesthetic, and though unable to drive, are able to go home once the operation has been completed. All

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in all, it is a procedure which most patients describe as quick and nearly painless. As cataract surgery is quite well understood, and has become safer and safer over the years, many doctors have come to view the procedure as routine. As cataract can often occur with a number of comorbidities, many doctors have begun considering whether it makes sense to perform cataract surgeries in combination with treatments for more serious conditions.

Should we combine PK and cataract surgeries? Penetrating keratoplasty (PK) is a procedure that could make sense to treat in combination with cataract. The most commonly performed transplantation, PK involves the removal and grafting of full-thickness corneal tissue. And as this is the tissue in which the incision required for cataract surgery is made, it has long been speculated that combining these two procedures into one makes the most sense. In years past, however, many doctors

have been hesitant to combine procedures. As progress in ophthalmic procedures specifically — and surgical procedures generally — evolves slowly, doctors have tended to treat comorbidities separately unless there was a specific need to proceed quickly. While corneal pathology can sometimes be quite time-sensitive, cataract surgeries are not considered urgent. Thus, doctors have perceived the potential risk of side effects to be not worth attempting a combination surgery. As such, successive surgeries became the norm.

Often, this is when complications like expulsive hemorrhage, posterior capsule rupture and vitreous loss can occur — and they are reported to be more common in patients undergoing combined surgeries compared to sequential. On the other hand, a significantly shorter recovery time and fewer office visits make combined surgeries a very appealing option for patients and for their doctors.

But now, recent advances in surgical science have made a number of doctors rethink this position. As the potential for side effects such as infection, inflammation, or even retinal detachment or glaucoma, has been reduced over time, many ophthalmologists have started performing combined cataract and PK surgical procedures with increased regularity.

Beyond comorbidities, several other factors motivate doctors to consider combining surgeries. High among these factors are patient convenience and comfort. Patients are often eager to experience improved vision as quickly as possible following a cataract procedure. We spoke with Dr. Francis Mah, an advanced corneal, cataract and refractive surgeon from La Jolla, California, USA, to inquire as to when and why successive procedures are favored over combined ones.

A study* published recently in the Turkish Journal of Ophthalmology sought to examine and compare the results of these combined procedures in comparison with the more traditional, successive surgical approach. Reviewing the two groups of patients at varied intervals subsequent to their surgeries revealed remarkably similar results, especially as graft survival was concerned. According to the authors, in the combined surgery (CS) and sequential surgery (SS) groups, 50% versus 69% of patients had CDVA ≥ 0.4 (p=0.04); 45.5% versus 25.4% had CDVA (0.10.3) (p=0.04); and 54.5% versus 73% had spherical equivalent ≤ ±2.0 D (p=0.02). Postoperatively, the most common complications were glaucoma (20.5% versus 15.9%, p=0.48) and allograft reaction (9.1% vs 23%, p=0.04). Importantly, the study showed that the graft survival rates were 95.2% versus 86.5% (p=0.10) at one year and 75.9% versus 68.9% (p=0.47) at five years, respectively. In spite of this, the study’s authors noted that concerns remain regarding the open-sky environment in which cataract procedures are performed in the combined surgical method.

Combined surgery in other situations

Dr. Mah began by explaining that in the past, methods for correcting cataract necessitated highly invasive procedures. Around 30 to 40 years ago, intracapsular surgeries, and even some extracapsular surgeries of the time, required large incisions and subsequent suturing. These procedures, particularly the intracapsular ones, had a high rate of complications, and often required up to three months of recovery before improvements could be seen in a patient’s vision. Today, Dr. Mah said that the vast majority of practices in the United States perform successive surgeries on a patient’s two eyes, separated by a gap in time of 2 to 4 weeks. Several factors influence this decision, foremost of which is the desire to maintain vision in one of the patient’s eyes at all times. While this does require more time, it is often more comfortable for the patient to have greater visual acuity throughout the procedure. Another factor influencing this decision is the financial one. Insurance companies are often reluctant to cover the full cost of combined procedures,

as successive procedures have been the norm for many years, and have become quite standard throughout the field. Despite these concerns, Dr. Mah noted that a valid argument can be made for performing combined surgeries on patients requiring cataract procedures on both of their eyes. Although he does not perform combined procedures, he suggested that a standard patient with two otherwise healthy eyes could probably do very well with bilateral, sequential, simultaneous surgeries. With today’s vastly improved cataract procedures, Dr. Mah noted that the rehabilitation period is very quick, with most patients able to see very well the next day. Though the idea of combined surgeries could save patients’ and doctors’ time, they remain quite unusual in the United States. Dr. Mah reminds us that concern for patient safety is paramount when performing these procedures, and though combined surgeries may very well be done without fear of greater complications, the overall consensus of the American ophthalmic world at this point is that it is far better to err on the side of caution.

* Özbek-Uzman S, Yalnız-Akkaya Z, Düzova E, Şingar E, Burcu A. Corneal Pathology and Cataract: Combined Surgery or Sequential Surgery? Turk J Ophthalmol. 2021 Jan; 51(1): 1–6.

Contributing Doctor Dr. Francis Mah, MD, is an ophthalmologist specializing in advanced corneal, cataract and refractive surgery. He believes in using the latest techniques to treat each patient with compassion and respect, just as though they were members of his own family. Dr. Mah has special clinical interests in corneal diseases and infections, corneal transplant surgery (DSAEK, PKP, DALK), advanced small incision laser cataract surgery, premium intraocular lenses, and refractive surgery, such as LASIK and PRK.

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Could Research in Key Proteins Unlock the Secrets of Age-related Cataracts? by Leon Ash


ith an estimated 95 million people worldwide affected, cataract remains the leading cause of blindness in middle-income and low-income countries.1 In higherincome countries, age-related cataracts are one of the most common etiologies of visual impairment.2 Women are statistically more likely to suffer cataracts than men (61% of women versus 39% of men).3 Cataracts affect lens transparency — without a clear lens an image can’t be sufficiently focused on the retina. Common symptoms are cloudy or hazy vision with indistinct color perception, yellow tint, poor night vision and occasionally, double vision. They can affect a patient’s ability to read, drive and operate machinery and eventually, as a degenerative condition, cause blindness.

Contributing factors to cataract development Previous studies point to oxidative damage as a contributing factor: Of the risk factors identified for cortical cataracts, those that seem most likely to cause increased oxidative damage are high sunlight exposure and diabetes.4 Smoking, long-term use of steroids, eye injury and (surprise, surprise) drinking too much alcohol are also said to increase the risk of developing agerelated cataracts. To learn more about the development of age-related cataracts, the National Eye Institute has awarded a professor at the University of Arizona College of Medicine in Tucson a $1.6 million grant


to investigate two protein ion channels suspected to be involved with the kind of lens cell changes that lead to cataracts.5 The award recipient was Dr. Nicholas Delamere, PhD, professor and head of the Department of Physiology in the College of Medicine, Tucson. He commented: “Human cataract is frequently associated with failure of the mechanisms controlled by TRPV1 and TRPV4. The hope is that studies like this might pave the way to the development of strategies to prevent or delay age-related eye diseases.” The discovery that TRPV4 and TRPV1 interact to regulate cell function in the specialized cells of the lens was based on previous work from Dr. Delamere and his research cohort. Among their findings was that TRPV1 and TRPV4 in cells on the surface of the lens act as sensors for the control mechanisms that maintain lens structure, as well as shape, size, optical clarity, water content and focus power. Now, further research will study the molecular connection between TRPV1, TRPV4 and the cytoskeleton of the eye.

The future of cataract intervention So, what could this mean? As things stand, the only available treatment for cataracts is surgery to remove the damaged lens and replace it with an artificial one. There are some two million or so of these procedures in the United States every year alone.3 Could we potentially be looking at pre-surgical intervention for age-related cataracts?

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Could lens replacement surgery become a thing of the past? That’s not yet clear — and seems a bit far-fetched, at least in the short-term. Initially, the object of the study will be to gain an understanding of age-related lens cell changes and the mechanisms that underpin them. The research aims to discover the role of micro-changes in pressure on the lens surface activating TRPV1 and TRPV4 and precipitating homeostasis. And the stakes are high. With almost half of Americans receiving cataract treatment by the age of 75, any additional insight into the loss of lens transparency in aging adults would be welcome. If even a small percentage of surgical cataract interventions could be avoided or delayed, it would represent a significant breakthrough. Dr. Delamere will be assisted by an able research team comprised of Mohammad Shahidullah, DVM, PhD, research associate professor in the Department of Physiology; and Rick Mathias, PhD; and Junyun Gao, PhD, of the Department of Physiology and Biophysics at Stony Brook University.

References 1.

Liu YC, Wilkins M, Kim T, Malyugin B, Mehta JS. Cataracts. Lancet. 2017;390(10094):600612.


Iroku-Malize T, Kirsch S. Eye Conditions in Older Adults: Cataracts. FP Essent. 2016;445:17-23.


Cataract data and Statistics. National Eye Institute. Available at learn-about-eye-health/outreach-campaignsand-resources/eye-health-data-and-statistics/ cataract-data-and-statistics. Accessed on 15 February 2022.


Beebe DC, Holekamp NM, Shui YB. Oxidative damage and the prevention of age-related cataracts. Ophthalmic Res. 2010;44(3):15565.


Maintaining Transparency: Study to Focus on Causes of Cataracts. National Eye Institute. Available at Accessed on 15 February 2022.

Editor’s Note: A version of this article was first published on


Collagen Crosslinking Possible Long-Term Keratoconus Treatment Study shows CXL could help patients avoid corneal transplant by Hazlin Hassan


newer treatment known as corneal collagen cross-linking (CXL) may help to slow or stop keratoconus from progressing and prevent the need for a cornea transplant, according to results from a nine-year clinical trial.* “Our findings indicate that the CXL procedure is an effective and a safe method for the treatment of keratoconus within a long-term postoperative follow-up duration,” said the paper by Dr. Akbar Derakhshan and colleagues. “In conclusion, we recommend the use of CXL for patients with early keratoconus.” These results could provide a ray of hope for patients with the condition to avoid a cornea transplant.

CXL in early keratoconus Keratoconus occurs when the cornea thins and gets weaker over time. This then results in it bulging outward into a cone shape due to biomechanical instability, leading to irregular astigmatism and a reduction in vision quality. Treatment options available for improving visual acuity and halting the progression of keratoconus consist of spectacles, rigid gas permeable contact lenses, collagen crosslinking, intracorneal rings and keratoplasty. If the condition progresses to an advanced stage, patients may need a cornea transplant. But according to the study, CXL in early

keratoconus seems to be a safe procedure that can effectively stabilize uncorrected visual acuity (UCVA), best spectacle corrected visual acuity (BSCVA), subjective spherical equivalent (SE) and central corneal thickness (CCT), while improving objective spherical equivalent. In corneal cross-linking, doctors use eye drops and ultraviolet (UV) light to strengthen the tissues in the cornea, to keep it from bulging further. It is called “cross-linking” because it adds bonds between the collagen fibers in the eye, to help the cornea remain stable. It has been reported that CXL could effectively stabilize keratoconus progression, with a good safety profile. The study aimed to evaluate the longterm outcomes of collagen cross-linking in early keratoconus.

The results are in In this hospital-based prospective study, 30 eyes of 20 patients with early keratoconus were enrolled. The indications of keratoconus progression included an increase of 1.00 D or more in the cylindrical component of the manifest refraction, an increase of 1.00 D or more in the maximum corneal curvature, an increase of 0.50 D or more in the SE manifest refraction in one year, and a decrease of ≥5% in the central corneal thickness in three consecutive topographies in six months. Pre- and postoperative evaluation after three, six and 12 months and then nine years of follow-up, consisted of UCVA


and BSCVA measurements, ultrasonic pachymetry, corneal computerized topography, and slit lamp and fundus examinations. For the surgery, the corneal epithelium was removed by mechanical debridement over 9.0 mm of the central region of the cornea following topical anesthesia. Photosensitizing solution (0.1% riboflavin within 20% dextran) was instilled every three minutes for 30 minutes, after epithelial debridement following anesthesia and inserting a wire lid speculum. Riboflavin penetrated into the anterior chamber and corneal stroma completely and the penetration was checked by slit lamp examination. Then, the UVA was irradiated on the cornea for 30 minutes (radiance of 3 mW/cm2), utilizing a 370 nm UVA double-diode light source. Over irradiating, the riboflavin solution was dropped every five minutes and a balanced salt solution was frequently applied intraoperatively to prevent dehydration of the cornea. Topical antibiotics were prescribed for five days along with tear substitutes for three to four weeks. The means of preoperative UCVA and BSCVA were 0.57 ± 0.34 and 0.15 ± 0.12 logMAR, respectively, and these values remained stable at the final follow-up (P = 0.990 and P = 0.227, respectively). The mean objective spherical equivalent decreased considerably from –6.00 ± 4.05 D preoperatively to –5.22 ± 3.71 D at the final follow-up (P < 0.05). The mean subjective cylinder value changed significantly from –4.05 ± 1.85 D preoperatively to –3.1 ± 1.42 D at the final follow-up (P < 0.05). There were no significant postoperative complications. The results of this study could mean that keratoconus patients could avoid a cornea transplant, which is major surgery. However, more studies with a larger sample size are required to confirm the effectiveness of CXL, said the paper. * Derakhshan A, Heravian J, Abdolahian M, Bamdad S. Long-term Outcomes of Collagen Crosslinking for Early Keratoconus. J Ophthalmic Vis Res. 2021 Apr-Jun; 16(2): 151–157.

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is a difference between corneal degeneration and CD. One occurs through trauma, infections and increasing age, while the other is a result of either inherited or de novo mutation. Corneal dystrophy also has a greater impact on eyesight than does corneal degeneration.

Rare, but Significant A review of corneal dystrophy by Joanna Lee


hen a patient presents with increasing, abnormal changes around the front corneal layer of their eyes, chances are corneal dystrophy (CD) could be lurking. CD is a hereditary, progressive disorder which worsens over time. In an exercise for continuing education on this disease, a group of researchers shared an overview, including its pathology, as well as its management.1

Classified and hereditary

of Corneal Dystrophies (IC3D) proposed that CD should be subcategorized according to the affected anatomic location on the cornea. Based on newer anatomic classifications, variants of CD are now listed under 1) epithelial and subepithelial dystrophies; 2) epithelialstromal dystrophies; 3) stromal dystrophies; and 4) endothelial corneal dystrophies. However, the researchers cautioned on the challenges of placing every single type of dystrophy under the four categories due to continuous discoveries and unique cases.

In 2015, the International Classification

It is important to be aware that there


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Interestingly, some genes, usually autosomal dominant, have been identified as factors leading to CD.2 The transforming growth factor-beta-induced (TGFBI) gene is mutated in epithelialbased dystrophies such as the Type I mutation of lattice corneal dystrophy (LCD) and granular corneal dystrophy (GCD Types I and II). A mutation in the Keratin gene (like KRT3 and KRT12) is found in Meesmann CD, while alterations in the UbiA prenyltransferase domain-containing protein 1 gene are behind Schnyder CD. X-linked dominant diseases like Lisch epithelial CD and X-linked endothelial corneal dystrophy (XECD) are X-linked dominant diseases where other inherited conditions like keratosis pilaris, or congenital hair-loss inducing inflammatory papules, could be concurrently present.3,4 Having said that, patients could present with a range of signs from asymptomatic to pain from corneal erosions, sensitivity to light, loss of visual acuity and other symptoms arising from genetic factors.

Signs of corneal dystrophy Historically, CD was diagnosed based on the patterns of deposits on the cornea — this was due to the lack of understanding of genetics.5,6 Currently, defining corneal dystrophies is determined according to the particular affected layers of the cornea. Corneal dystrophy symptoms usually show as a progressive loss of visual acuity. Some CDs present early in life, while others only surface in the later decades of life. A few types can already be in the severe form once detected, such as macular CD, congenital stromal CD and gelatinous drop-like corneal dystrophy (GDLD). These require keratoplasty to decrease the chances of serious vision loss.7 The first step in defining the type

of CD normally involves slit-lamp (biomicroscopy) examinations. Under examination, different types of CD subtypes can be identified further using light microscopy of histologic specimens. Besides histologic exams, genetic testing is also another way to more accurately diagnose the type of CD.

Symptoms and management For epithelial and subepithelial dystrophies (this category also covers epithelial-stromal dystrophies), patients usually have recurrent painful corneal erosions particularly in the mornings, due to the sloughing of the epithelial layer from night-time corneal drying. Under this category, one could find subtypes such as epithelial basement membrane corneal dystrophy (EBMCD); Meesmann CD (known as juvenile epithelial corneal dystrophy); ERED (epithelial recurrent erosion dystrophies), which covers Franceschetti corneal dystrophy; dystrophia smolandiensis and dystrophia helsinglandica. The treatment for epithelial dystrophies usually starts with artificial tears to smooth the friction from blinking and decrease sloughing on the epithelium. The same effect could be achieved through hypertonic nighttime lubricants which also reduce corneal edema within the intracellular space. For pain management, NSAIDs and bandage contact lenses could bring relief. However, for more serious erosions, doctors could perform superficial keratectomy, anterior stromal puncture, and phototherapeutic keratectomy (PTK). Stromal dystrophies have a high possibility of developing a loss of visual acuity8 as corneal haze is commonly found in conditions under this type of CD (such as macular CD). Macular CD presents with “grainy, ground glass-like opacities,” which are glycosaminoglycans that can look more like granular corneal dystrophy (GCD). Severe loss of visual acuity and photophobia in the second to third decade with mild erosions often occur as symptoms. Meanwhile, in Schnyder CD, expect to find a ring-like structure due to central crystalline subepithelial

deposits with a stromal haze. Other types of stromal dystrophies include congenital stromal CD (symmetric corneal clouding with white flaky stromal opacities), fleck CD, posterior amorphous CD and preDescemet CD. Because some dystrophies affect both the epithelium and the stroma, they are frequently linked with corneal erosion. On top of the more modest measures similarly employed for epithelial dystrophies, there may be a need for more invasive methods to manage stromal dystrophies. As such, automated lamellar keratoplasty (ALK), unlike the PTK, employs a microkeratome to cut deeper into the corneal surface, about 100 to 300 microns, to eliminate abnormal cells from the stroma.9 For patients whose dystrophy goes to the Descemet’s layer, deep automated lamellar keratoplasty (DALK) may be done for more corneal tissue removal. Endothelial corneal dystrophies are associated with Fuchs’ endothelial corneal dystrophy (FECD), posterior polymorphous corneal dystrophy (PPCD), congenital hereditary endothelial dystrophy and XECD.10 Generally, the signs of endothelial dystrophies are blurriness and halos as a result of corneal edema and thickening. In the case of FECD, there will be guttae along the Descemet’s membrane aside from corneal haze and edema, affecting visual acuity. PPCD can show up with vesicles, breaking bands and gray haze, along with the pain and eyesight issues related to glaucoma.5,11 Keratoconus is also a common feature. For XECD, endothelial cells that look like moon craters can be seen with “diffuse milky opacities.” In the treatment of endothelial dystrophies, Descemet’s stripping endothelial keratoplasty (DSEK) and Descemet’s membrane endothelial keratoplasty (DMEK) have been pivotal toward enabling better outcomes postsurgery in terms of speedier recovery rate, improved visual acuity, and less rejection of the graft due to non-impact on the ocular surface’s anterior side.

Often, physicians would be required to differentiate CDs. There may be an overlap of types of CD, and findings of different types need to be differentiated. Again, this is where genetic testing may be useful. Also, the symptoms of CD may arise from the presence of other ocular diseases. Considerations to include would be infectious keratitis, chronic uveitis (which deposits calcium in the cornea), hypercalcemia and sarcoidosis. Overall, CD is a collection of rare, hereditary diseases which affect the transparency of the cornea. Although uncommon, the review urged medical professionals to look for its signs when viewing through the slit lamp and checking the patient’s family history. A team approach among professionals in the field through physical examinations and lab testing would be beneficial to obtain a more accurate diagnosis and thus, enable patients to receive relevant treatment, surgeries if necessary, and follow-ups.


Moshirfar M, Bennett P, Ronquillo Y. Corneal Dystrophy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. 2021 Aug 11.


Bass SJ. Corneal dystrophies. Optom Clin. 1991;1(4):31-44.


Blanco-Kelly F, Rodrigues-Jacy da Silva L, Sanchez-Navarro I, et al. New CDH3 mutation in the first Spanish case of hypotrichosis with juvenile macular dystrophy, a case report. BMC Med Genet. 2017 Jan 07;18(1):1.


Verma R, Bhatnagar A, Vasudevan B, Kumar S. Keratosis follicularis spinulosa decalvans. Indian J Dermatol Venereol Leprol. 2016 MarApr;82(2):214-6.


Weiss JS, Møller HU, Aldave AJ, Seitz B, et al. IC3D classification of corneal dystrophies — edition 2. Cornea. 2015 Feb;34(2):117-59.


Miller DD, Hasan SA, Simmons NL, Stewart MW. Recurrent corneal erosion: a comprehensive review. Clin Ophthalmol. 2019;13:325-335.


Lin ZN, Chen J, Cui HP. Characteristics of corneal dystrophies: a review from clinical, histological and genetic perspectives. Int J Ophthalmol. 2016;9(6):904-13.


Klintworth GK. Corneal dystrophies. Orphanet J Rare Dis. 2009 Feb 23;4:7.


Lewis DR, Price MO, Feng MT, Price FW. Recurrence of Granular Corneal Dystrophy Type 1 After Phototherapeutic Keratectomy, Lamellar Keratoplasty, and Penetrating Keratoplasty in a Single Population. Cornea. 2017 Oct;36(10):1227-1232.


Adamis AP, Filatov V, Tripathi BJ, Tripathi RC. Fuchs' endothelial dystrophy of the cornea. Surv Ophthalmol. 1993;38(2):149-168.


Chaurasia S, Mittal R, Bichappa G, Ramappa M, Murthy SI. Clinical characterization of posterior polymorphous corneal dystrophy in patients of Indian ethnicity. Int Ophthalmol. 2017 Aug;37(4):945-952.

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The New Wave in Simplifying Cataract Surgery Workflow by Elisa DeMartino


n 2022, every industry of the world is datafied. And from artificial intelligence to big data and remote monitoring systems, fresh, databolstered potential constantly surfaces in medical technology. Ophthalmologists can, and should, expect more and more technological conveniences in their practices and procedures. Efficient datafication means immediate gratification when it comes to imaging and analysis. Equipped with wavefront aberrometry and its classic gold standard functions, the Pentacam AXL Wave by OCULUS Optikgeräte GmbH (Wetzlar, Germany) is quite literally riding the data wave. What does the Pentacam AXL Wave look like in action? Dr. Robert Ang, senior consultant at the Asian Eye Institute, is a long-time user of the Pentacam as well as the Corvis ST tonometer by OCULUS. The refractive, cataract and glaucoma specialist weighs in on how technology from OCULUS has simplified his workflow to help him better treat cataract, glaucoma and vision impairment. “They’ve [OCULUS] done a good job of putting in built-in software. You don’t have to go online or compute it any other way; it’s there for you to print out, both for refractive and cataract. I think that’s the biggest benefit of using the Pentacam system. Not only have they gone out of their way to make the machine accurate … but because of the interpretation of the print-outs, you can streamline it,” explained Dr. Ang. The Pentacam AXL Wave analyzes parameters taken from the patient during measurements. HartmannShack wavefront technology measures

high- and low-order aberrations of the whole eye; meanwhile, the Pentacam’s Scheimpflug-based tomography measures and analyzes the anterior eye segment. The machine also takes measurements for objective refraction


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and optical biometry. All of this is processed into an easy-to-read overview display. “We have this Fast Screening Report and Cataract Pre-OP Display where

almost all the data is there for me to see if the patient qualifies for LASIK, PRK or ICL (implantable collamer lens),” he said. Along with the combined Belin Ambrosia Display (BAD) and Corvis ST overview, Dr. Ang finds these two summary displays to be the most handy features of the newest Pentacam. “My principle is that by looking at it for one minute, you should already see all the data to make a decision of what to do — and you have that [with the Pentacam].”

“I test the same eye one month after surgery,” continued Dr. Ang. He reports that the Corvis ST is useful not just for screening, but also postoperatively to cross-check if the cornea remains structurally strong. Meanwhile, Dr. Ang uses the Pentacam AXL Wave after surgery to confirm if aberrations are within normal limits and to help explain the outcome to patients.

Before upgrading to the Pentacam AXL Wave, Dr. Ang used earlier iterations of the Pentacam for seven years, starting with the Pentacam Basic, which he acquired in order to validate corneas before laser refractive surgery.

These devices are pleasant to use for both the patient and the doctor. The patient doesn’t need to keep their eyes open for more than a few minutes overall: It takes just 1-2 minutes to use the Pentacam AXL Wave and another 1-2 minutes for the Corvis ST. There are no flashing lights and there’s no direct contact.

“I think Pentacam corneal screening is top-of-the-line or the most sensitive, especially with the software that has evolved in the Pentacam such as the BAD (Belin Ambrosia Display) and the TBI (Tomographic Biomechanical Index). These metrics help me screen an eye and decide which treatment I can do and which treatment I should avoid,” said Dr. Ang. The expert chose to upgrade to the Pentacam AXL Wave because of its ability to analyze aberrations, which helps him determine if the patient needs wavefront-guided LASIK. While adding the Pentacam AXL Wave features, Dr. Ang also ordered the Corvis ST to use in combination, which he says has been useful for him in everyday practice. “It adds another higher level of analysis: Aside from the structure of the cornea that the Pentacam analyzes, the Corvis ST evaluates the biomechanics — the strength of the cornea — which is not visible with the Pentacam. The Pentacam shows you the visible aspect of the cornea and analyzes that, whereas the Corvis ST reinforces it with the biomechanical index which helps me analyze further if the cornea is normal or abnormal, strong or weak,” he explained. The Corvis ST looks at the corneal biomechanical response to a defined air pulse using high-speed Scheimpflug images while also measuring its tonometry and pachymetry.

Serene overview sheets…

“Comfort-wise and speed-wise, it’s very patient-friendly. And it’s very easy for the technician: Click and autoshoot,” continued Dr. Ang. While the Pentacam, AXL and Wave used to be three machines, they’re now combined into one, requiring less space in the office and a third of the staff to operate them. “[There is] so much data in one sheet. We can use that sheet to make decisions and explain the basis of the decisions to the patient,” he said. It’s all there for the patient to see with pictures and color coded results: Red for nonviable options and green meaning “go ahead.” Dr. Ang also outlined the crucial data for cataract surgeries found on the Cataract Pre-OP sheet: “Number one: Does this patient have high astigmatism that needs a toric IOL? It’s there on the sheet. Second, [do they] have irregularities or higher order aberrations? If it’s higher than the cut-off, do not implant a multifocal IOL. If it’s lower than the cut-off, you can use a multifocal IOL. And the third is regarding spherical aberrations, where it tells you to use a non-aspheric or aspheric lens. These metrics have made decision-making safer for the patient.”

…for pristine results Dr. Ang leaves us with two final takeaways about incorporating the Pentacam AXL Wave into practice. “Let’s not forget that the AXL in the Pentacam means it checks axial length and biometry — this means it can help calculate the power of the lens to be put in the eye during cataract surgery. So, the AXL feature of the Pentacam is for cataract surgeons to compute the IOL with the formula the surgeon chooses. That’s the most important feature as the other biometry machines I have can only measure the IOL power. “But because I have a Pentacam AXL Wave, I can measure the IOL power and I can also check the cornea for any irregularities,” he shared. Why is this important? With the Pentacam AXL Wave, he can not only compute the IOL but also know whether the cornea is regular and what kind of lens can be put in. “That is very crucial for cataract surgeons who have a premium practice and want to implant premium ocular lenses. That data is critical in decisionmaking.” Again, it comes back to the value of datafication. “I’ve watched the hardware and software evolve over the years. The good thing about the Pentacam machines,” Dr. Ang said, “is that the company gathers more and more data into a database and keeps improving the software.” As always, OCULUS makes waves in ophthalmic technology by harnessing the power of data.

Contributing Doctor Dr. Robert Edward Ang is a senior consultant and head of Cornea and Refractive Surgery Services at the Asian Eye Institute in Makati City, Philippines. In 2018, he was voted as one of the Power List 100 by The Ophthalmologist Magazine. In 2019, Dr. Ang received the International Society of Refractive Surgery (ISRS) Presidential Recognition Award at the American Academy of Ophthalmology Refractive Surgery subspecialty day.

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t y l Sustainabi i gy

o l o in Ophthalm e e n p r ac t i c e s r g t a ok o l a ro u n d t h e w A e c a l p orld in by Ben Collins

and intensive agriculture being at the forefront.


limate change, and its potentially catastrophic effects, are now clearly observable and beginning to be felt all over the world. More unpredictable and extreme weather events, increased prevalence of disease, food scarcity and even political unrest are examples of this. The reality is, even in the best case scenario, our planet is going to be about 2.5 degrees Celsius warmer by the end of the century.

Health care and our carbon footprint


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Many of us are aware of the major emissions contributors in our lives. We all know we need to use our cars less. Reduce, reuse and recycle more. We’re most likely familiar with industries that are big polluters as well. Energy

But are we conscious of the contribution the health sector makes toward global emissions? The figures may surprise you. Globally, health accounts for around 5% of all greenhouse gas (GHG) emissions. The U.S. has the highest carbon footprint from health, sitting at 10% of total emissions. While in the U.K. it’s around 5%, and within New Zealand and Australia, numbers range from between 4-7%.1 These stats should be (and are), a cause for concern.

Dr. Cassandra Thiel, PhD, a leading researcher in sustainable healthcare, explained it well at the recent plenary session at RANZCO Brisbane 2022 where she was a guest speaker. “We have finite financial and environmental resources. In healthcare, we have been given a pass quite often (on both counts), when actually we can’t afford, financially or environmentally (or socially for that matter), to keep doing things the way that we have been,” she said. Ophthalmology is as guilty as any other department here, too. Cataract treatment, in particular, is a huge emissions producer. Using existing practices (those employed in most affluent Western countries), a single cataract surgery emits around the same amount of CO2 as the average person generates in a week. Most of this is taken up by transport and energy costs (both in the procurement of materials and commuting of patients and staff), but there is a great deal of waste involved also. According to 2011 estimates, Dr. Thiel shared that drug waste from cataract surgery in the U.S. alone results in an unnecessary 23,000-105,000 metric tonnes of CO2 emissions per hospital. That’s equivalent to driving the length of that country 4,600-51,000 times!

But what can we do about it?! So, we know the scale of the problem, the question is what is being done to fix it? Well, there is action. While tackling climate change can seem overwhelming, especially from a health perspective, there are emerging success stories we can aspire to and learn from. We touched briefly on the huge carbon footprint generated by modern cataract treatment techniques like phacoemulsification. There are, of course, alternatives to this method. Manual small incision cataract surgery (MSICS) has been found to be a safe and effective technique for cataract

Cataract footprinting Measuring your carbon footprint is not technically or conceptually difficult, but requires a researcher to collect and measure some data.

the cost and with drastically reduced emissions. This is mostly due to their high volume approach (performing up to 1500 cataract surgeries a day) which minimizes energy and electrical footprints. They also sterilize and reuse materials extensively. Phacoemulsification undertaken at AECS results in the generation of around 6kg CO2eq, compared with 130 kg CO2eq per procedure in the U.K. That’s around a 95% reduction in emissions!1 So with the proven effectiveness of the AECS’ treatment model (and given the urgency of the climate crisis), one could be forgiven for wondering why these techniques have not been adopted worldwide?

extraction. It’s also considerably better for the environment. Phacoemulsification machines use more energy, create more waste and are 1.4 to 4.7 times more expensive than MSICS. Unsurprisingly, MSICS is used predominantly in developing countries where cost effectiveness is of the utmost importance.1

Dr. Jesse Gale, an ophthalmologist from Wellington, New Zealand, and RANZCO chair of sustainability, muses much the same.

New Zealand has a largely renewable energy grid, so energy emissions were lower.

“The carbon footprint of cataract surgery in India is about 5% of the footprint in the U.K. or New Zealand, and yet the safety and quality of their surgery is maintained (i.e, infection rates, visual outcomes). So, they save huge amounts of money, have an incredible work rate, and emit far less carbon, which are all things we could aspire to in our practice. It is interesting to think about the barriers that stop New Zealand ophthalmologists from immediately practicing like Indian ophthalmologists.”

The main source of emissions is procurement.

Lessons from the developing world In many ways, developing nations are in fact leading the world when it comes to sustainable ophthalmological practices. A particularly inspirational example of this can be found coming out of India. The Aravind Eye Care System (AECS) is able to perform phacoemulsification procedures (to the same exacting standards of safety and efficacy as expected in the West), at a fraction of

Indeed. While existing regulations are ostensibly in place with patient safety

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in mind, and liability (particularly in the U.S.) is a factor for manufacturers, perhaps it is time we readjusted our expectations and ideologies? Both as patients and practitioners, to be more in line with sustainable surgical practices in other parts of the world?2

Sustainable ophthalmology in the antipodes*? On that note (and being from the region myself), I wanted to know where exactly things were Down Under,** in terms of coming up with and implementing a strategy to mitigate unnecessary emissions in the ophthalmology sector… Aotearoa/New Zealand and Australia


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are both renowned for their spectacular scenery and relatively untouched natural beauty. New Zealand, in particular, has been the poster child for the “clean and green” image for decades. But are these accolades really warranted? What policies or actions are these countries implementing across the board (health and ophthalmology included) toward a more sustainable future? Because despite their relative geographical isolation Down Under, neither is excluded or exempt from the global existential threat posed by anthropogenic climate change. Well, it seems their resident ophthalmologists are not only keen to ensure your eye health is in tip top shape to take in all those breathtaking views, but they also want to make certain that it's done sustainably

Let’s survey the ophthalmological landscape of the area The first steps (which are well under way), center on assessing/ measuring emissions, as well as gauging the sector's willingness to be proactive in tackling the issue. A recent survey conducted by RANZCO (Royal Australian and New Zealand College of Ophthalmologists) suggests whilst ophthalmologists in the region are generally on board and up to speed with what's required, there are some notable gaps around the implementation and incentivization of sustainable practices.

Climate change skepticism in eye care The survey also revealed a not insignificant minority of ophthalmologists who disagreed with statements on anthropogenic climate change in general. In New Zealand, some 15 to 19% disagreed that climate change was urgent, or that climate change required mitigation, or that climate change would affect health. A larger minority of 19 to 23% disagreed with the proposal that ophthalmologists or RANZCO should advocate in the domain of climate change.3 Over the ditch,*** the numbers were even higher, with up to 28% of Australian practitioners expressing opinions of this nature.4 While this is concerning, Dr. Gale, one of the survey's co-creators, says it’s important to focus on the positives. “I was a bit surprised that the level of concern around climate change was lower in ophthalmologists than the

* New Zealand and Australia are sometimes called the “antipodes” because they are on the other side of the earth from Britain. ** The term “Down Under” refers to the relative geographical location of Aotearoa/NewZealand and Australia at the bottom of the global atlas. ***“Over the ditch” is an affectionate colloquial expression used by Kiwis (New Zealanders) and Ozzies (Australians) to refer to their respective neighbors' location on the other side of the Tasman Sea, a stretch of water which divides the two countries.


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general population of New Zealand and Australia,” said Dr. Gale. “The surveys showed that female, urban and younger ophthalmologists had more concern about climate change and more appetite for action to address it, so our profession is catching up. I don't think there is a significant roadblock or barrier to progress in this domain, as even the most climatedenying individuals will not affect the momentum of the college or society generally. There is 70% agreement that climate change needs action from the health sector, which is fairly solid agreement on any issue.”

Coordinated central government policy, highlevel and top-down changes required

“I have been very pleased by the encouragement and enthusiasm from the RANZCO board, so I feel our professional organization is moving in the right direction. Within our public hospitals (DHBs) in New Zealand, I know that sustainability officers are very busy, mostly with the first task in the process of measuring emissions. There was a brief government statement that all public sector work would be carbon neutral by 2025, but there is a lot of work to be done before that looks realistic. The Greener NHS project in the U.K. is much further along this pathway, with a goal of neutrality in 2045, and their efforts lead the way in this field,” pointed out Dr. Gale.

separate state and local public ophthalmology services, so it is less easy to create a unified approach and to motivate decarbonization. In the New Zealand system, our 20 DHBs are to come under one operational body in the near future, and a carbon neutral public sector is now an urgent priority, so the work to decarbonize health care is rapidly accelerating,” he continued.

Measuring, made easier! New technologies with the potential to help optimize resource use and reduce unnecessary emissions are emerging within the ophthalmology sector as well. Eyefficiency, an application which can be used to estimate carbon footprints, is proving to be particularly useful. This application was used as the primary measurement tool in a recent study which aimed to assess the carbon footprint of cataract surgery in Wellington, New Zealand.5 The study examined emissions generated from phacoemulsification procedures within four hospitals, two public and two private. It focussed on four main areas: (1) power consumption, (2) procurement of disposable items and pharmaceuticals, (3) waste disposal emissions and (4) travel.










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In New Zealand, efforts are being made to optimize sustainability in outpatient clinics, where patient travel accounts for 10 to 16% of emissions. Virtual clinics, combining onestop surgical clinics with community postoperative checks, and community optometry clinics for low-risk glaucoma st are some strategies so sa ur being used to minimize lie ce p p of su unnecessary travel. The study found cataract em se u iss e l ion More investment in cloudsurgery in Wellington, New Zealand ing s is d of s n r i ve n by o i t based technologies to support had a similar carbon footprint to that p consum telemedicine (online consultations/ seen in the U.K. and other developed diagnosis) would help to reduce nations. The average emissions unnecessary travel. Following the UK’s lead produced by cataract surgery in the region were estimated to be around However, most of these initiatives “The British National Health Service 152kg CO2. This is equivalent to are not supported by current private is a massive public health system burning 62 liters of petrol, and would practice funding, or prioritized by with central governance and funding take 45m2 of forest approximately one district health boards (DHBs). Unless and they have been working towards a year to absorb. Extrapolate this data sustainability initiatives are encouraged sustainable system for years longer than across the 30,000 cataract surgeries and used as performance indicators, us,” said Dr. Gale. performed annually in New Zealand, ophthalmological practices are going and we wind up with approximately to lack the motivation to implement “The Australian system is more 4,500 tonnes of CO2. This would take them.3 fragmented, with more ophthalmology 134 hectares of forest roughly one year delivered in private settings and to absorb!

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The majority of emissions were from procurement, mostly of disposable materials, and the second largest contribution was from travel (driving). Emissions from electricity were much less significant in New Zealand (1.8kg CO2eq compared to the U.K. 66kg CO2eq). This is predominantly due to the majority (82%) of the country’s electricity coming from renewable sources such as hydroelectricity. New Zealand government policy aims to increase the renewable energy sector to the theoretical maximum by 2030, so this is an area where the small island nation is really leading the way. While there may be some discrepancy in emissions measurements for procurement (measurements were based on 2011 data for production and supply of general medical equipment, relying on cost to calculate emissions and don’t necessarily take into account product life cycles, etc.), this is quite clearly an area where New Zealand can work on reducing emissions. The study points to the importance of The

Pharmaceutical Management Agencies (PHARMAC) role here in future procurements. Their newly designated role to bulk-purchase surgical supplies represents a major opportunity both to improve measurement of emissions related to procurement, and to leverage reductions in emissions during contract negotiations. More innovative commuter options are suggested to mitigate travel emissions. Examples of subsidy partnerships between local government and public transport such as the BusinessEcoPass initiative in Boulder County, Colorado, USA, are seen as viable incentives. Hospitals should also invest in facilities to make active modes of transport such as walking or cycling more attractive (e.g., more safer cycle ways, walking paths, etc). Active commuting not only leads to reduced emissions and improved air quality, but an active population leads to better physical and mental health. Reducing demand for healthcare is itself a key component for a low carbon health system.

The study provides a useful benchmark for comparing cataract surgery in New Zealand with other hospital systems around the world. It highlights areas where emissions reductions can be targeted (namely travel and procurement), as well as the requirement for more complex systemic changes. It calls for comprehensive top down sustainability policy from central and local government, as well as changes in behavior from individual practitioners.

COVID-19: Sustainability setback or opportunity? It’s important to remember all of this has been unfolding against a backdrop of the global COVID-19 pandemic. Many sustainability initiatives (especially within the health sector) were put on the back burner in favor of stricter hygiene practices. Personal protective equipment (PPE) was in such demand that supply chain issues were experienced worldwide. Although necessary, increased use and production of PPE obviously creates more waste and emissions. It’s important that we learn from this crisis and innovate for the future. As we know, pandemics are also a symptom of climate change, and it’s unlikely this will be the last. Many innovative sustainability strategies actually emerged during the pandemic. These can and should be applied to healthcare moving forward. Telemedicine, virtual reality, artificial intelligence, and even smartphone apps for testing vision, are all technologies which can be applied not only to minimize risk in terms of spreading disease, but also to reduce emissions by limiting unnecessary hospital visits. Use of multidose pharmaceuticals should be encouraged over single-use products. Reusable or biodegradable medical equipment has a minimal environmental footprint, and production could be scaled up and materials stockpiled for future crises.6


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“Technology will help with creating more reusable things, like reusable drapes, gowns, phaco tubing and cassettes, and surgical blades. There are companies that collect single-use blades and check, sharpen and sterilize them, then sell them back cheaper than a brand new one. As carbon pricing starts to come in, reusable technologies will suddenly be much cheaper than single use items,” said Dr. Gale, who is somewhat of an innovator in this area himself, with a research interest in producing inexpensive 3D printed medical devices. “We do need to learn quickly that safety does not always require single-use disposable PPE. Reusable PPE is very safe and effective in most situations, and this could be an area where technology can help. Remember when we found out that masks can be washed in the washing machine at least 10 times? Amazing how many [disposable] masks could have been avoided. We have learnt some things from COVID that are helpful lessons for future sustainability, like considering flights carefully, working from home can be effective, and telemedicine can reduce resource consumption and travel,” he continued.

effective. Climate change affects all of us, and so it is everyone's responsibility to do whatever we can to mitigate it. Doctors in particular enjoy a position of influence and leadership in society, and have a responsibility to act for public health. There is growing acceptance in the ophthalmology community that all doctors should have a voice to support a healthy climate future through decarbonizing healthcare and adapting health systems.

Where to from here? In summary, it might be useful to look back at some of the key points and comments from the RANZCO Brisbane 2022 plenary. Climate change and sustainability remains a broad reaching conundrum. It’s easy to feel overwhelmed, or that our actions as individuals are insignificant. But if our efforts are targeted and unified, they can still be

For RANZCO itself, Dr. Gale outlined some key areas where the College can actively seek to mitigate climate change. He talked about advocacy and collaboration with other colleges and industry, both locally and internationally, to establish sustainable practice guidelines. Continued engagement with trainees and fellows, especially around developing tools and systems for accurately measuring emissions, will continue. Corporate sustainability means measuring the footprint of College activities and investments, and acting to divest from polluting industries and minimising the emissions from college activity. Finally, he touched on the importance of continually looking to innovate in ways that are more sustainable, but that don't compromise on the quality of treatment or patient safety.

Contributing Doctor REFERENCES: 1.

Wong YL, Noor M, James KL, et al. Ophthalmology Going Greener: A Narrative Review. Ophthalmol Ther. 2021 Dec; 10(4): 845–857.


Thiel CL, Schehlein E, Ravilla T, et al. Cataract surgery and environmental sustainability: Waste and life cycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017;43(11):1391-1398.


Chandra P, Gale J, Murray N. New Zealand ophthalmologists' opinions and behaviours on climate, carbon and sustainability. Clin Exp Ophthalmol. 2020 May;48(4):427-433.


Gale J, Sandhu SS, Loughnan MS. Australian ophthalmologists' opinions on climate and sustainability. Clin Exp Ophthalmol. 2020 Nov;48(8):1118-1121.


Latta M, Shaw C, Gale J.The carbon footprint of cataract surgery in Wellington. New Zealand Medical Journal. 2021 Sept;134(1541):3.


Thiel C, Schuman JS, Robin AL. Severe Acute Respiratory Syndrome Coronavirus Disease 2019: More Safety at the Expense of More Medical Waste. Ophthalmol Glaucoma. 2022 January-February; 5(1): 1–4.

Dr. Jesse Gale is an ophthalmologist in Wellington, New Zealand. He chairs the RANZCO sustainability committee and practices mostly in glaucoma and neuro-ophthalmology. He has a range of research interests including sustainable ophthalmology and inexpensive 3D printed medical devices, biomechanics and pressure gradients affecting the optic nerve, and electrophysiology of optic neuropathy.

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How can we make cataract surgery more sustainable?


t’s no secret that the environmental cost of cataract surgery is high, and that the healthcare sector is a major contributor to global carbon emissions. So, what practices can ophthalmologists incorporate today for a more sustainable tomorrow?

To find out, a recent survey* was answered by 1300 cataract surgeons and their operating room (OR) nurses. Here’s what they found…

On the threat of global warming



were concerned about global warming

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On operating room waste


believe that operating room waste is excessive and should be reduced

On reusable instruments





believe more supplies should be reused (i.e., topical and intracameral medications, phacoemulsification tips, irrigating solutions/ tubing, blades, cannulas, devices and surgical gowns) consider single-use product packaging wasteful

believe that profit, liability reduction and the failure to consider carbon footprint drives manufacturers to produce more single-use products want more reusable products and more regulatory and manufacturer discretion over when and which products can be reused

On reducing waste


93% 97%

* Chang DF, Thiel CL, Ophthalmic Instrument Cleaning and Sterilization Task Force. Survey of cataract surgeons' and nurses' attitudes toward operating room waste. J Cataract Refract Surg. 2020 Jul;46(7):933-940.

currently were using or would consider using short-cycle sterilization currently do or would send unused topical medications home with patients currently do or would donate unused surgical supplies

On the role of ophthalmic societies


wanted medical societies to advocate for reducing the surgical carbon footprint

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How to Succeed in 2022 as a Female Ophthalmologist by Elisa DeMartino


very March 8, the global community devotes one day to celebrating the women of the world. While the tradition of setting aside a day to highlight the struggles and achievements of females goes back decades further, the official global holiday was recognized in 1977 by the United Nations, when it was proclaimed an official day to commemorate women’s rights. International Women’s Day 2022 has come and gone, but recognizing female achievements is always relevant, especially in fields typically dominated by men, like medicine. As recently as the 1970s, a female ophthalmologist was a rare, practically mythical being. So rare, in fact, that when Dr. Patricia Bath joined the UCLA faculty as their first female ophthalmologist in 1974, she was given a desk in the female secretaries’ room instead of in an office with a man. She graciously faced the obstacles of being a female, AfricanAmerican doctor and became known for inventing the Laserphaco Probe


device for laser cataract surgery (TIME, 2017).

challenges. I learned through the school of hard knocks.”

Dr. Cynthia Matossian is another pioneering female in ophthalmology. When Dr. Matossian started her own practice 35 years ago, there were still few female ophthalmologists in the U.S. and around the world. Her OR locker was in the nurses room since female surgeons‘ locker rooms were non-existent. She spoke with CAKE magazine about her experience opening integrated ophthalmology offices in New Jersey and Pennsylvania.

Dr. Matossian specializes in refractive cataract surgery and dry eye. She works to deliver the best corrective vision postoperatively to her patients by using advanced technology implants and by taking each person’s visual needs and hobbies into consideration. With her foresight and passion, she also built herself a subspecialty in dry eye disease early on.

“When I started the practice, there weren’t many women ophthalmologists, whereas now about 50% of medical school students are women and almost 50% of residents going into ophthalmology are women. But 35 years ago, the landscape was very different. To start one’s own practice in that era was even more atypical. I was not only working full-time, but having a family as well … I’m so glad I did it despite the

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“To get really good refractive outcomes you need a stable tear film in order to capture reliable data … and to get that data you have to truly tune up and optimize the surface. So that’s how I got into dry eye disease years and years ago before it was a hot topic,” Dr. Matossian clarified about her subspecialty. A few years ago, the specialist sold her practice, Matossian Eye Associates, to a private equity-backed entity; she no longer owns Matossian Eye Associates, which is now an affiliate

of PRISM Vision Group. As of March 1, 2022, Dr. Matossian stopped direct patient care and has now pivoted over to a consulting and advising role.

in Ophthalmology (WIO), previously holding the role of chair of the development committee and chair of one of their skill transfer labs “With organizations called the “Dry Chatting from Eye Wet Lab,” like OWL and WIO, Antigua and held at their women are encouraged positively glowing annual meeting. to further hone their in light of her WIO hosts both accomplished physical and leadership skills [and] milestones — or virtual sessions get an opportunity to perhaps that focusing on was thanks to clinical trials, network with people in the Caribbean financial literacy, the C-suite of different sunshine — she inclusivity, companies. All of these offered advice diversity and to female young more; they create opportunities to ophthalmologists even have a further one’s career. By starting on the path scholarship she was once on. having these connections program for underand these established represented relationships, forging Reaching out minority women for which they those paths for women In 2022, women fund medical has become easier.” in ophthalmology students’ trips are fortunate to meetings to to have many resources at their expose them to ophthalmology. disposal to successfully establish themselves. Harnessing the support of The organization provides a means a professional network is, like in most for women to reach out to each other. industries, an irreplaceable part of They can harness the community’s building a career. infrastructure to send emails or use the chat lines for employment Ophthalmic World Leaders (OWL) is opportunities, partnership negotiation a membership organization founded advice or get input for challenging over 15 years ago that aims to case management. Some practices promote diverse leadership to advance also use the network to recruit new ophthalmic innovation and patient physicians. care. It creates opportunities for collaboration as well as professional “The medical advice provided by and personal development. Dr. colleagues for complex cases really Matossian is involved in various OWL helps you help your patients; you functions; a few years ago, she was the don’t feel alone.” Dr. Matossian recipient of OWL’s Visionary Award, spoke highly of WIO: “It’s a real which honors individuals who have sisterhood of ophthalmology.” paved the way for diversity in their field through significant achievement. In some countries, women are free from the role of sole homemaker and OWL holds several events throughout child-rearer, enabling them to devote the year, hosts a fellows program, and equal time to the workplace as their gives three annual awards. “They have partners. In others, women are still virtual functions on specific topics, like expected to fill traditional roles, and inclusivity, diversity, and leadership they struggle to be seen as equals training,” Dr. Matossian explained. professionally, so their challenges as doctors are multiplied. That’s why WIO The expert is also involved with Women also has an international chapter for

women from all over the world to share their struggles and receive words of encouragement or advice from their cohorts. Dr. Matossian sees OWL and WIO as game changers for female doctors. “When I started in ophthalmology, I didn’t have a woman mentor; there weren’t women I could reach out to like the women in these two organizations … these didn’t exist. I’m so happy that times have changed, providing many more wonderful opportunities for women in ophthalmology now.” Before heading back to the beach to continue her well-deserved vacation, Dr. Matossian voiced a final bit of guidance to female ophthalmologists struggling or just striving to accomplish their goals. “Don’t feel that you are alone; don’t feel that you’re in a silo. Reach out! Take the initiative to contact other women ophthalmologists. Most are more than willing to help, but they can’t read your mind, so unless you reach out, people won’t know.”

Contributing Doctor Dr. Cynthia Matossian, MD, FACS, is the founder 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 the president of the American College of Eye Surgeons and the president of the NY IOL Implant Society. She was on the board of 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.

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eLos: The Cream of the e-Learning Crop by Sam McCommon


n the medical world, the last couple of years have seen an enormous proliferation of digital conferences, online learning platforms, webinars and more. Indeed, we here at CAKE magazine have been deeply involved with this proliferation, and think it’s one of the neatest things we’ve come across in our many years in the ophthalmic field. But inevitably, the cream rises to the top in the medical world, and the same holds true with online educational platforms. There’s only room for so many — there’s not only a limited number of ophthalmic professionals, but also limited attention span for each individual. Such is the premise of the paper Tips to optimize digital education in ophthalmology: Results from ESASO survey, on behalf of the eLOS study group which has recently been accepted for publication in the European Journal of Ophthalmology.*


So, that’s why we’re here to talk about the eLos learning platform, supported by the European School for Advanced Studies in Ophthalmology (ESASO). The platform is unique in terms of its quality, privacy and interaction. To get a better feel for the platform, we spoke with Prof. Mario Romano, professor of ophthalmology at Humanitas University in Milan, Italy, and holder of other illustrious titles as well. Notably, he’s the scientific director for ESASO’s eLos platform. We also spoke with Richard Packard, a veritable legend in the ophthalmic world and guru of cataract surgery, having taught in more than 60 countries and performed surgeries in more than 20. So, what makes the eLos platform so special? What can we expect from it now and in the future? Let’s dive in.

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eLos: Connectivity, community, learning and privacy Prof. Romano introduced us to the concept of the eLos platform, which we just love. Simply put, it’s a custombuilt online learning platform and an active community where ophthalmic specialists can share information with confidence. There are four key elements that define the eLos platform, said Prof. Romano. It’s a community for ophthalmic specialists, it’s private (i.e., requires an invitation and/or confirmation that the members are health care professionals), it’s a safe place for sharing and learning, and the functionality of the platform facilitates interactivity and keep the engagement between the doctors as well as between the students and the teachers. Because ophthalmology is a unique specialty, ophthalmologists need a place that’s just theirs. That idea led to the concept of a specialist community, defined by what it is rather than what it isn’t.

ESASO is currently the gate keeper for membership, which helps ensure that active members are indeed not just knowledgeable ophthalmologists, but those that are genuinely interested in learning and sharing their experiences. Trolls and fake accounts are booted out, of course, as are those who produce poor content, but these types of accounts are usually prevented from entering in the first place.

a current or aspiring ophthalmologist can get top-notch information without having to book a plane ticket.

Industry support

With the support of industry pioneers like HOYA Surgical Optics (Singapore), ophthalmologists on the platform can also count Prof. Mario Romano and Mr. Richard Packard on additional information and resources. Their freely uploaded and questions freely group called “Masters,” Crucially, because ophthalmologists asked — negativity, badmouthing and offers high-quality educational content, frequently share videos and ask the like have no place on the platform. courses, and events to meet surgeons’ questions on the platform, they need to This ensures a positive atmosphere that learning needs. It’s a place where be able to do so away from the prying encourages learning and improvement. ophthalmic specialists can exchange eyes of patients and detractors. As Prof. their points of view and learn from other Many viewers may simply want to Romano noted, one bad review or leak masters. And their group called “CME communicate directly with the lead of confidential information can make courses for aspiring masters” hosts surgeon that has shared a video and not doctors reluctant to share information. courses available for continuing medical with the wider community — and the So, to ensure confidence, the platform education credit. In fact, the first series platform offers that possibility. is limited to those who are confirmed of courses are taught by Mr. Packard. health care professionals. As of now, As readers well know, keeping current Mr. Packard alluded to a bit of “content the majority of the 13,000 members on with surgical trends and educational fatigue” when it comes to online the platform are European. However, we requirements is crucial to success in content in ophthalmology, and we can reasonably expect membership to the modern world of ophthalmology. We completely understand. That’s why grow across other continents as well in all know how quickly treatments evolve, differentiation through the quality of the coming years. and having industry backers keeps eLos content and the interactive experience especially relevant. provided is paramount, and why we A major focus of eLos is on active think eLos will succeed in the long run. learning. While a platform like YouTube Want to know more? Be sure to check can be great for passive learning by out the eLos website and see what’s watching videos, those who share going on at ESASO. Be sure to also Learning across borders their videos and queries on eLos can regularly check the ESCRS website, be sure their viewers and responders Mr. Packard’s home turf, for continual One crucial element that’s lacking in will be knowledgeable and respectful updates and publications. And be sure much online learning is interactivity professionals. That’s the kind of to come check back with us regularly, — something that many ophthalmic situation real learning can take place too, as we’ll keep a close eye on eLos. trainees may not get much of in many in. May the winds of fortune carry you to countries. As Mr. Packard poetically put favorable pastures. it, training is often far too didactic in many places. It can ignore the human What kind of content is on elements of curiosity, experience and connectivity. That’s where eLos really eLos? * Ferrara M, Romano V, Iovino C, et al.; e-LOS shines: With real, human connectivity Study Group. Tips to optimize digital education in ophthalmology: results from ESASO survey. The eLos platform hosts a wide variety and a lack of fear of judgment, learners Eur J Ophthalmol. [In press] of content that can be beneficial to of any ability level can up their all in the ophthalmic industry. For knowledge levels. example, live and recorded surgery This article is sponsored by HOYA Surgical Optics videos, webcasts, tele-mentoring and Completing a fellowship in a country in cooperation with ESASO – European School for Advanced Studies in Ophthalmology for educational company-shared information can all like the U.K. or Italy isn’t always purposes. find a home on eLos. doable, but ophthalmologists in countries around the world still need One thing that sets eLos apart from the most up-to-date educational info to its competitors, as mentioned, is that give best possible care to their patients. ESASO moderates the community. So, a platform like eLos fits that bill While this is passive — content can be just right: In a collegial atmosphere,

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Accessible Eye Care for All

Measures for improving eye health among Aboriginal and Torres Strait Islanders by Tan Sher Lynn


ine years after the release of the Roadmap to Close the Gap for Vision policy framework in 2012, eye health access and outcomes for Aboriginal and Torres Strait Islander Australians have improved measurably. Yet, more needs to be done. On Day 4 of the 52nd Annual Scientific Congress of The Royal Australian and New Zealand College of Ophthalmologists (RANZCO Brisbane 2022), ophthalmologists discussed strategies and approaches to improve eye health outcomes for this particular group of patients

Expediting access for indigenous patients Dr. Kristin Bell from the Royal Hobart Hospital (RHH) shared how her hospital’s eye department is expediting access to services for indigenous patients.

She noted that a huge number of referrals per week (typically faxed and paper referrals) and unwieldy processes are just some of the referral and surgical booking barriers that exist in the hospital. Patients who identify as Aboriginal and/or Torres Strait Islander are rarely included in referrals, and this information is not visible in the patient’s digital medical record (DMR) details.

(the Outreach Eye Team) work closely with the visiting optometrists, remote doctors, nurses and indigenous health workers. However, the number of ophthalmologists required to service the Northern Territory population is not being met yet. There are currently only five ophthalmologists available, while the number required for the population is more than nine,” she said.

Dr. Bell added that solutions are being undertaken to overcome these barriers. These include educating referral bases — working with general practitioners, optometry and AMS liaisons; having triaging processes in place — ensuring measures to ‘close the gap’ are wellknown by triage staff; providing reception staff to ask questions which identify patients as aboriginal; and having e-referrals.

Dr. Whist noted that a change for outreach approach might be needed, as some of the communities that they are visiting have very low attendance rates.

Overcoming more challenges

“Aboriginal and Torres Strait Islander people make up 4.6% of the Tasmanian population (2016 consensus data) and 5.3% of outpatient appointments at the RHH eye clinic,” shared Dr. Bell. “Areas that we are focusing on in order to expedite access to services for this group of patients include prioritizing new outpatient appointments and access to elective surgery, locating indigenous patients already on the waitlists and expediting their care, and ensuring the RHH Eye Clinic is providing a welcoming and safe space,” she added.

Meanwhile, sharing her outreach experience in the Top End, Dr. Eline Whist from the Royal Darwin Hospital said that practicing ophthalmology in rural and remote areas comes with its own unique set of challenges and rewards.


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“Traveling in the Top End involves vast distances. Due to the tropical weather, many communities are completely inaccessible by road during the wet season,” shared Dr. Whist. “Hence, trips to these areas tend to be resource and labor-intensive. We

Currently, approximately 100 cataract surgeries are performed a year at the Katherine and Gove hospitals, and the number of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections given during outreach trips continues to rise. In total, the outreach team spent more than 100 days a year in the Top End.

“Non-attendance numbers are observed to be lower in clinics with long-term and enthusiastic staff that know the community well,” she said. Other ongoing challenges that are to be addressed include inconsistent funding, staff shortage, remoteness and logistics, cultural and language barriers (no aboriginal liaison officer positioned in the Top End for the last two years), poor health literacy, and social and financial barriers.

Editor’s Note: A version of this article was first published in Issue 4 of CAKE & PIE POST, RANZCO Virtual 2022 Edition.



A unique hybrid show with hundreds of in person guests, international speakers and exhibitors as well as engaging and entertaining coverage available online.



Email to register.

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Paradigm Shift Taking a proactive approach to glaucoma management by Joanna Lee


ith the greater availability of surgical options offering good safety profiles, Dr. David Woo — consultant ophthalmologist and assistant medical director at International Specialist Eye Centre (ISEC) in Kuala Lumpur, Malaysia — said it may be time to switch from traditional reactive mode to a more proactive approach in managing patients’ intraocular pressure (IOP).

This statement succinctly captured the approach and essence of the recently held Asia-Pacific Glaucoma Society (APGS) webinar on New Surgical Techniques in Glaucoma Treatment. Helmed by experienced glaucoma specialists, this webinar explored fresh perspectives on glaucoma management and surgical techniques.

Benefits of earlier interventions Traditional glaucoma surgeries


have long been reserved as a last resort for advanced-disease stages. Nevertheless, according to Dr. Woo, benefits for early surgical intervention are emerging. “The way we treat glaucoma is changing and we may be headed toward earlier interventions in glaucoma surgery,” he said. The advantages include proactively lowering IOP, which can decrease the burden of topical treatments while possibly mitigating adherence issues. By achieving a lower IOP earlier, there are fewer IOP fluctuations — and thus, resulting in better quality of life (QoL) for the patient. This is also more costeffective over their lifetime, Dr. Woo said. There are several minimally-invasive glaucoma surgery (MIGS) devices with a better risk-benefit profile. These include MIGS devices that target the trabecular meshwork such as iStent (Glaukos, California, USA) and Hydrus

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(Ivantis, California, USA), as well as those that take the subconjuntival approach like the XEN gel stent (Allergan, an AbbVie company, Dublin, Ireland) and the PRESERFLO microshunt (Santen, Osaka, Japan). The iStent has a good body of evidence for reducing IOP and dependency on medication. Meanwhile, the Hydrus also shows positive outcomes when compared to standalone cataract surgery,1 the two G1 iStents,2 as well as selective laser trabeculoplasty (SLT).3 The XEN implants for subconjunctival MIGS were FDA approved in 2016 for POAG (primary open-angle glaucoma), PxF (pseudoexfoliative glaucoma), and PDG (pigment dispersion glaucoma) with open angles. Dr. Woo shared that XEN can be combined with cataract surgery, using an ab interno approach. However, XEN has its reported risks: Up to 46.2% of patients require

needling or revisions for bleb fibrosis in the first 12 months, and up to 39.2% of patients require more than one needling in the first 24 months. Hypotony and late erosions are also possible.

Cataract surgery in glaucomatous eyes There has been insufficient evidence to justify performing cataract surgery for lowering IOP in POAG patients. But for PAC (primary angle-closure) and PACG (primary angle-closure glaucoma) patients, it may be justified. “It’s like killing two birds with one stone (for cataract) as demonstrated in the EAGLE study,” said Prof. Poemen Chan of Chinese University of Hong Kong. In a discussion about cataract surgery in glaucoma patients, Dr. Chan raised the issue of IOP spike shortly after phaco, which is very risky for eyes with retained viscoelastics, prolonged surgery, retained lens debris, iris pigment, inflammation and hyphema. Other complicating factors include posterior capsule rupture (PCR), vitreous prolapse, placement of sulcus IOL, and pseudoexfoliation, among others. Thus, careful preoperative, intraoperative, and postoperative measures are vital, shared Dr. Chan. Dr. Woo added that the EAGLE study showed that in PACG patients with a clear lens and ocular pressure of 30 mmHg or

higher, removing the lens itself (i.e., via cataract surgery) may be more efficacious than performing peripheral iridotomy.4 “We may well be shifting to early cataract extractions for PACG patients. MIGS may not lower IOP as much as traditional surgery, but they might be sufficient to prevent the patient from progressing,” Dr. Woo concluded.

Subconjunctival bleb forming innovations? According to Dr. Chelvin Sng, adjunct associate professor at the National University of Singapore and visiting consultant at the National University Hospital: While the XEN gel stent are usually implanted ab interno, the PRESERFLO microshunt is implanted ab externo — and both devices are protective against long-term hypotony. Dr. Sng added that few studies have pointed towards the efficacy of XEN implantation, one of which was a multicenter investigation that she was involved in while based at Moorfields Eye Hospital in London, United Kingdom.5 There, they found the mean IOP decreased from 21.4 mmHg (pre-op) to 15.2 mmHg at two years, with a reduction in medication from 2.7 to 1.1. Results from a retrospective 2018 study also found no significant differences in the risk of failure and safety profiles between standalone ab interno microstent with mitomycin C (MMC) and trabeculectomy with MMC.6 In another of Dr. Sng’s studies on combined phaco and XEN in Chinese eyes, similar good results were seen with IOP in the teens.7 She said they were also the first to report outcomes of

XEN in angle-closure eyes. For uveitic glaucoma eyes, 62.5% of patients implanted with XEN8 did not require any topical glaucoma medications within 12 months postoperatively.

A new “flo” for MIGS While the XEN gel stents have been around for several years, the PRESERFLO microshunt is the “new kid on the block”. Made from a novel material known as SIBS (styrene-block-isobutylene-blockstyerene), PRESERFLO is exclusively implanted ab externo and is currently commercially available in Europe and in Singapore. Unlike XEN, PRESERFLO is a hydrophobic device, so flow through the implant does not begin spontaneously. Dr. Sng explained: “One way of initiating the flow is to bend the device to create a negative pressure which facilitates a slow trickle of aqueous flow toward the device. With fluorescein, you could see the aqueous flow more clearly.” During the webinar, Dr. Sng demonstrated her technique of inserting PRESERFLO starting with a peritomy, a sub-Tenon’s dissection before applying MMC and using a 25-G needle for implantation. “Some might argue this isn’t a MIGS procedure at all due to the conjunctival peritomy. However, it is certainly less invasive than a trabeculectomy, with no need for a scleral flap or flap sutures.” Noting its efficacy, she shared results from a study by Batlle et al.,9 which reported the longest term data on the PRESERFLO microshunt, showing an IOP reduction in the low teens and a reduction of glaucoma medication at three years. According to Dr. Sng, these results are similar to a two-year Singaporean pilot RCT she is now working on.

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Microshunt versus gel stent The XEN gel stent takes five to 10 minutes to implant, while PRESERFLO implantation takes about 30 minutes. Both the XEN gel stent and PRESERFLO microshunt showed similar efficacy in a two-year study and had high safety profiles.10 However, PRESERFLO lowers IOP with fewer medications, and has a higher rate of complete success. The data in Dr. Sng’s study of Singaporean patients showed PRESERFLO achieved lower IOP than the XEN implant, despite more advanced glaucoma. “I tend to favor the PRESERFLO microshunt over the XEN for patients with severe glaucoma,” she said. In addition, the reported needling rate for XEN is 41%10 — it’s only 4% for the PRESERFLO microshunt.9 “This is because the microshunt is implanted ab externo. Hence, it is less likely for the Tenon’s capsule to occlude the implants. If the XEN is implanted ab externo with conjunctival peritomy, the needling rate will also be reduced,” explained Dr. Sng. Both implants also have an internal resistance that protects against hypotony — that means they are likely


safer than trabeculectomy, especially for eyes at risk for hypotony, (e.g., high myopes).

required on the outcomes for these subconjunctival MIGS devices and other glaucoma subtypes.

However, Dr. Sng did share that bleb-related infections remain a concern. Ab interno-implanted XEN is associated with unpredictable bleb morphology, just like trabeculectomy. “The blebs can be nice and diffuse, but I do get some anterior and ischemic-looking blebs,” she said.

In conclusion, she said subconjunctival MIGS devices are potentially capable of achieving lower IOP compared with trabecular bypass procedures. Though subconjunctival MIGS devices are associated with fewer complications when compared with trabeculectomy, bleb-related infection remains a potential concern.

On the other hand, the PRESERFLO is a longer device and gives rise to a more posterior and diffuse bleb. And as the device is implanted ab externo, with proper implant placement and conjunctival closure, the bleb morphology is more predictable. “Because of this, my opinion is that the risk of bleb-related infections is higher in the ab interno XEN compared with the PRESERFLO microshunt. Though, of course, it is possible with both devices,” shared Dr. Sng. Lastly, both PRESERFLO and XEN are only approved for POAG. As mentioned earlier, Dr. Sng said there are some small studies reporting the outcomes of the XEN implant in angle-closure eyes and in uveitic glaucoma, but these are off-label indications. Ultimately, more data is


The Santen styreneblockisobutylene-block-styrene (SIBS) Microshunt is CE-marked in The European Union and currently marketed under the brand name of PRESERFLO™. It is not yet approved for use in other countries except Canada, Australia, Singapore, Malaysia, The Philippines and Thailand. This educational article is based on the speaker’s own presentation and does not necessarily reflect the official policy or position of Santen.

Editor’s Note: The Asia-Pacific Glaucoma Society (APGS) webinar on New Surgical Techniques in Glaucoma Treatment was held virtually on November 20, 2021. Reporting for this article took place during the webinar.




Pfeiffer N, Garcia-Feijoo J, Martinez-de-la-Casa JM, et al. A randomized trial of a Schlemm's Canal microstent with phacoemulsification for reducing intraocular pressure in open-angle glaucoma. The Rotterdam Eye Hospital and Rotterdam Ophthalmic Institute. Ophthalmology. 2015;122(7):128393.


Ahmed IIK, Fea A, Au L, et al. A Prospective Randomized Trial Comparing Hydrus and iStent Microinvasive Glaucoma Surgery Implants for Standalone Treatment of Open-Angle Glaucoma: The COMPARE Study. Ophthalmology. 2020;127(1):52-61.


Fea AM, Ahmed II, Lavia C, et al. Hydrus microstent compared to selective laser trabeculoplasty in primary open angle glaucoma: one year results. Clin Exp Ophthalmol. 2017;45(2):120-127.


Azuara-Blanco A, Burr J, Ramsay C, et al. Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial. Lancet. 2016;388(10052):1389-1397.


Reitsamer H, Sng C, Vera V, et al. Two-year results of a multicenter study of the ab interno gelatin implant in medically uncontrolled primary openangle glaucoma. Graefes Arch Clin Exp Ophthalmol. 2019;257(5):983-996.


Schlenker MB, Gulamhusein H, Conrad-Hengerer I, et al. Efficacy, Safety, and Risk Factors for Failure of Standalone Ab Interno Gelatin Microstent Implantation versus Standalone Trabeculectomy. Ophthalmology. 2017;124(11):1579-1588.


Sng CCA, Chew PTK, Htoon HM, Lun K, Jeyabal P, Ang M. Case Series of Combined XEN Implantation and Phacoemulsification in Chinese Eyes: One-Year Outcomes. Adv Ther. 2019;36(12):3519-3529.


Sng CC, Wang J, Hau S, Htoon HM, Barton K. XEN-45 collagen implant for the treatment of uveitic glaucoma. Clin Exp Ophthalmol. 2018;46(4):339345.


Batlle JF, Fantes F, Riss I, et al. Three-Year Follow-up of a Novel Aqueous Humor MicroShunt. J Glaucoma. 2016;25(2):e58-e65.


Scheres LMJ, Kujovic-Aleksov S, Ramdas WD, et al. XEN® Gel Stent compared to PRESERFLO™ MicroShunt implantation for primary open-angle glaucoma: two-year results. Acta Ophthalmol. 2021;99(3):e433-e440.

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The Dawn of Gene Editing

Is Asia-Pacific ready for precision ophthalmology? by Tan Sher Lynn


ustralia is at the forefront of genetic discoveries, foremost of which is identifying genetic eye disorders early on using the CRISPRCas9 system, a technology that can cut or edit DNA at specific sites. “On this front, Australia has led the way in many genetic discoveries by dissecting many of the genotype and phenotype correlation,” noted Tasmanian clinician-scientist Prof. Alex Hewitt, who presented the Dame Ida Mann Memorial Lecture during the opening plenary of the 52nd Royal Australian and New Zealand College of Ophthalmologists Annual Congress (RANZCO Brisbane 2022) yesterday. Among the highlights of his presentation was the recent developments in gene-editing technology, which holds tremendous promise in treating hereditary eye diseases. Genetic eye disorders are typically hard to treat due to the complexity of the genome. “But thanks to the rapid advancement of science and technology, we can now diagnose disease earlier and earlier, and identify the genetic cause in seven out of 10 unselected patients,” enthused Prof. Hewitt.


Front and center Prof. Hewitt’s team was the first to demonstrate the adaptation of the clustered, regularly interspersed, short palindromic repeats (CRISPR) system in adult mammalian cells using mice vectors, which resulted in an 84% reduction of gene expression. The CRISPR-Cas9 system, used by bacteria to counter viral intrusion, can cut or edit DNA at specific sites. Applied in inherited disease, this technology can make changes in a person’s DNA by replacing an existing segment with a customized DNA sequence, thereby effectively correcting genetic defects. Prof. Hewitt gave examples of recent advances in correcting disease-causing variants using gene editing, such as the programmable editing of a target base in genomic DNA without doublestranded DNA cleavage, as well as the programmable base editing of AT to GC in genomic DNA without DNA cleavage by notable chemist David Liu’s team the following year. “Combining CRISPR-Cas9 with base editors not only allows the ‘spelling mistake’ in the genome to be corrected but also causes other ‘letters’ to

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be corrected as well. Thankfully, researchers have found where to hide the base editor in the Cas9 protein in order to eliminate this issue,” he added.

All about the patient The next step is production. “The solution is to have a distributed manufacturing process,” Prof. Hewitt noted. “The Tasmanian Eye Institute has recently refurbished a water tank in Hobart into a laboratory, which can fully function as a GMP production facility. The aim is to link this approach with all active clinicians across Australia and New Zealand.” Finally, the last and pressing issue to address is the patient. “There are two major things to consider,” he explained. “First is the clinical trial framework, which needs to be redesigned for rare orphan diseases. For example, the phase 1 and 2 in the clinical trial framework can be condensed and a greater focus be placed on the postlicensing surveillance.” The second is to ensure that the patient would want to do it. To address this issue, an online questionnaire was set up and completed by 12,000 participants with a median age of 24. The questionnaire found that overall, there is firm support for gene editing. “Interestingly, those who did not agree to it said that they did not understand the technology. Hence, education can potentially address this issue,” Prof. Hewitt said. “In conclusion, the full clinical route in the translation of gene-editing technology is almost complete,” he noted. “We are almost set to transform the care of patients with a well-defined genetically characterized disease if diagnosed early.”

Editor’s Note: A version of this article was first published in Issue 1 of CAKE & PIE POST, RANZCO Virtual 2022 Edition.



Yoga and Glaucoma

as a practice that can have beneficial implications for both physical and mental health. To dedicated practitioners, it may come as no surprise that pranayama diaphragmatic breathing exercises (simply put, yoga pranayama is a breath regulation technique) can lower IOP, and recent clinical studies appear to support this hypothesis.

Can holistic approaches lower iop? by Ben Collins


espite the proven effectiveness of modern medical-based treatments, some patients will opt for a more holistic approach to managing their eye health. Glaucoma sufferers are no different. It’s natural to want to seek out alternative/ adjuvant therapies. This could be due to concerns around side effects of medications or surgery, or that patients simply want to try anything that could potentially improve their condition. So what of these other methods? Are they actually beneficial? And is there anything more than anecdotal evidence to support their merits? Below, we examine the latest research and its potential implications in terms of alternative/conjunctive therapies for glaucoma sufferers. Antioxidants, herbal remedies, alcohol and even cannabis have been touted to lower IOP. However, none of these have passed clinical trials, and the potential side effects (namely with alcohol and cannabis) may outweigh any health benefits. Exercise and a healthy lifestyle and diet (used alongside proven medical techniques) might be your best bet in terms of ensuring a positive outcome as a glaucoma sufferer. Studies have shown exercise can have a moderate impact on lowering IOP, although the correlation between this and the mitigation of glaucoma progression has yet to be proven.1 Certain meditation techniques have also been purported to have an effect on IOP. And although research in this area is still in its infancy, it seems there may be some truth to the claims.

Yoga for eye health?! Many of us are familiar with yoga

In a randomized clinical trial of 90 patients suffering from primary openangle glaucoma, IOP measured at one, three and six months was significantly reduced for patients in the YPDB (Yoga Pranayama Diaphragmatic Breathing) group compared with the control group. It should be noted these techniques were used in conjunction with eye drop medications. It was also a relatively small/ homogeneous study group (studies across a larger range of ages/demographics would be useful), and diurnal IOP measurements are known to fluctuate. Nonetheless, the findings are promising. In fact, the results were encouraging enough to warrant recommending pranayama diaphragmatic breathing exercises as adjunctive therapy for primary-open angle glaucoma sufferers.2 So does this mean as a glaucoma sufferer, we should immediately rush out and join our local yoga class? Well, not exactly. It’s important to remember yoga pranayama breathing exercises have specific characteristics that help to relax the central nervous system, potentially leading to an increase in melatonin production and subsequent reduction in aqueous humor (the fluid which controls IOP) secretion. Not all yogic exercises have this effect. In fact, certain yoga positions (e.g., downward facing dog) can have the opposite impact, actually leading to a rise in IOP. Participants in the aforementioned study were provided with expert instruction from a qualified instructor.3

Could there be other beneficial yoga practices? Another yoga technique that may have an effect on IOP and subsequently be of benefit to glaucoma sufferers is tratak kriya. The practice of tratak

kriya involves focussing the eyes on a particular point (usually a light like a candle or a lamp) for a prolonged period of time. This is said to help quiet the mind and improve concentration. Researchers have hypothesized that accommodative exercises (the process of adjustment of optical power to maintain clear vision) such as tratak kriya could lead to a reduction in IOP. But again, studies are lacking.4 One of the potential implications of these findings could be that alternative health treatments in general warrant further investigation and more rigorous research. Modern medicine is certainly not adverse to different/complementary treatment regimes. In fact, practitioners are generally open to encouraging any kind of activity which will improve patient outcomes. But they need to be backed up by solid data and proven peer-reviewed studies. “You can’t depend on your eyes when your imagination is out of focus,” as Mark Twain once said. Or from the Hatha Yoga Pradipika: “When the breath wanders, the mind is unsteady, but when the breath is still, so is the mind still.”


Hetherington J. Alternative Therapies for Glaucoma. Glaucoma Research Foundation. Available at: treatment/alternative-therapies-for-glaucoma. php Accessed on 7 February 2022.


Udenia H, Mittal S, Agrawal A, Singh A, Singh A, Mittal SK. Yogic Pranayama and Diaphragmatic Breathing: Adjunct Therapy for Intraocular Pressure in Patients With Primary Open-angle Glaucoma: A Randomized Controlled Trial. J Glaucoma. 2021;30(2):115-123.


Cramer H, Krucoff C, Dobos G. Adverse events associated with yoga: a systematic review of published case reports and case series. PLoS One. 2013;8(10):e75515.


Sankalp, Dada T, Yadav RK, Faiq MA. Effect of Yoga-Based Ocular Exercises in Lowering of Intraocular Pressure in Glaucoma Patients: An Affirmative Proposition. Int J Yoga. 2018;11(3):239-241.

Editor’s Note: A version of this article was first published on

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Winter ESCRS 2022 Highlights: What’s New in Cornea? by Joanna Lee


t seems that there’s plenty new in cornea, rising from a plethora of studies around Europe. Researchers have been busy comparing surgical techniques, testing new strategies and technologies, and observing cases. The results, discussed and presented at the recently held 26th European Society of Cataract & Refractive Surgeons Winter Meeting (Winter ESCRS 2022) comprise a smorgasbord of interesting medical insight.

Tectonic keratoplasty and CXL for resistant corneal abscess In many cases of resistant corneal abscess, the abscess is unresponsive to medical treatment and requires other interventions such as tectonic keratoplasty or cross-linking (CXL). At the Memorial Institute for Ophthalmic Research (MIOR), Dr. Hazem Elnashar and his co-researchers compared outcomes of using the two methods in a prospective interventional study of 20 patients with unilateral resistant corneal abscess.

disappeared. Only one eye with fungal keratitis showed resistance to CXL and needed keratoplasty. In contrast, only 60% of the eyes (n=6) treated with tectonic keratoplasty improved. In this study, cross-linking showed better results than tectonic keratoplasty, which had a higher incidence of reinfection. “In cases in which cross-linking has failed, we still have a chance to do tectonic keratoplasty,” said Dr. Elnashar.

Statistical mapping of keratoconus’ natural progression Despite a few parameters such as maximum keratometry (Kmax), minimum corneal thickness (TCT) or corneal cylinder (CYL) that have been described to observe the progression in keratoconus, no consistent definition of ectasia progression has emerged. Thus, researchers set out to understand the natural progression of keratoconus through a time series approach.

Each method was performed on 10 eyes. The results showed that 90% of the eyes (n=9) treated with CXL had marked improvement within a few days; the cornea started to be vascularized with less pain and hypopyons

Dr. Karina Fernandez Berdasco presented her team’s investigation into predicting visual and topographic outcomes of untreated keratoconus at the Hospital Universitario Central de Asturias in Oviedo, Spain. Through SPSS statistics software, they created


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a time series model involving data from 57 eyes of 35 patients under the age of 30 who were diagnosed with keratoconus. The topographic follow-up period was about 12 months. What did they find? “We observed that corneal volume was consistent over time and less variable than Kmax, for example,” she said. It was shown that this statistical method could describe the natural progression of keratoconus where topographic variables in the Sirius device like asphericity, Slf (symmetry index front) and Slb (symmetry index back), BCV (Baiocchi Calossi Versaci), corneal volume and LSA (longitudinal spherical aberration) may change earlier than BCVA, Kmax or TCT. The research concluded that all of these could be a prompt indicator of ectasia progression.

Tale of two endothelial keratoplasty surgical methods Meanwhile, researchers from The Mater Hospital in Dublin, Ireland, were curious about the efficacy of corneal transplantation surgery, in particular, endothelial keratoplasty (EK) to treat corneal endothelial dysfunction. EKs make up 60% of the 185,000 corneal transplant surgeries taking place

worldwide each year. Dr. Daire Hurley said there has been a trend toward using thinner grafts (150 μm for DSEK and 10-15 μm for DMEK) which has resulted in superior visual acuity in DMEK, thanks to a lack of stroma-to-stroma graft interface. Thus, they performed a systematic review and meta-analysis comparing the ultrathin descemet stripping automated endothelial keratoplasty (UT-DSAEK) and descemet membrane endothelial keratoplasty (DMEK). They looked into the differences in terms of visual acuity outcomes, endothelial cell count, central corneal thickness and complications between the two forms of endothelial keratoplasty. The results? DMEK showed better visual acuity rates coupled with speedier recovery and less graft rejection. On the contrary, UT-DSAEK (at 100 μm) has a “more favorable complication profile,” with lower rates of complications like re-bubbling. They found this to be a better option for eyes with a poor surgical view, complex anatomy and for less experienced surgeons.

Bromfenac and mini-PRK success Postoperatively, adjunct treatment with 0.09% topical bromfenac ophthalmic solution (marketed in Europe as Yellox) is showing good efficacy for preventing early pain associated with the aftermath of photorefractive keratectomy (PRK) surgery. Dr. Anastasios John Kannelopoulos’ randomized prospective study of this solution used after their own “mini-PRK technique” surgery with the ORCA EBK device indicated that this yellow solution may be considered as a primary adjunct treatment to corticosteroids. The results also showed that miniPRK may minimize postoperative discomfort and visual debilitation, and accelerate re-epithelialization and early visual recovery compared to traditional larger-epithelial zone PRK, or the recent transepithelial PRK for myopic laser vision correction. The topical bromfenac used in their

study contributed significantly toward better patient comfort and adaptability to the procedure. The results, Dr. Kannelopoulos said, appeared superior to LASIK and SMILE surgeries.

Square off: Tomographyguided versus standard techniques At the St. Thomas’ Hospital in King’s College London, Dr. Khayam Naderi and his colleagues compared the efficacy and safety of tomography-orientated riboflavin/ultraviolet A corneal collagen cross-linking (the gold standard for progressive keratoconus both in adults and children) with the standard axial epithelium-off technique, used to stop the rampage of progressive keratoconus and improve corneal shape. In the prospective, single-masked randomized controlled trial, they compared tomography-guided CXL which targeted specific optical zones versus the standard treatment which targeted an optical zone of 9 mm. The comparison showed both methods were able to halt the progression of keratoconus over a 15-month period with no adverse effects in either group. To date, no patients in either group needed further CXL. Thus, the tomography-guided method is neither inferior nor superior to the standard technique.

Rare cocaine-induced midline destructive lesion In an interesting case from Spain, a 45-year-old man with a history of chronic osteolytic sinusitis due to intranasal cocaine abuse and persistent bacterial infection came in with sudden vision loss of his right eye and periocular pain. After a series of tests, Dr. Amparo Ortiz and her coresearchers at Hospital De Denia and Hospital Universitari, found that he had fixed right mydriasis with extraocular movement limitation. After an endoscopic transnasal test and a biopsy of his right medial orbital wall, her team diagnosed the patient with orbital apex syndrome secondary to CIMDL — cocaine-induced midline destructive lesions. Later, a corneal ulcer with characteristics of peripheral ulcerative

keratitis (PUK) accompanied by corneal hypoesthesia was observed, along with an upper respiratory bacterial infection.

Bowman’s layer impact assessed with different technologies The distribution of collagen in the cornea has a direct impact on medical and surgical procedures. Dr. Emilio Torres-Netto and his co-researchers in Zurich, Switzerland, attempted to assess whether Bowman’s layer (BL) contributes to corneal biomechanical strength, a controversial subject. While atomic force microscopy has demonstrated BL to have an E-modulus three-times more than corneal stroma, whole corneal studies have not shown how BL played significant clinical roles. Thus, his team tested and evaluated Bowman’s biomechanical impact on human corneas with different technologies, including stress-strain extensometry and quasi-static optical coherence elastography. The results, through looking at the thin corneal lamellae, showed no significant differences between flaps with and without BL. Of note, the differences in strain distribution observed between whole corneas with and corneas without BL were found inside the stroma, and not on top of the anterior surface as expected. The presence or absence of Bowman’s layer did not change corneal stiffness in corneal thin flaps. Dr. Torres-Netto shared that the results may have implications for both refractive laser surgeries and Bowman’s layer transplantation for keratoconus.

Editor’s Note: The 26th European Society of Cataract & Refractive Surgeons Winter Meeting (Winter ESCRS 2022)was held virtually from February 18-20, 2022. Reporting for this story took place during the event.

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Of Genes, Plasma and Digital Learning: Insights from AOS Virtual 2022 by Tan Sher Lynn


octors presented their latest findings on dry eye treatment, computer vision syndrome, as well as a case of nanophthalmos due to MFRP and BEST1 mutations, during a free paper session at the recently held 5th meeting of the ASEAN Ophthalmology Society (AOS Virtual 2022).

Nanophthalmos and ocular genetics Nanophthalmos is a rare and blinding disease characterized by a small


eye with a short axial length, severe hyperopia, an elevated lens/eye ratio, and a high incidence of angleclosure glaucoma. Due to its rarity, this disease may go undiagnosed until adulthood. Dr. Carmelita Jocson from the Philippines presented the first genetically confirmed case of nanophthalmos in the Philippines involving a 27-year-old female. Two weeks before the initial consultation, the patient started having sudden and severe pain in the left eye with redness, blurring of vision and left-sided headache. Two days

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before the consultation, she was seen by a private ophthalmologist and was diagnosed with acute angle-closure glaucoma. Upon observing the unusual use of very thick corrective glasses in the patient — who had no history of intraocular surgeries or trauma, glaucoma, cataract or ocular neoplasms — Dr. Jocson and her colleagues suspected and confirmed the presence of a high hyperopia refractive error. Family history revealed that the patient’s parents were first-degree cousins (consanguinity).

Meanwhile, ocular examination revealed that the left eye had a 6 mm pupil that was non-reactive to light, with a hazy cornea and an elevated intraocular pressure of 42 mmHg. At this point, the patient was diagnosed with angle-closure glaucoma, likely secondary to nanophthalmos. Upon referral to a retina specialist, the patient was found to have cystoid macular edema in both eyes. She was also referred to an ocular geneticist and a microphthalmia/anophthalmia panel showed mutations in the MFRP and BEST1 genes. MFRP mutation is associated with autosomal recessive nanophthalmos and retinal dystrophy. “In comparison to normal eyes, the ocular parameters of the patient are below normal range, except for increased lens-to-eyeball volume ratio (LEVR), scleral thickness and macular thickness, all of which are consistent with a nanophthalmic eye,” she said. “Nanophthalmic eyes pose a great challenge to ophthalmologists, but prognosis may be favorable if correctly identified and promptly treated by piecing together a comprehensive history, examination and ocular imaging with a high index of suspicion. Our findings highlight the importance of integrating genetics unto medical practice. Ocular genetics is vital for forthcoming generations to make informed decisions on early detection and risk reduction,” explained Dr. Jocson.

Potential of PRP in dry eye treatment Autologous platelet rich plasma (PRP) has emerged as a significant tissue regenerative therapy due to its anti-microbial, anti-fibrotic and anti-inflammation properties. These characteristics exalt PRP as an appropriate treatment for ocular surface disorders, such as dry eye syndrome. Dr. Thapakorn Sirirattanasoporn from Thailand evaluated the efficacy of autologous PRP eye drops in nine patients

with dry eye disease (DED) who did not respond to autologous serum treatment. The patients received topical PRP six times a day until week 6, before changing to topical autologous serum treatment on week 12. Results showed that their ocular surface disease index (OSDI) improved significantly at weeks 1, 4 and 6. Signs of dry eye also improved significantly as shown in corneal staining, conjunctival staining and Schirmer’s test with anesthesia. This likely occurred because PRP has a higher content of growth factors and reduced proinflammatory activity compared to autologous serum. “Our study shows that topical use of PRP demonstrated therapeutic efficacy in terms of DED symptoms in patients with DED refractory to autologous serum treatment, and is a good option for treatment of severe dry eye,” he said.

Health effects of e-learning during lockdown During the pandemic, students spent an increasing number of hours on digital devices due to digital or e-learning replacing face-toface classroom sessions, thereby increasing the prevalence of computer vision syndrome (CVS). Dr. Kasem Seresirikachorn from Thailand investigated the effects of digital devices and online learning on CVS in 2,476 students from grades 7-12 in Bangkok, Thailand, during the COVID-19 pandemic through a crosssectional, online, questionnaire-based

study. The data was collected for 15 days. “We found that more than half of the students used digital devices for 9-12 hours per day, and over 60% spent over 6 hours in online learning during the lockdown period (mean = 7.03 ± 2.06 hours/day). Seventy-point-one percent (70.1%) of students have CVS, with headache as the most common symptom, followed by eye burning and pain. The number of hours on digital devices, the number of hours of online learning, myopia, multiple digital device use, presence of back pain, presence of neck pain, and younger age are contributory factors of developing CVS,” he said. He noted that among those with CVS, the severity was significantly correlated with the number of hours of screen time, and inversely correlated with age. “In this study, we found that the overall hour of digital device usage of over 6 hours, and online learning of over 5 hours increased the risk of CVS by nearly 2 and 5 times, respectively. Hence, learning schedules should be adjusted to have appropriate durations and breaks. The overall hours of digital device usage should be under 6 hours per day, and online learning should be limited to 5 hours per day, especially in younger students,” he suggested.

Editor’s Note: The 5th AOS Congress was held virtually on March 26-27, 2022. Reporting for this story took place during the event. A version of this article was first published on

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