CAKE Issue 15: The ebook version (The 'East Goes West' Issue)

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THE WORLD’S SECOND FUNKY OPHTHALMOLOGY MAGAZINE

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THE 'EAST GOES WEST' ISSUE Sept/Oct 2022 cakemagazine.org

What the West can learn from the East about sustainable and affordable eye care p14


LETTER TO READERS

Shifting Equilibriums

This isn't the point in the column where I list every legend of ophthalmology that hails from east of the Urals, but it is the point where I pontificate for a bit.

here are celebrities in the real world (90% of whom simply don't deserve the status and power), and then there are celebrities in your own small field of expertise, most of whom rock and deserve the respect accorded to them. I mean, people actually stop and listen to what they have to say.

The direction of knowledge transfer — historically mostly West to East — has started to reverse. Why? It all comes down to priorities. Here's my perspective. When I lived in the U.K., I watched science funding slowly — then after Brexit, rapidly — dwindle. I completed my PhD there over 15 years ago, and even then, I could see that a science career in the U.K. is not a secure one. Smart, dedicated, productive researchers had to leap from grant to grant just like Tarzan would leap from branch to branch. You miss one, you crash to the ground. I knew post-docs and PIs that sometimes spend half their time or more writing grant proposals. What a waste of smart people's energy!

I remember chatting to Matt Windsor in the press room at ARVO when Shigeru Kinoshita walked past — we both stopped and stared at him for a bit. After he'd picked up a ribbon and walked on his way, Matt and I both started talking about how awesome his work with Rho-associated protein kinase (ROCK) inhibitors on corneal endothelial disease was.

Let's look at the Chinese post-docs I have worked with. Most were funded by the Chinese government in some way or another. They were (and are) highly motivated to learn and be productive. I think it's easier to be productive when you have a job and a career path ahead of you if you perform well, and you don't have to spend half your time writing grant applications.

I could make a joke about how he’s a “ROCK star” in our industry but, frankly, his work could dramatically reduce the amount of lamellar corneal surgeries needed to treat corneal keratopathies. Indeed, Eastern innovation heads west — and north and south, too.

When the people that run the country support science, things happen — and that impact amplifies over time. I'm now seeing European surgeons and researchers go to places like Singapore, China, Japan, and Vietnam to spend a year or more doing cool work that they just couldn’t do back home — either for funding or regulatory reasons. I'm thinking it might simply be easier to innovate in the East.

Who’s learning more from whom these days?

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The East also leads the way in finding the best ways of dealing with the other global pandemic of our times: myopia. Granted, the continent leads the way in terms of myopia prevalence (and the behavior that probably causes it — close work and spending lots of time indoors). But you only need to look at the huge and powerful atropine-for-myopia-prevention clinical trials led by Donald Tan to see that once again the East is leading the way. Ningli Wang proposed new glaucoma nomenclatures, as well as several groundbreaking glaucoma pathophysiology studies, surgical techniques, and even imaging technologies.

Ah, but what about big tech and healthcare, you ask? Isn't Google doing great things in AI? Isn't Microsoft about to make digital healthcare records work well? Aren't there loads of European and North American tech startups that will revolutionize the world? Yes, and maybe. But big tech with an interest in healthcare isn't limited to Silicon Valley and Redmond in Washington State. We also have Huawei, Sony, Xiaomi, and a plethora of others in this world. From a Western perspective, it's always been the case that the West has learned from the East. We always will. But in terms of knowledge transfer, that equilibrium seems to be increasingly drifting towards the direction of East to West. This will change both power and economic dynamics with it. And that's on you, sāi yàn.

Mark Hillen Mark Hillen, PhD

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

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IN THIS ISSUE...

Cataract Matt Young CEO & Publisher

Hannah Nguyen COO & CFO

Robert Anderson Media Director

Gloria D. Gamat Chief Editor

Brooke Herron Editor

Mark Hillen Editor-At-Large International Business Development

Ruchi Mahajan Ranga Brandon Winkeler Writers

Andrew Sweeney April Ingram Hazlin Hassan Joe Schreiber Matt Herman Nick Eustice Roger Shitaki Sam McCommon Maricel Salvador Graphic Designer

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6001 Beach Road, #09-09 Golden Mile Tower, Singapore 199589 Tel: +65 8186 7677 Email: enquiry@mediamice.com www.mediaMICE.com

Anterior Segment

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Highway to Health On the road to better refractive outcomes after cataract surgery

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Two Birds in One Shot For two conditions — cataract and DME, seek a combined cure

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Multifocal IOLs, Posterior Capsulotomy and the Role of Nd:YAG Pentacam and Corvis ST Refractive surgery prerequisites

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Don’t Let Astigmatism Get Your Outcomes Down … and turn that frown upside down with SMILE

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A Glaucoma Conundrum Unraveling the mystery of Asian eyes and POAG

Cover Story

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East Meets West

What the West can learn from the East about sustainable and affordable eye care

Kudos

Enlightenment

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Making Headway Anterior segment set for major breakthroughs in treatment

24 Continuing Fred Hollows’ Legacy From the ground up… all the way to the stars!

Gender and Refractive Error More than just measurements

28 Women in Ophthalmology Perspectives from around the world (and eye!)

Conference Highlights

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Pearls for Calculating IOL Power A Marvelous Look into Corneal Melts Highlights from ASCRS 2022

We are looking for eye doctors who can contribute articles to CAKE magazine. Interested? Let's talk! Send us an email at editor@mediamice.com. To place an advertisement, advertorial, symposium highlight, video, email blast, or other promotion in CAKE magazine contact sales@mediamice.com. | Sept/Oct 2022 3


ADVISORY BOARD MEMBERS

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

boris.malyugin@gmail.com

Dr. Chelvin Sng, BA, MBBChir, MA(Cambridge), MRCSEd, FRCSEd, MMed, FAMS, is the Medical Director of Chelvin Sng Eye Centre at Mount Elizabeth Novena Hospital. She is also an Adjunct Associate Professor at the National University of Singapore (NUS), a Visiting Consultant at the National University Hospital, Singapore, and an Adjunct Clinician 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 an open access book on "Minimally Invasive Glaucoma Surgery", 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 (currently known as the "Paul Glaucoma Implant"), which was patented in 2015. Dr Sng has received multiple international awards, including the Asia Pacific Glaucoma Society Young Investigator Award and the Asia Pacific Academy of Ophthalmology Achievement Award. When not working, Dr. Sng can be found volunteering in medical missions in India and across Southeast Asia. chelvin@gmail.com

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 peer-reviewed 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. george.beiko@sympatico.ca

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. harveyuy@gmail.com Dr. Harvey S. Uy

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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. Prof. Jodhbir S. Mehta

Dr. William B. Trattler

jodmehta@gmail.com

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. wtrattler@gmail.com

SOCIETY FRIENDS

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 )

World Ophthalmology Congress

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ATARACT

IMPROVING OUTCOMES

On the road to better refractive outcomes after cataract surgery by Hazlin Hassan

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ataracts are the leading cause of blindness worldwide — and the demand for cataract surgery will continue to rise as populations age. And as common as cataract surgery is today, meeting patients’ expectations isn’t always a walk in the park. Advances in technology have paved the path for better visual outcomes — and handin-hand, many of today’s patients want spectacle-free vision following cataract surgery. Postoperative refractive errors and residual astigmatism negatively impact visual acuity (VA) and patient satisfaction, and therefore are of key concern to cataract surgeons, noted Prof. Dr. Ramin Khoramnia and colleagues in a paper titled Refractive Outcomes after Cataract Surgery.* “Various pre-, intra- and postoperative factors influence refractive outcomes

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after cataract surgery, and accurate assessment and optimization of these factors are essential to achieving desired vision,” the authors said. For example, getting postoperative manifest refractive error as close as possible to target is key when performing cataract surgery with intraocular lens (IOL) implantation, given that residual astigmatism and refractive errors negatively impact patients’ vision and satisfaction.

The journey to improved outcomes takes root It’s said that a “journey of a thousand miles begins with a single step.” As does the road to improving outcomes. Looking back at history, the authors noted that the introduction of ultrasound biometry in the 1960s greatly improved refractive outcomes. In the 1990s,

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optical biometry offered enhanced resolution and greater precision. Further, the non-contact method eliminated inaccuracies due to corneal compression, in addition to being more comfortable for patients. According to the paper, the effect of optical biometry on refractive outcomes after cataract surgery can be seen by the increasing percentage of patients achieving within ±1.0 D or ±0.5 D of their target refraction in studies between 1992 and 2017. Between 1992 and 2006, 72–87% of patients achieved a deviation from the target refraction of ±1.0 D; this increased to 90–97% between 2007 and 2017. The authors continued: “With further refinements in optical biometry, the proportion of patients achieving their target refraction has steadily increased. Innovations in optical


biometry have continued to emerge with the introduction of biometers that utilize swept-source optical coherence tomography (SS-OCT).”

~0.27 D. Measurements of AL using SSOCT are more accurate than ultrasound biometry, with a median accuracy of 0.05 mm and 0.12 mm, respectively.

Indeed, current research is advancing OCT methods further. One example is the utilization of a large number of optical probe beams simultaneously to capture accurate anatomical snapshots with no eye motion degradation.

Modern-day optical biometry has improved refractive outcomes in several ways. A key example is represented by optical biometers, which allow a high success rate of AL measurements, ranging from 77–88% with PCI biometers; 79% with optical lowcoherence reflectometry biometers; to 93–99% with SS-OCT biometers — with the best results to date reported using ARGOS (96–99%).

The optical biometry tech highway These advances in cataract surgery have resulted in higher expectations for excellent postoperative outcomes — especially in regard to spectacle independence — and particularly in developed countries. Innovations in optical biometry technology have continued to emerge with the introduction of biometers that use SS-OCT, such as the IOLMaster 700 (Carl Zeiss Meditec AG, Jena, Germany) and ARGOS (Alcon, Geneva, Switzerland) to provide OCT images of the entire eye. This preoperative biometric data is essential to determine the refractive power of the IOL to be implanted. Accurately measuring axial length (AL) is one of the most critical steps in IOL power calculation: This parameter should ideally be accurate within 0.1 mm because such a small error equates to a postoperative refraction error of

Corneal power is also key in order to optimize refractive outcomes, as keratometric errors of 0.5 D in corneal power can lead to an error of 0.5 D in postoperative refraction. An incorrect assessment of the anterior chamber depth (ACD) is the largest source of refractive error. An estimated 1 mm error in postoperative ACD equates to a refractive error of 1.44 D for regular eyes.

Cruising the IOL formula freeway Accurate IOL power calculations are fundamental to achieving ideal refractive outcomes. These calculations rely on several factors, including accurate preoperative biometric measurements, precise prediction of effective lens position (ELP), appropriate IOL formula selection, and optimization of the IOL constant.

Previous corneal refractive surgery should be considered when obtaining biometric measurements and selecting the appropriate IOL formula because keratometric values change after surgery. Inaccurate biometric measurements and inappropriate IOL formula selection may lead to a refractive surprise. Hyperopic surprise often occurs in patients with previous myopic correction, and myopic surprise in patients with previous hyperopic correction. Surgical technique is the key intraoperative factor that may influence refractive outcomes after cataract surgery. The authors noted that the predictability of refractive outcomes has improved because of refinements in surgical procedures. Optimal refractive outcomes can be achieved by employing good surgical technique, aiming for a low rate of posterior capsular rupture, having a capsulorhexis size smaller than the optical diameter, and having an inthe-bag IOL placement. Continuous curvilinear capsulorhexis ensures positional stability and enhances refractive predictability, while small incisions without sutures and the use of foldable IOLs reduce the incidence of complications and surgically induced astigmatism (SIA). In addition, complete ophthalmic viscosurgical device removal reduces the likelihood of IOL misalignment. Non-intentional SIA can be prevented by preoperative assessment of corneal hysteresis and biomechanical properties of the cornea, followed by microincision surgery using corneal topography data and standard IOL power formulas. Improvements such as these, along with advances in microsurgical techniques, new IOL technologies and enhancements to IOL power calculations continue to positively impact patients’ refractory status after cataract surgery, concluded the authors.

Reference *

Khoramnia R, Auffarth G, Łabuz G, Pettit G, Suryakumar R. Refractive Outcomes after Cataract Surgery. Diagnostics (Basel). 2022;12(2): 243.

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ATARACT

RESEARCH

Two Birds in One Shot

For two conditions — cataract and DME, seek a combined cure by Andrew Sweeney

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t is a well-known fact that in most Western and East Asian countries, populations are aging at a considerable rate. This causes all sorts of societal and medical issues — ranging from concerns about the economic impact of increased pension payments to the need to replace manual labor, and a general trend toward conservatism in domestic politics. When it comes to medicine, geriatric and palliative care becomes more important, hospital beds become increasingly difficult to find as treatment backlogs occur and, of course, more and more people find their eyes getting cloudy due to cataracts.

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A case of two misfortunes As we age, we also become more unhealthy — especially in the more fast food-friendly countries in the West (we’re looking at you, USA). As a result, diabetes is caused in no small part by a sedentary lifestyle and poor food choices that lead to obesity.

Before we get into the meat as it were, let's sit down for a starter by reminding ourselves of the implications of cataracts, one of the most common conditions ophthalmologists treat on a day-to-day basis. Though most cases are curable, cataract remains a major public health problem in developed and developing countries alike.

While not tied as closely to age as cataracts are, diabetes is still associated — and when you combine the two, you create two ocular health problems for the price of one. This is particularly the case with diabetic macular edema (DME), a destructive condition that in severe cases causes vision loss.

Out of the estimated 36 million people that are blind worldwide, over 12 million find themselves in this condition due to cataracts. It’s caused by aging and the deterioration in the quality of the eye, as well as some genetic and environmental factors, such as smoking cigarettes and ultraviolet light exposure. Certain

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diseases, like diabetes and uveitis, are closely associated with cataracts, too.1 Diabetic eye disease in its various forms is also an eyesight thief. Nearly as common as cataract, with particular prevalence in developed countries, DME is one of the most common variants. It affects the central vision leading to a decline, ranging from slight visual blurring to blindness — not only substantially affecting independence and quality of life, but also potentially leading to total vision loss.2 Diabetic macular edema is a nasty condition, one that can start in silence and causes a few symptoms in the early stages … and by the time it is apparent, the damage can be irreversible. So, early screening and intervention are an absolute must.

When edges blur… Unfortunately for millions of patients out there, there is a clear correlation between being afflicted with cataracts and developing DME — and the prevalence of cataracts in diabetic patients is five times higher than in the non-diabetic population. Then, when you consider that cataract surgery is associated with an increased risk of post-surgical edema (or worsening of the pre-existing edema due to post-surgical inflammation), you understand the problem faced when patients have both DME and cataracts.2 Given the aforementioned culinary metaphor used to describe the situation of sufferers of both DME and cataract, it is perhaps fitting that research into

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the problem comes from a country associated with some of the world’s best food: Italy. A group of researchers based in the south of the country, in the cities of Bari and Catania, authored a study on alternatives to conventional cataract surgery for DME patients. This was to find a solution for better patient outcomes in both patients who undergo cataract surgery with DME, and for those at the risk of developing it afterward.3

… color outside the lines Now, for the question of the day: What’s the best way to treat both conditions? Our Italian friends conducted a retrospective, comparative, cohort study on 46 patients affected by nonproliferative diabetic retinopathy and with any degree of DME and cataract. The group was split in half: 23 patients were treated with phacoemulsification associated with dexamethasone (Phaco-Dex) and matched with 23 consecutive subjects treated with

phacoemulsification according to standard procedure (Phaco-alone). Exclusion criteria included treatment of DME with corticosteroid six months before surgery, untreated proliferative diabetic retinopathy, and a history of ocular hypertension or glaucoma. Now for the results: In the Phaco-Dex group, best-corrected visual acuity (BCVA) increased significantly from 20/100 at baseline to 20/50 at month 1 (P = 0.0005) to 20/50 (P = 0.005) at month 2, and 20/50 (P = 0.005) at month 3. In the Phaco-alone group, mean BCVA was 20/80 at baseline, 20/63 at month 1 (P = 0.35 vs. baseline), 20/80 at month 2 (P = 0.86 vs. baseline), and 20/80 at month 3 (P = 0.86 vs. baseline). Now, that’s as obvious a result as a good pizza pie! The authors of the study, therefore, concluded that in DME patients with visually significant cataracts, combined treatment with phacoemulsification and dexamethasone is effective, safe and may be favorable over standard phacoemulsification, considering both functional and tomographic parameters.

References 1.

Hashemi H, Pakzad R, Yekta A, et al. Global and Regional Prevalence of Age-Related Cataract: A Comprehensive Systematic Review and MetaAnalysis. Eye (Lond). 2020;34(8):1357-1370.

2.

Varma R, Bressler NM, Doan QV, et al. Prevalence of and Risk Factors for Diabetic Macular Edema in the United States. JAMA Ophthalmol. 2014;132(11):1334-1340.

3.

Furino C, Boscia F, Niro A, et al. Diabetic Macular Edema and Cataract Surgery. Retina. 2021;41(5):1102-1109.

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ATARACT

RESEARCH

Multifocal IOLs, Posterior Capsulotomy and the Role of Nd:YAG by Matt Herman

Posterior capsule opacification … I am your father.

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he necessity of posterior capsulotomies are the dark side of cutting-edge multifocal IOLs (MIOLs). A new study out of China on Nd:YAG capsulotomy rates sheds some light on why the procedure is necessary. It’s a free-for-all out there in the premium IOL space, and MIOLs are the belles of the ball. Never-beforeseen results at all ranges of vision are being achieved. Presbyopia sufferers are seeing clearer and higher-quality vision than ever before. The age of refractive cataract surgery is here, and manufacturers scale new heights year after year with unparalleled innovation in design.

surgery, PCO typically rears its ugly head months to years after cataract surgery. And the bad news is that the rate of PCO in implantees of high-tech MIOLs is significantly higher.1,2

New study makes headway The good news, however, is that researchers the world over are starting to take notice. The life-changing nature of MIOLs, coupled with their profitability, have given research into what is underpinning these higher PCO rates a much-needed shot in the arm.

But there is a dark cloud obscuring the pinnacle of MIOL design — posterior capsule opacification (PCO). One of the most common complications of cataract

A 2021 study2 out of China is of particular interest on this front as it is among the first wave of attempts to isolate variables that could lead to a higher incidence of PCO. In the study, the asymmetric refractive SBL-3 MIOL

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(Acri. Tec GmbH) was compared with the diffractive AT LISA tri 839M (Carl Zeiss Meditec), with a nearly even split of 98 patients (121 eyes) and 99 patients (120 eyes), respectively. Implantations took place from May 2016 to September 2018, and follow-ups were conducted for the next three years. All surgeries were performed using the same surgeon and surgical system (Stellaris Vision Enhancement System, Bausch + Lomb); variance in other variables such as temporal incision length (2.2 mm), IOL power and capsulorhexis (5.5-6.0 mm) were kept to a minimum. The decision criteria for performing Nd:YAG capsulotomy were quite simple. After checking for PCO via routine postoperative examinations, when two or more lines of uncorrected distance visual acuity were lost or the patient complained about diplopia or blurred vision, the patient was treated with


Nd:YAG capsulotomy, and the rates of Nd:YAG capsulotomy were recorded.

Oh, the difference diffraction makes And what a disparity was found between the diffractive and asymmetric refractive IOL groups. Rates of Nd:YAG capsulotomy for the asymmetric refractive SBL-3 MIOL were 3.3% in year one, 14.88% in year two and 21.49% in year three; for the diffractive AT LISA tri 839M, rates were much higher at 7.5%, 22.5% and 34.17% in years one, two and three, respectively. Though these numbers at first seem manifestly mammoth in proportion, the study authors make it clear that there is more to this data than just the raw numbers. Firstly, before the first seven months, no divergence between the two groups was found. In other words, there must be something related to the passage of time causing PCO. Secondly, although the differences in these percentages seem like whoppers, a statistically significant (p < .05) difference was only actually observed after month 27.

This unexpected reversal — where an IOL consisting at least partially of hydrophobic materials caused higher PCO rates — goes a long way toward fingering the culprit as the diffractive design of the lens itself. But why?

sensitivity to degrees of PCO and a higher degree of similarity in materials.

The study designers put forward one possible hypothesis that could be at the root of the problem. Asymmetric refractive MIOLs have less light loss (7%) and higher contrast sensitivity than diffractive MIOLs (17%). The two lens designs also differ in the way they split light passing through them. Asymmetric refractive MIOLs split it through two distinct refractive regions, whereas diffractive MIOLs divide light through a diffraction ring.

The good news is that Nd:YAG laser capsulotomy is an effective, painless and routine fix to the problem of PCO. Typically performed on an outpatient basis with few complications, doctors and patients are fortunate that Nd:YAG laser capsulotomy will always be a viable option when things get wonky with MIOLs.

In the end, the study authors settled on contrast sensitivity and light loss as possible explanations for the statistically significant differences between the two lenses. However, they did call on further research with larger sample sizes, higher

Tip of the hat, ‘YAG’ of the finger

With that being said, loss of visual acuity and the prospect of a second surgery are not exactly what those paying top dollar for the best IOLs on the market want. And while Nd:YAG lasers will always be a clinical mainstay, more research must be done to help isolate the root cause of PCO-causing deficiencies in MIOLs.

Intriguing results light up more avenues of research Though this study was small-scale in nature and dealt with only two IOL designs, the avenues for further research that it opens up are as interesting as they are varied. For one, these results are of particular interest as previous studies3-5 have found that IOLs made from more premium hydrophobic materials saw lower rates of PCO in implantees. In this study, despite the diffractive AT LISA tri 839M’s hydrophobic coating, it still saw worse rates of PCO that lead to intervention with Nd:YAG laser.

If rupture you must; Nd:YAG, you will.

References 1.

Ursell PG, Dhariwal M, Majirska K, et al. Three-year incidence of Nd:YAG capsulotomy and posterior capsule opacification and its relationship to monofocal acrylic IOL biomaterial: a UK Real World Evidence study. Eye. 2018;32(10):1579-1589.

2.

Bai H, Li H, Zheng, Sun L, Wu X. Nd:YAG Capsulotomy Rates with Two Multifocal Intraocular Lenses. Int J Gen Med. 2021;14:8975-8980.

3.

Iliescu IM, Constantin MA, Cozma C, Moraruand OM, Moraru CM. Posterior capsule opacification and Nd-YAG rates evaluation in a large series of pseudophakic cases. Rom J Ophthalmol. 2017;61(4):267-274.

4.

Joshi RS. Postoperative posterior capsular striae and the posterior capsular opacification in patients implanted with two types of intraocular lens material. Indian J Ophthalmol. 2017;65(6):466-471.

5.

Gauthier L, Lafuma A, Laurendeau C, Berdeaux G. Neodymium: YAGlaser rates after bilateral implantation of hydrophobic or hydrophilic multifocal intraocular lenses: twenty-four month retrospective comparative study. J Cataract Refract Surg. 2010;36(7):1195-1200.

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OCULUS CORNER

everywhere has developed at breakneck speed recently. That’s true for OCULUS, as well — and Dr. Logan noted he’s appreciated how the company has helped introduce the (free) upgraded software.

Pentacam and Corvis ST Refractive Surgery Prerequisites

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tatistics can be cool and all — but when we want information we can trust, we turn to industry veterans. In this case, the information we wanted was ophthalmologists’ real-world experience with Pentacam and Corvis ST (OCULUS Optikgeräte GmbH, Wetzlar, Germany). So, the veteran we reached out to was New Zealand’s Dr. Andrew Logan, a refractive specialist with nearly three decades of experience. Perhaps there should be some sort of category like “uber-veteran,” but that’s a discussion for another day. Dr. Logan operates Wellington Eye Centre and has served tens of thousands of patients over the years. Those years have included nearly a dozen using Pentacam and Corvis ST — as soon as they became available in New Zealand. This begs the question: Well, just how have these tools served him and his patients? Let’s dig in.

A refractive surgery prerequisite

by Sam McCommon

But let’s dig a bit deeper. Pentacam combines Scheimpflug imaging — which gives a very high resolution of a small object — with software that gives surgeons oodles of data to play with. One of the prime advantages of the Pentacam that Dr. Logan mentioned was that one test can provide a number of different data sets for a single patient. This makes the tool a huge time saver for both doctor and patient. Doctors, for example, don’t have to decide what they’re looking for before they test the patient. Rather than guessing, you’re playing a game of Battleship where you can see all your opponent’s pieces. Combining Corvis ST with Pentacam makes essentially a horse and carriage combination. The Pentacam shows what needs to be done, while the Corvis ST helps determine whether or not it can be done safely. The two tools combined can produce the Tomographic Biomechanical Index (TBI), which predicts the reasonable likelihood that the patient will or will not develop ectasia. By giving more accurate measurements, more patients can safely be treated without being turned down unnecessarily.

Dr. Logan was unequivocal in his support for both tools. As he put it, “You can’t safely do refractive surgery without this kind of device. It’d be indefensible.” If you’re looking for a quick takeaway, this would be it.

Evolution leads to satisfaction

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You may have noticed software

Patients, of course, appreciate a doctor who has the latest tech. It instills confidence and gives any clinic credibility. In addition to the credibility, patients like looking at the pictures the Pentacam produces, or using Corvis ST to see just how distorted their cornea has become. As Dr. Logan explained, there’s no way to not have the Pentacam in any refractive clinic — and the Corvis ST basically plays Robin to Batman.

Always more coming There’s much more coming for both Pentacam and Corvis ST in iterative software developments — which can lead to some pretty exciting developments. Dr. Logan hinted at the possibility of data gleaned from Pentacam and Corvis ST leading to structural engineering approaches to cornea strength. That’s a pretty neat concept in itself, and we can’t wait to see where it goes.

Contributing Doctor Dr. Andrew Logan is the founder of Wellington Eye Centre and has been an ophthalmologist, or eye doctor, for over 35 years. He qualified as a doctor with a Bachelor of Medicine (MB) and Bachelor of Surgery (CH.B) from Otago University in 1976, and completed his training as a specialist ophthalmologist in 1983. Dr. Logan is proud to call himself an early adopter of new proven technology, and stays at the forefront of this by attending seminars and training in New Zealand, Australia and the United States. His interests include femtosecond laser graft surgery; refractive laser surgery (SMILE, LASIK, PRK, laser blended vision); intracorneal ring segment implantation (kerarings); and corneal collagen crosslinking (accelerated topography guided). andrewjlogan@me.com


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| Sept/Oct 2022

13


COVER STORY

by Nick Eustice

G

lobalization has expanded the boundaries of what we think of as “our world.” In doing so, through communication technologies and manufacturing, this has made this world of ours feel a good deal smaller at the same time. We can take a Zoom meeting with friends and colleagues from a dozen time zones away, and afterward pick up a snack made across the world at the local convenience store. Our global network has now grown larger than ever, all the while bringing everything so much closer to home.

Globalization is not a oneway street A lot of what we think about globalization involves what we perceive as the flow of ideas and technology from West to East, in that contentious process known as Westernization. And while in some quarters this is undeniably true — from English being the second language virtually everywhere, to the ubiquitous presence of Western clothing in every major city on earth — the process of globalization is nowhere near a one-way street. The flow of goods is the simplest and shallowest example. Those famous shoes named after an American basketball

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player, worn perhaps on the streets of Cairo, are often made in a factory in Vietnam. But as Thomas Friedman pointed out almost 20 years ago, the world is not just getting bigger, but flatter. Globalization isn’t just about the outsourcing of manufacturing from West to East, but of greater opportunities being made available to people everywhere, and the overall leveling of the playing field. We often talk about knowledge and technology traveling from the West — presumed to be more robustly developed — toward the less developed East. But this notion has become less and less true. And even in areas where a greater degree of technological development exists in the West, there are still a great many ways that innovations have been developed in the East to accomplish tremendous feats despite having fewer resources. In this issue, we’re going to be looking at

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a few of the many eye care innovations coming from the East that we in the West could put to greater use. Some of them involve resourcefulness that comes from treating patients without the financial resources available elsewhere, while other developments arise from the unique conditions where they were conceived. What all of these unique approaches to treatment have in common, however, is that they are part of a growing dialogue in the medical community. And this growing exchange of information can only lead to better patient care.


is also a prolific writer and publisher of books, videos and software for the eye care industry, and brings a wealth of experience in working with underserved and impoverished communities within India.

Necessity is the mother of invention: The preference for MSICS To explore a few of the lessons we can learn from the East, we spoke with two of India’s leading ophthalmologists. First, we interviewed Dr. Sudhir Singh, an ophthalmologist, medical writer, reviewer, medical software programmer, web editor and volunteer ophthalmologist for international expeditions. In addition to being a recognized expert in cataract, glaucoma, oculoplastic, pediatric ophthalmology and strabismus procedures, Dr. Singh

Dr. Sheetal Brar is a senior cataract and refractive surgery consultant and research director at Nethradhama Superspeciality Eye Hospital in Bangalore, India. An avid and prolific educator, Dr. Brar has been training ophthalmologists for over 12 years and has authored over 50 peer-reviewed publications on diverse topics specific to her field. She frequently hosts workshops and skill-transfer courses on advanced surgical techniques and is a recognized thought leader both in India and internationally. To begin with, we asked both doctors about the differences that exist between the conditions in India and generally in the West. While a great many factors

lead to differences in treatment, both Dr. Singh and Dr. Brar began by talking about economics. “In India, due to socioeconomic reasons, the rural population does not have ready access to eye care facilities,” said Dr. Brar. This lack of access, she went on to say, has created a significant backlog in treatment, and led to a huge burden of avoidable blindness due to cataracts. In order to address this dearth of medical care, a significant number of the country’s cataract surgical procedures take place in field hospitals set up as part of outreach programs. Dr. Brar pointed out that these surgeries are either completely free or heavily subsidized, in order to make them affordable to the patient. Because of the limited resources available for cataract care, Dr. Brar noted that many such patients in India present symptoms at a very late stage, when their cataracts are already mature, intumescent or very dense. Due to these limitations in resources, cataract

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15


COVER STORY

surgeons in India typically prefer a manual small incision cataract surgery (MSICS) over phacoemulsification. Dr. Singh began in a similar vein and spoke at greater length about the prevalence of MSICS surgery in India, beginning by pointing out India’s singularity in its size and position in the world. As a developing country with more than 1.4 billion people, the technological means for Western-style care are not simply unavailable within the country, but often do not exist at the required scale. Therefore, he said that Indian doctors have come to embrace a practical approach to effective, lowtech solutions instead of seeking out high-tech treatment methods. Where surgical techniques can provide the same outcome as expensive technology, doctors in India have come to rely upon their skills more than automation and machines. MSICS is a perfect example of this preference for surgical technique as opposed to a technological approach. While MSICS has no establishment cost, the most basic phacoemulsification machine carries a cost of around US$30,000, and the femto laserassisted cataract surgery (FLACS) suite can cost considerably more, often in the neighborhood of US$500,000. Already, the start-up cost makes the latter prohibitively expensive for many ophthalmologists in India. Beyond that up-front expense, however, Dr. Singh noted that the MSICS consumables cost (including intraocular lenses) per cataract surgery in India is about $20, while the per cataract surgery cost (excluding intraocular lens cost) of the phacoemulsification cataract and the FLACS are $100 and $400, respectively. The annual maintenance costs of the phacoemulsification machine and the femto laser machine are also very high, while again, MSICS has no ongoing cost. For this reason, Dr. Singh stated that millions of manual small incision cataract surgeries are performed under the National Programme for Control of Blindness and Visual Impairment (NPCB&VI) in India. Through mass manual small incision cataract surgeries, doctors in India have been able to reduce the burden of preventable cataract blindness very economically

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and quickly, all while saving billions of dollars. As the per cataract cost of phacoemulsification and femto laserassisted cataract surgery is too high, no developing or developed country can afford it for a large population. Dr. Singh said that MSICS was among the most important things that ophthalmologists from the West could learn from India or the East. “MSICS is a simple, inexpensive, fast, less technology-dependent and reproducible technique,” he said, “by which all types of cataracts can be operated with comparable visual outcomes to any other cataract surgery modalities like phacoemulsification and femto laserassisted cataract surgery.”

Achievements that have made the voyage from East to West When asked about some of the breakthroughs in the past and present that the East has introduced to the West, Dr. Singh’s thoughts turned immediately to the world of pharmacology. “Two advances come to my mind,” he said, “the off-label use of the vascular endothelial growth factor (VEGF) inhibitor drug bevacizumab and the intracameral use of moxifloxacin. Both drugs have been used extensively in India for many years, and now these are being used in the West, too.” Indeed, both of these widely-used drugs, both developed initially in the West, have found a wider range of applications to treat patients’ vision through more explorative uses in the East. Dr. Brar focused instead on surgical techniques. “In the field of cataract surgery,” she said, “there have been many innovations and practices introduced by surgeons from the East. Prof. Amar Agarwal from India has innovated techniques such as glued intraocular lenses, four-throw pupilloplasty, and intraocular lens (IOL) scaffold, which have been widely accepted and practiced by surgeons in the West.” In the field of refractive surgery, Dr. Brar also spoke of the contributions made by Dr. Sri Ganesh. Dr. Ganesh is

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one of the pioneers of the technique of femtosecond intrastromal lenticule implantation (FILI) using a SMILEderived lenticule for potential management of high hyperopia and keratoconus. This technique, Dr. Brar explained, has also been accepted and researched by surgeons from Europe, who have access to the SMILE-derived tissue. Another procedure that Dr. Brar mentioned is corneal allogenic intrastromal ring segment (CAIRS). Invented by Dr. Soosan Jacob from India, CAIRS is a groundbreaking treatment for keratoconus which shows great promise in treating the disease, and has also recently received attention in the West.

Communication: Building better bridges One area where both of our doctors were highly optimistic, while still seeing a lot of room for positive change, was that of the ever-growing lines of exchange between the East and the West. This should come as no surprise, for while dialogue across geographic and cultural boundaries has come a long way from where it was even in the recent past, there is still a lot of progress that can still be made. Dr. Brar said that an area of focus she would like to see improved is a deepened understanding of the unique situations faced by ophthalmologists in different parts of the world. “I feel that appropriate dialogue between East and the West would help in better understanding of the current challenges being faced in the area of providing eye care facilities throughout the world,” she said. In order to achieve this sort of discourse, Dr. Brar suggested that doctors could focus on identifying specific issues, which can then be addressed using a targeted approach. One such area where Dr. Brar felt that this could be especially helpful is the area of corneal transplantation. As India has a huge demand for corneal tissue that cannot be met with the current eye donations, she said that she would like to see an effective means developed to facilitate the supply of corneal tissue


from the Western world. In addition, and to further aid in this process, she advocated for the creation of eye awareness programs to be conducted collaboratively between East and West, in order to improve upon the huge gap between demand and supply of corneal tissue. Dr. Singh compared the advantages both the West and the East have in being able to aid one another. The West, he said, is way ahead in innovations and new technologies, while the East is good in surgical techniques. This, he reasoned, is because the Western world is industrydriven, perhaps sometimes to a fault. “Femto laser-assisted cataract surgery (FLACS) is a perfect example of how too much technology is pushed without a substantial gain in the final visual outcome as compared to conventional phacoemulsification,” he said. “In my opinion, phacoemulsification is the standard modality for cataract removal for both East and West that is affordable for their populations, but all types of cataracts cannot be conquered by phacoemulsification alone.” Dr. Singh went on to say that he felt femto laser-assisted cataract surgery does not provide any substantial benefit to the visual outcome when compared to the standard phacoemulsification. Rather, he suggested that for treating conditions such as white cataracts and the densest nuclear cataracts with comorbidities such as a crowded anterior segment, coagulopathy, corneal opacity or severe miosis, FLACS could indeed be the riskier procedure for the endothelium or posterior capsule compared to the more traditional phacoemulsification. Such cataracts with comorbid conditions, Dr. Singh noted, are safely treated by manual small incision cataract surgery. “If our Western counterparts learn and adopt manual small incision cataract surgery,” Dr. Singh concluded, “then they can tackle any type of cataract with comorbidity without serious vision-threatening complications. In my opinion, manual small incision cataract surgery is a wonderful technique and every cataract surgeon must learn this to tackle complex cataract with comorbidities with excellent visual outcomes.”

Innovations to bring a brighter future When asked about some new techniques and products that have already taken root in India, but have not yet been introduced to the West, both doctors had quite a few ready. Dr. Brar mentioned a new capsulotomy-fixated IOL developed by Dr. Sri Ganesh. It has shown measured improvements in terms of antinegative dysphotopsia, stable effective lens position and excellent rotational stability in toric models, and has been deployed with great success in India. However, it has not begun the lengthy clinical evaluations required in the West.

“MSICS surgery is a wonderful technique and every cataract surgeon must learn this to tackle complex cataract ...” Another innovation Dr. Brar brought up was the “Bhattacharjee Ring.” Innovated by Dr. Suven Bhattacharjee, this device expands small pupils during cataract surgery. This is already in use and popular in India and throughout Asia-Pacific. But it is yet to be commercialized in the West. Dr. Singh pointed out that India is manufacturing and exporting quality generic medicines, medical disposable items, intraocular lenses and vaccines to the world at very economical prices as compared to those in the West. He closed by saying that this is the most important thing that the medical community can focus on: Bringing affordable health care to everyone. While technology is useful, it must provide a benefit to patients, regardless of their financial status. And whether that message travels from East to West or any other direction, providing treatment to patients in need is the best result of an ever-more connected world of health care.

Contributing Doctors Dr. Sudhir Singh is a renowned ophthalmologist and is currently a senior consultant and department head at JW Global Hospital Research Centre in Mount Abu, India. He completed his MBBS and SMS, M.S. Ophthalmology from Medical College Jaipur. He was trained in pediatric ophthalmology and strabismus by Orbis International. Dr. Sudhir Singh has been an invited speaker for various national and international conferences and has performed live surgeries at various conferences as well. He has intratunnel phacofracture technique MSICS, SquintMaster software and many other Innovations to his credit. He has more than 30 national and international publications to his name, and is an awardee of the All India Ophthalmological Society’s prestigious International Ophthalmic Hero Award 2020. drsudhirsingh@gmail.com Dr. Sheetal Brar is a senior consultant at the Phaco and Refractive Department and research director at Nethradhama Super Speciality Eye Hospital in Bangalore, India. Dr. Brar has a special interest in cataract and refractive surgery and has trained over 75 national and international surgeons in refractive surgery, including SMILE. She has participated in over 70 master classes and instruction courses and performed live SMILE and phacoemulsification surgeries. Dr. Brar has over 40 publications in national and international peer-reviewed indexed journals and served as a peer reviewer for JRS, Cornea, BMC Ophthalmology, Open Journal of Ophthalmology and Indian Journal of Ophthalmology. She has received several prestigious accolades, including being the recipient of the “Young Physician” exchange program grant by the APACRS 2017 and APACRS Certified Educator (ACE) award at the APACRS 2019 in Kyoto, Japan. brar_sheetal@yahoo.co.in

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17


NTERIOR SEGMENT

ASTIGMATISM

Don’t Let Astigmatism Get Your Outcomes Down … and turn that frown upside down with SMILE

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he past few decades have produced significant advances in the evolution of corneal laser refractive surgery. Innovations in technique and technology have delivered increasingly precise and highly predictable results. One of the first trailblazers in corneal refractive surgery were surface ablation procedures, like photorefractive keratectomy (PRK). These were originally used for correcting myopia and myopic astigmatism and came with a reputation for requiring prolonged recovery, discomfort, corneal haze, and increased potential for regression of the achieved refractive correction. To address some of these original pitfalls, laser in situ keratomileusis (LASIK) introduced the ability to perform laser correction on the corneal stroma, accessed via a flap created by a microkeratome.

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by April Ingram

Although LASIK appeared to be the answer, demonstrating high patient satisfaction, some patients still experienced a spectrum of flap-related complications that negatively impacted outcomes.

A little lenticule will do ya A recent step in the refractive evolution to boost both safety and outcomes comes in the form of small‑incision lenticule extraction (SMILE). SMILE — it even sounds like a pleasant procedure. SMILE, in particular, is performed using the Zeiss VisuMax (Carl Zeiss Meditec AG, Jena, Germany) and was the first of its kind. Today, there are other devices available for refractive lenticule extraction surgery. But back to SMILE: It is minimally invasive and uses a femtosecond laser to

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deliver high‑frequency pulses that ablate corneal tissue without the need to create a flap — eliminating the dreaded flaprelated complications. The intrastromal lenticule created inside the intact cornea can then be extracted through a tiny (2 mm) incision, minimizing recovery time. By leaving the cornea intact, its biomechanical stability is maintained, while protecting more of the corneal nerve fibers. A stable, intact cornea means none of the post‑LASIK ectasia; meanwhile, healthy nerve fibers reduce post-refractive surgery dry eye that can negatively impact visual outcomes.

But what about astigmatism? The U.S. FDA approved SMILE in 2018 for the treatment of myopia up to 10 D and astigmatism to 3 D. Previous


studies of the SMILE technology have demonstrated accurate and reliable correction of myopic astigmatism, up to 3 D of cylinder, without the requirement for iris registration to offset cyclotorsional eye movement. Recently, Dr. Arulmozhi Varman, Dr. Aadithreya Varman and Dr. Dinesh Balakumar from the Uma Eye Clinic in Chennai, Tamil Nadu, India, published their data from a series of patients who underwent SMILE for the correction of high cylinder (>2.5 D) myopic astigmatism in the Indian Journal of Ophthalmology.* The series included 42 adult eyes that underwent SMILE between October 2019 and February 2021. All eyes had preoperative myopia of -0.5 to -6 D with myopic astigmatism of -2.5 to -4.5 D and normal central corneal thickness. It is important to note that all eyes had a stable refractive error for a year or longer, and that any ocular surface issues, such as dry eye, were addressed prior to undergoing the SMILE procedure. [Pro-tip: Always resolve dry eye or other ocular surface abnormalities prior to laser refractive correction or cataract surgery for the best possible refractive outcomes and the most satisfied patients.] All the SMILE procedures were performed by a single experienced surgeon using the VisuMax laser system. The laser was set to a repetition rate of 500 kHz, a pulse energy of 132 nJ, delivering a spot size of 5 microns. Lenticule diameter was 6.0 mm, cap diameter was 6.5 mm, with an intended cap thickness of 110-130 microns. Once the refractive lenticule was created, it was carefully removed via 2 mm side cuts. Post-surgery, each patient was instructed to administer topical antibiotic‑steroid eye drops for one week, and then topical steroid drops for four weeks. Prior to SMILE, the mean spherical error in these eyes was ‑3.75 ± 1.96, and mean cylindrical error was ‑2.92 ± 0.50. The mean spherical equivalent of refraction was 5.36 ± 1.92, which after one month improved to an impressive ‑0.28 ± 0.89 and a mean cylinder of ‑0.40 ± 0.18.

“Small incision lenticule extraction has proven its efficacy in the correction of myopia and myopic astigmatism. The small incision, lack of a flap, and considerably lesser damage to the sub-basal nerve plexus give it an edge over LASIK.” — Dr. Aadithreya Varman, director of the Uma Eye Clinic Surgeons must be aware of the potential for intraoperative complications of SMILE, which include retention of refractive lenticular fragments, tears of the incision, and improper dissection. Thankfully, none of these occurred in this series from Uma Eye Clinic. Dr. Aadithreya Varman, director of the Uma Eye Clinic, shared how SMILE has established itself as the refractive procedure of choice for his patients. "Small incision lenticule extraction has proven its efficacy in the correction of myopia and myopic astigmatism. The small incision, lack of a flap, and considerably lesser damage to the subbasal nerve plexus give it an edge over LASIK.”

their publication, Dr. Varman and colleagues noted that there is better wound healing and a lesser inflammatory response in SMILE as compared to FS‑LASIK, which settles in the first week after the procedure. They added that the reduced apoptosis of keratocytes, proliferation and inflammation are crucial factors as to why SMILE has an edge over FS‑LASIK. Correcting myopic astigmatism >3 D is no small feat, but Dr. Varman achieved excellent efficacy and safety, performing the SMILE procedure for this complex patient group. In this series, compensatory mechanisms for the cyclotorsional movement of the eye were not used. However, they were able to achieve excellent postoperative visual outcomes, which they credit to their meticulous preoperative planning and accuracy of pre-op refraction. The faster healing and flapless advantage, coupled with the low incidence of dry eye, have an edge over the conventional laser vision corrective procedures. Dr. Varman concluded: “Lenticule extraction will soon be the ‘goto’ procedure for refractive surgery."

Reference *

Arulmozhi Varman NV, Varman A, Balakumar D. Post-operative outcomes of small-incision lenticule extraction in patients with moderate to high astigmatism. Indian J Ophthalmol. 2022 Feb;70(2):396-399.

The proof is in the pudding Naturally, what patients really want to know is how their vision will be after undergoing SMILE. Of the 42 eyes in this series, only one day after SMILE, two eyes had visual acuity of 6/9, while 40 eyes achieved 6/6. By post-op day 10, all 42 eyes achieved 6/6! Dr. Varman described the good recovery of visual acuity as early as post-op day one, with results that made his patients “smile.” “The use of low-energy settings can provide patients with early recovery and the day one ‘wow factor’ that one has come to expect from refractive surgery today,” he said. Uma Clinical has been providing advanced eye care for decades. Within

Contributing Doctor Dr. Aadithreya Varman is the director of the Uma Eye Clinic in Tamilnadu, Chennai, India. Since 1985, Uma Eye Clinic has been offering the most advanced treatments across all areas of eye care in state-of-the-art tertiary care, super specialty eye care center. Dr. Varman and colleagues are the pioneers in the country to introduce Phacoemulsification surgery for cataracts and multifocal IOL implants, as well as being premier providers of Laser Refractive procedures, Intralase (femtosecond) bladeless LASIK, SMILE, C3R for Keratoconus Treatment and Selective Laser Trabeculoplasty. aadithreyavarman@gmail.com

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19


NTERIOR SEGMENT

GLAUCOMA

A Glaucoma Conundrum Unraveling the mystery of Asian eyes and POAG

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n Asian eyes, glaucoma is largely determined by two antagonists: normal tension glaucoma (NTG) and primary angle-closure glaucoma (PACG). And while these two have garnered much attention, primary open-angle glaucoma (POAG), appearing as high tension glaucoma (HTG) in Asian ethnicities, has largely slipped under the radar. Therefore, we were happy to come across a recent review study¹ by six authors who gallantly pulled together findings of POAG and Asian eyes going back to the year 2000. This could not have been more timely since the issue of

20

by Roger Shitaki

POAG in people of Asian descent is not just a cursory topic.

Putting the numbers into perspective

India and China, is expected to carry the largest burden of POAG cases, or a 79.8% increase on their current levels.² The highest regional increase is forecast for South and Central Asia, with China and India being the second and third most prevalent globally.

Current impasses in the POAG terrain in Asia The key issue with understanding POAG pathogenesis (excluding NTG) within Asian ethnic groups is a lack of clear and systematized data to work with.

Open-angle glaucoma is the most common form of glaucoma, while primary open-angle glaucoma is most prevalent among Hispanic and African ethnicities.

Structural characteristics of the eye associated with glaucoma progression have been noted in Asians in comparison to other racial groups. However, more research is needed to determine how differences in the optic disk, retina and cornea contribute to this progression.

The spotlight, however, is now shifting somewhat in a new direction. Asia, partly due to the rapidly aging populations of

Differences in vascular structures and vascular pathologies in glaucoma, including cardiovascular and

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A decrease in these parameters correlates to an increased risk factor. But further study may help in understanding pathogenesis in other ethnic groups.

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Specific vascular morphology studies in Asians are fairly limited and lack repeated findings. On the surface, though, Indians may have the largest arteriolar and venular calibers, Chinese the smallest, and Malays in between. Chinese have been identified to have the largest arteriolar and venular tortuosity and venular fractal dimension.

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One key morphology concerns the central corneal thickness (CCT), where

Comparative Vascular Morphologies

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Structural Morphological Differences

East Asians as a group also tend to have a thicker retinal nerve fiber layer (RNFL). For Malay eyes, the difference is negligible, but Indians have thinner RNFL overall. Likewise, the average ganglion cell complex is the densest in Chinese followed by Malays and then Indians, where it was significantly thinner.

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The progression of glaucoma is characterized by structural parameters with distinct racial morphologies, which may impact diagnostic standards. As a clearer picture emerges, specific morphologies of various Asian subgroups are also starting to reveal themselves, which is very promising.

Concerning optical disc areas, European Americans have a significantly smaller area, especially when compared to the Chinese. Differences between other races have not proven clinically noteworthy. Although important in diagnosis and glaucoma management, disc size and ratios are not evidenced as independent risk factors.

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What we know about Asian eyes

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Additional studies in Asia suggest that systemic high IOP risk is also significantly inherited. Inheritable high IOP risk can be up to 10% if parents have high IOP. However, it appears that genetic inheritance can vary substantially between ethnic groups.

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Among the Asian subset, East Asians, more specifically Chinese, have the lowest healthy IOP followed by Malays and then Indians.

Variations in CCT, however, correlate to a much higher glaucoma risk factor in Africans and Hispanics than for Asians. Additionally, the role of CTT in normal tension-glaucoma is not well understood.

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Studies in racial IOP variations are promising yet inconclusive. One key study has shown Europeans in comparison to the Chinese to have lower IOP and a slower aqueous flow rate. This is now suspected to be one reason for lower POAG rates in Europeans.

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Apart from an incomplete picture regarding the causes and high prevalence of NTG in this group, Asians also show a negative inverse relationship between IOP and age, without a reduced risk of glaucoma. The key challenge here is finding novel therapies that rely on more than just IOP reduction.

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Peculiarities of IOP in Asian eyes

There have been a number of interesting studies concerning blood pressure and hypertension. Some are contradictory, others inconclusive, but they do provide crucial insights into the progression of glaucoma in Asian and non-Asian groups. ha

Among the key risk factors — such as age, intraocular pressure (IOP), cornea thickness, gender, genetics and race — the increasing prevalence of myopia in younger generations of Asians is also of particular concern.

a thin thickness is considered a key glaucoma risk factor. Chinese, Japanese, and Koreans have somewhat thicker corneas than South and South East Asians, including Filipinos and Pacific Islanders.

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hypertension parameters, are likewise less studied across Asian groups.

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In some instances, hypertensive Chinese patients had a higher prevalence of NTG, which also correlated negatively with a range of RNFL thickness and positively with mean IOP. In one study, low diastolic blood pressure, mean OPP, and diastolic OPP were found to be independent factors in POAG risk; while in another, low and high systolic OPP correlated to higher POAG risk.

Genetic Markers In terms of genetic markers of POAG, East Asians, Koreans, and Africans have distinct patterns for single nucleotide polymorphisms and risk alleles. While, on the other hand, South Asians also share a similar genetic heatmap to European and American populations. Further studies are needed here to map out commonly shared genes and those specific to Asian subsets.

What this means moving forward Asians have a unique glaucoma risk and disease profile. A better understanding of structural parameters of the optical disk, retina, and cornea as potential risk factors in Asian populations could lead to more effective mitigations and novel treatments. More targeted research and a comprehensive study of ocular blood flow parameters are likewise needed.

References 1.

Belamkar A, Harris A, Oddone F, et al. Asian Race and Primary Open-Angle Glaucoma: Where Do We Stand? J Clin Med. 2022;11(9):2486.

2.

Allison K, Patel D, Alibi O. Epidemiology of Glaucoma: The Past, Present, and Predictions for the Future. Cureus. 2020;12(11):e11686.

| Sept/Oct 2022

21


UDOS

NEW TREATMENTS

Making Headway Anterior segment set for major breakthroughs in treatment by Andrew Sweeney

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laucoma and cataracts are two of the most commonly encountered diseases that ophthalmologists deal with on a daily basis — so, any new advances in treatment are a cause for celebration. At Media MICE we’re constantly scouring the web, conferences, and symposiums to learn about the latest advancements in treatment and technology. And boy, have we found some cool stuff. Here are some of the latest…

We won’t shoot your eye out These days, whenever we hear about a new innovation in ophthalmic technology, it often seems like such news comes from Israel — and today is no exception. The Silicon Wadi, a region in Israel known for its plethora of high-tech industries, produces a lot of really cool stuff. The latest offering that piqued our interest is a new automated and non-contact glaucoma laser treatment by BELKIN Vision (Yavne, Israel): The Eagle laser. BELKIN Vision specializes in developing innovations in glaucoma care and the Eagle laser is marketed as the only non-contact laser treatment currently available. It’s also completely automated, which should significantly improve access to treatment as the

laser does not require specially trained technicians to operate. Also, it utilizes direct selective laser trabeculoplasty (DSLT), which provides fully automated glaucoma treatment: It’s intuitive, efficient and pretty darn cool.

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| Sept/Oct 2022

An eye drop to treat cataracts?! Now for cataract — let’s talk about the possibility of a drug treatment for the condition — which can only be


treated with surgery at present. Thanks to a group of researchers from Anglia Ruskin University (Cambridge, U.K.), we might see the deployment of oxysterol compound VP1-001 to the market soon. It might need a catchier name by then, but this compound already holds some serious promise.

Cataract inflammation no more? We all know that when it comes to cataracts, it’s usually a good idea to get them surgically treated if safe to do so. However, there can be postoperative side effects like inflammation and pain, and no patient wants that.

During laboratory trials, the compound exhibited considerable improvement in refractive index profiles (which is a key optical parameter required to maintain high focusing capacity) in 61% of lenses. The effect of this is to reduce the protein organization of the lens being treated, which in turn allows the lens to focus better on foreign objects. As a result, lens opacity was reduced in 46% of cases. When you consider that millions of people are currently affected by cataracts, you can see the potential of this treatment.

Aldeyra Therapeutics reported that a statistically significant reduction in ocular redness could be observed in just 10 minutes after Repoxalap was administered, and after 90 minutes as well. Now the company is planning a crossover clinical trial as part of a new drug application (NDA) to include data on ocular redness and the Schirmer test, pending discussions with the Food and Drug Administration (FDA). Awesome news for ocular redness and DED sufferers everywhere!

American ophthalmology company Eyenovia (New York, New York) has been making some interesting moves recently. One of which was partnering up with Arctic Vision, based in the mainland Chinese city of Shanghai. The latter obtained from the former an exclusive license for the development and commercialization of ARVN003 (MicroLine) for both mainland China and South Korea. As part of this arrangement, Arctic Vision has now enrolled its first patient in a phase 3 clinical trial on the use of ARVN003 for presbyopia. Presbyopia is a major growing health concern in many countries as populations begin to age, so it will be fascinating to read the final results of this trial. As the company points out, this is particularly true as the search for alternatives to spectacles or surgical treatment for presbyopia continues. This is the first time that a clinical trial has been approved in China to evaluate a pharmacologic treatment for presbyopia, and we wish them the best.

Get ready for the tears Bob Marley might have sung “no woman, no cry” but sometimes it’s medically important to be able to do so — so sufferers of dry eye disease (DED) should feel some relief. With that said, we're happy to report that a new treatment is in the cards! Aldeyra Therapeutics (Lexington, Massachusetts, USA) has announced that it successfully tested Reproxalap as a new treatment for DED, finding that it was statistically superior according to two key metrics. These are ocular redness in a dry eye chamber (P=0.0004), and the Schirmer test (P=0.0005), a measure of tear production.

Presbyopia is going down

Promising outcomes Step in phase 3 OPTIMIZE (Once-daily Post ocular surgery Treatment for InflaMmation and paIn to minimiZE drops) trial by Oculis (Lausanne, Switzerland), for once-daily OCS-01 — a novel, high-concentration, preservativefree, topical OPTIREACH formulation of dexamethasone. The company hopes that this new drop will have a major outcome on minimizing patient discomfort and maximizing quality of life. The trial is randomized, double-blind and placebo-controlled, and is taking place in 25 participating sites across the U.S. Oculis hopes that the OCS01, an “efficacious, preservative-free alternative, administered just once a day,” could provide significant advantages over current options and help cataract patients experience less discomfort. Considering the drop has longer residence time on the eye surface and enhances bioavailability in relevant eye tissues (particularly the retina), we can surely expect to see some great results.

Will these exciting new developments help to revolutionize their respective areas of treatment? Time will tell, but we can say with certainty that they exhibit tremendous promise — especially the oxysterol compound VP1-001 as a nonsurgical treatment for cataract. Let’s hope that they will all work out (especially as this will allow us to do some more writing and say “we told you so” at the same time). So, check out CAKE for updates and let’s hope they all enjoy a strong entry to the market.

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

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EYE CARE ORGANIZATION

Continuing Fred Hollows’

Legacy From the ground up… all the way to the stars! by Joe Schreiber

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rof. Fred Hollows — a New Zealand-Australian ophthalmologist known for dedicating his career to saving eyesight around the world — dreamed of an end to the economic disparity between urban and rural communities and first- and third-world countries. He did his part in that vision quest by focusing on the elimination of blindness in rural and far-reaching parts of Australia, eventually branching out to other countries, such as Nepal, Eritrea, and Vietnam. Tragically, Prof. Hollows passed away from cancer in 1993 at the age of 63. But shortly before his death, he and his wife, Gabi Hollows, laid the groundwork for The Fred Hollows Foundation — a non-profit organization that continues the eye surgeon’s legacy to this day. Today, The Foundation operates in 18 countries stretching from Rwanda to Timor-Leste.

A gift that keeps on giving “It’s obscene to let people go blind when they don’t have to,” Prof. Hollows once said. “What we’re doing is giving these people the chance to help themselves. We are giving them independence.”

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The Foundation’s ideal is not just to cure blindness by flying doctors in, but to focus on sustainability and capacity-building that operate for the people, by the people — by building institutions that can stand on their own. Prof. Hollows put it well when he said: “Teach the teachers first, then the teachers can teach others.” According to its website, The Foundation works with communities by funding and facilitating; training doctors, nurses, and eye health workers; advocating for stronger health systems; providing new techniques and technology; and empowering local communities to “take their eye health in their own hands.”

Creating a thriving community… One of the key values defined by

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The Foundation is collaboration. For this issue, we asked two prominent Foundation members — an optometrist and an ophthalmologist — about working with The Foundation, their collaboration at home and away (that’s an Aussie soap opera joke), and if they’ve met actor Joel Edgerton — an Australian actor best known for starring in the recent Star Wars series and who has been one of their ambassadors since 2013. Dr. Lila Raj Puri, MD, is an ophthalmologist and medical health advisor at The Foundation. He shared that ophthalmologists can support The Foundation in many different ways by “performing surgeries, like cataract surgery or entropion surgery for trachomatous entropion; as well as training junior ophthalmologists, cataract nurses, and other eye health workforce.” They can also conduct screening camps, advocacy, and community education while establishing and strengthening eye care centers and clinical services. According to Dr. Lila: “Assuring quality service strengthening, upgrading clinical services, contributing to the public health aspects of eye care, capacity-building of the staff,


supporting the project development, and monitoring are other areas [that ophthalmologists can help].” Dr. Suit May Ho, OD, was named an eye health hero in 2018. “As an optometrist,” she told us, “I am part of the medical team that provides advice to country program teams on matters related to uncorrected refractive errors, primary eye care, school eye health programs, health promotion, and eye health workforce.” In general, she said, optometrists can contribute to the “provision of primary eye care, vision screenings in the community and schools, referring patients needing care, health promotion and research, as well as refractive error services.” Both Dr. Ho and Dr. Lila joined The Foundation towards the beginning of the COVID-19 pandemic, and while they have not worked together in the field, Dr. Lila said they “collaborate to provide support to the country teams in South East Asia.” In particular, Alina Hospital in Hanoi, Vietnam, is one of the central hospitals that benefits from foreign training. Both doctors support Alina by contributing to monthly quality reviews and are part of the quality improvement team.

From the ground up… Dr. Ho shared that when she “first started working in Hanoi in 2008, the eye doctors and ophthalmologists hadn’t been exposed to optometry before.” She began by creating the first refraction training course in 2008. But in 2013, there were still only three optometrists operating throughout Vietnam, all of which were trained outside the country. So in 2014, she established Vietnam’s first full optometry course to begin training more optometrists in-country. The new generation of optometry arrived in 2018, and Vietnam now has considerably more capacity to treat optometry problems nationwide.

When asked what drives her to do her work, Dr. Ho shared: “The level of commitment that I see in the young optometrists, who provide care to patients and teach the new optometry students, struggling at the same time to get the profession recognized.” As far as the interactions between ophthalmologists and optometrists are concerned, Dr. Lila said they “work side by side to provide cost-effective and accessible eye care.” Optometrists are community-based and the “first port of call” for patients. They prescribe medications, treat conditions, and refer patients to ophthalmologists. He stressed the importance of simple conditions being managed at the community level by optometrists, while more complicated procedures be referred to ophthalmologists. Building a brand-new, sustainable, and easily accessible system within a country is essential to developing those relationships.

… all the way to the stars! Finally, this writer got to ask the big question: “Have you met Joel Edgerton? I hear he’s a supporter. If doctors work with The Foundation, will they get to meet Luke Skywalker’s Uncle Lars?” I was disappointed that the answer from both was: “No, we have not met Joel, but he is a strong supporter of The Foundation’s work.” Sadly, he did not get to collaborate directly with superstars like Dr. Lila and Dr. Ho. Still, I will conclude this article with a quote from Edgerton anyway: “There’s something very special about the organization (that is) not just trying to tackle the problem on one level, but it’s trying to tackle the problem by setting up an ongoing infrastructure, which I think is really important.”

Contributing Doctors Dr. Suit May Ho is an Australianregistered optometrist working in public health and international eye health for the past 30 years. Currently, she is an optometry and primary care adviser at The Fred Hollows Foundation. She started as an optometrist at the Australian College of Optometry. Before joining The Foundation, she was employed at the Brien Holden Vision Institute Foundation, most recently as director of education and development. Dr. Ho has worked extensively in the development and implementation of sustainable eye care and education programs in various countries in the Asia-Pacific and Africa regions. Another area of interest is research, where she has been involved in key publications on myopia, presbyopia, refractive errors and low vision. Dr. Ho also contributed to the “IAPB School Eye Health Guidelines for Low-and Middle-Income Countries” and IAPB position papers on refractive errors and their correction. She currently serves on the World Council of Optometry Public Health Subcommittee, Optometry Victoria South Australia Education Advisory Committee, IAPB School Eye Health Working Group, and Low Vision Working Group. sho@hollows.org Dr. Lila Raj Puri is an ophthalmologist based in Kathmandu, Nepal, and has been a medical advisor at the Fred Hollows Foundation since 2020. He practiced for 10 years at Sagarmatha Chaudhary Eye Hospital in Lahan before obtaining a Master’s degree in public health for eye care from The University of London. An ophthalmologist, oculoplastic surgeon and public health specialist, Dr. Lila completed his degree in Ophthalmology at the Institute of Medicine, Nepal; a fellowship in Oculoplasty from Ludwig Maximillian University in Munich; and a Master of Public Health for Eye Care from the London School of Hygiene and Tropical Medicine. He is an ophthalmologist with over 14 years of experience in the clinical and surgical management of eye diseases and hospital management. He also has vast clinical experience, having performed more than 70,000 cataract surgeries. drlila_raj@yahoo.com

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GENDER & REFRACTIVE ERROR

Gender and Refractive Error More than just measurements

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o the untrained eye, an eye is just an eye. For those with insight and training, of course, the story is more complicated. There are always surprises lurking in data, waiting to pounce out of the shadows and into focus. Focus is what we’re talking about here — specifically, intraocular lens (IOL) measurement techniques to get patient focus right. Some eyebrow-raising data have led to conclusions that can improve predictive IOL measurements. The surprise? Gender is a major predictor of IOL measurement error in all five modern formulas studied by a University of

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by Sam McCommon

Michigan group of researchers.* And it’s a much more major predictor than many had anticipated. We’ve long known that men and women have differences in their eyes. But as we’ve recently learned, the physical parameters defined by gender are only part of the issue. We may have found a medical rabbit hole here, but for now, we’re just going to discuss the measurable outcomes of accounting for gender in predicting refractive error. So, the upshot? Including gender into predictions of refraction error can help optimize IOL selection and decrease

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prediction error. Not only does including gender help, but including gender in parameters may be a crucial and previously overlooked step in reducing predicted refractive error. Let’s take a look at just what spurred this study, the specific results, and how its findings can be used in a clinical setting.

Optimization of IOL by gender: Gaps in the data One might be forgiven for assuming someone had thought about the impact gender might have on IOL


measurements before, but apparently not. As the study’s authors noted: “No prior studies have explored optimization of lens constants by gender despite clear differences in ocular biometry between men and women.” After all, there are well-known differences in ocular biometry between men and women. Accordingly, as the authors pointed out, “Women have smaller axial lengths, anterior chamber depths and horizontal white-to-white distances, in addition to greater mean keratometry than men.” Men also have greater central cornea thickness and crystalline lens thickness. This is true across race and geographical location, so there’s something fundamental going on here. Conflicting evidence regarding the effects of gender on IOL power calculation formulas left some gaps in our collective knowledge. Specifically, while the SRK/T formula had been noted to result in myopic calculation errors for women, data was not quite conclusive. That led to the curiosity which, in turn, led to the University of Michigan study we’re discussing here. Before this study, only preoperative axial length, anterior chamber depth and central corneal thickness had been demonstrated to predict prediction error. While these measurements certainly correlate with gender, there appears to be more to the story. In short, gender itself, rather than simply the measurements that are influenced by gender, tends to play a significant role as an independent predictor of prediction error.

Hyperopic and myopic errors The study found that each of the five modern IOL formulas led to significantly different prediction errors between men and women. Specifically, errors tended to be hyperopic in men and myopic in women, at -0.120 ± 0.529 and 0.072 ± 0.585, respectively. Again, it’s not just ocular size or other factors that make the differences — it’s gender itself. Even age doesn’t affect prediction error as much as gender does. Indeed, the coefficient for gender was an

order of magnitude more significant than that of age in predicting prediction error. “Predicting prediction error” might sound redundant, but it’s not. In this case, it simply means that adding gender to the equation can give clinicians a pretty good idea of how much they’ll need to correct IOL formulas for each individual patient. Optimizing lens constants using gender can lead to improved refractive outcomes. Essentially, there’s a powerful variable in the five modern formulas that’s been overlooked until recently.

Reducing predictive error So, just how much can optimizing for gender reduce absolute error in IOL optimization? It varies depending on which formula you use, but we’re looking at significant differences here.

Study limitations Like every study, this one had some limits. These include relying on a retrospective rather than a prospective dataset. In addition, despite the study’s reasonable size (431 eyes of 5,519 cataract patients), both race and geographical location were limited, drawing all data from a single location in the United States. The Hill-RBF and Holladay 2 methods weren’t included in the study due to technical constraints. Furthermore, the authors couldn’t exclude all potential ocular conditions that could lead to formula error. Consequently, the authors excluded patients who had prior corneal refractive surgeries.

IOL progress marches on Specifically, optimizing for gender led to a: •

1.177% reduction in error in the Holladay formula

2.249% reduction in error in the SRK/T formula

1.074% reduction in error in the Hoffer Q formula

0.162% reduction in error in the Haigis formula

0.418% reduction in error in the Barret formula

These changes led the researchers to consider optimizing lens constants separately based on gender. Every step ophthalmologists take to improve outcomes is another step toward patient satisfaction and improved vision.

The march of progress in the IOL world over the last few decades has been astounding, and it’s largely due to incremental studies like this one. Finetuning measurements and formulas leads to more predictable outcomes, greater surgeon confidence, and — naturally — better vision for patients. If we were to chart IOL progress on an X/Y graph, it’d probably look exponential. That’s a wonderful thing for all involved. We’ll be keeping a look out for just what other kinds of gender differences in eyes bubble up in data. The researchers in this study may have just begun pulling on a much longer thread than one might initially expect. Kudos to them, and we can’t wait to hear more.

Reference *

Zhang Y, Li T, Reddy A, Nallasamy N. Gender differences in refraction prediction error of five formulas for cataract surgery. BMC Ophthalmol. 2021; 21:813.

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WOMEN IN OPHTHALMOLOGY

Women in Ophthalmology

Perspectives from Around the World (and Eye!) by Brooke Herron

I

t goes without saying that the world is a diverse place: From East to West, there can be pretty vast differences in culture — including a woman’s role in society. However, there can be a lot of similarities, too — especially in the medical field. In this Women in Ophthalmology series, we interviewed five female ophthalmologists from the United States, Singapore and Malaysia to hear their thoughts on the challenges, celebrations and joys of being both a woman and an ophthalmologist. Let’s hear from them…

Dr. Chelvin Sng, Singapore At CAKE, we often turn to Dr. Chelvin Sng for her ophthalmic insight and expertise. In fact, she has been with the magazine since its first “baking,” serving on the Advisory Board and regularly contributing to articles. Dr Sng is the Medical Director of Chelvin Sng Eye Centre at Mount Elizabeth Novena Hospital and an Adjunct Associate Professor at the National University of Singapore (NUS).

“I was aghast that she even asked whether my menstrual cycle coincided with the date of her surgery, as she believed that would affect my surgical performance!”

All dressed up: Dr. Chelvin Sng and her family.

— Dr. Chelvin Sng

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#1: Do women face additional challenges compared to men in ophthalmology? Dr. Sng: Indeed, women do face additional challenges compared to men in ophthalmology. Societal expectations


that mothers should remain the primary caregivers of their young children still remain in many cultures — even if the mothers are working full-time. Hence, many female ophthalmologists are forced to compromise on their careers once they start a family.

surgery, as she believed that would affect my surgical performance! Fortunately, the surgery went well and she has since rightfully changed her perception of female surgeons. This really highlights the misogyny that female ophthalmologists are faced with sometimes.

#5: What does your perfect day off look like?

#2: Why is it important to celebrate women in ophthalmology?

Dr. Cathleen McCabe, Florida, USA

It is timely to recognize the significant achievements of women in the field of ophthalmology, especially because women are often poorly represented in international forums and key leadership positions. Celebrating the talents and achievements of these women would also inspire the next generation of young female ophthalmologists to overcome their own challenges and break gender stereotypes.

Dr. Cathleen McCabe serves as chief medical officer at Eye Health America. She is one of the foremost eye surgeons today, specializing in bladeless laser cataract surgery and LASIK at The Eye Associates in Sarasota, Florida. Over the years, Dr. McCabe has worked with CAKE on different educational projects, articles — and even as a speaker at our own CAKE & PIE Expo. So, it was natural that we’d come to Dr. McCabe to share her thoughts on the way forward for women in ophthalmology.

#3: What is your proudest professional achievement?

In addition, both fellow ophthalmologists and patients often harbor gender stereotypes that female ophthalmologists have to overcome. I was once referred a female patient who required glaucoma surgery. She admitted that she preferred male surgeons and had never had a female surgeon prior to this. I was aghast that she even asked whether my menstrual cycle coincided with the date of her

I am proud that I helped launch the MIGS movement in the Asia-Pacific region. I was fortunate to be the earliest Asian surgeon to use several MIGS devices and was appointed the Convenor of the Asia-Pacific Glaucoma Society (APGS)-MIGS Interest Group, which trains and educates regional surgeons in the appropriate use of these devices. I am also proud to be a co-inventor of the Paul Glaucoma Implant, which is a novel tube device that I now implant in patients with refractory and advanced glaucoma, with good outcomes.

A lazy day spent with my wonderful husband and two sons, with lots of outdoor time to stave off the onset of childhood myopia!

“I am very proud to have been recognized and asked to lecture on a technique I developed for suturing in-the-bag dislocated IOLs.” — Dr. Cathleen McCabe #1: Do women face additional challenges compared to men in ophthalmology?

Dr. McCabe: Although there has been progress and women now make up a greater percentage than ever before of doctors graduating from ophthalmology #4: If you could residencies, women are wave a magic wand Dr. Cathleen McCabe and her still underrepresented husband during Holi. to improve one in academic leadership thing for women, positions, at the podium, what would it be? in organizational leadership positions, and serving as board members. Some I hope that “manels” would cease to of the challenges include balancing exist. Women deserve to be heard and to child-rearing, a desire for better work/ have a voice. life balance and more flexible hours, and only slowly improving mentorship

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models for women in the earlier parts of their careers.

#2: Why is it important to celebrate women in ophthalmology? Drawing attention to the many accomplishments of women surgeons, clinicians and researchers in ophthalmology shine a light that can inspire and guide younger female physicians. More diversity in our physicians improves patient care. Women bring different communication skills, different perspectives and different approaches to patient care and surgery, enriching the variety of solutions we have available to treat our patients.

#3: What is your proudest professional achievement? I am very proud to have been recognized and asked to lecture on a technique I developed for suturing in-the-bag dislocated IOLs. This low-technology technique can be used anywhere in the world with very little special instrumentation and avoids more complex surgery in most cases. It has been wonderful to hear from other surgeons how it has helped them to care for their patients.

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WOMEN IN OPHTHALMOLOGY

#4: If you could wave a magic wand to improve one thing for women, what would it be? Equal numbers in leadership, mentorship, research and advisory positions. It would be great for there to be a time where all women panels, faculty or boards would be as frequent and unremarkable as all-male panels, faculty and boards and that the majority would be mixed men and women. I would love for a time when young women saw examples of how they would like to craft their professional lives in women leaders everywhere they looked.

#5: What does your perfect day off look like?

“There is a gender bias in choosing males over females for training opportunities or career progression during a woman's childbearing years.” — Dr. Cheryl Ngo #1: Do women face additional challenges compared to men in ophthalmology?

Dr. Ngo: Yes, there is a gender bias in choosing males over females Delicious fancy coffee and for training opportunities breakfast with my family or career progression … made by my husband during a woman's who is an amazing childbearing years, cook. No agenda. as maternity Lots of sunshine leave may be and outdoor time deemed to be hiking, kayaking, disruptive to walking on the the service. beach or paddle As working boarding. A board mothers, game or movie with we have the Dr. Cheryl Ngo enjoys a relaxing day off at the beach. the family and friends additional — truffle popcorn (!) challenges of — and topped off with a managing the good book. Bonus points if I get family and children some yoga in too! — on top of managing our professional careers, by taking on similar responsibilities as our male colleagues. Dr. Cheryl Ngo, Women are also often remunerated less than male colleagues of similar seniority/ Singapore rank. Dr. Cheryl Ngo is a consultant and medical #2: Why is it important to celebrate director at the Adult women in ophthalmology? & Child Eye Clinic in Singapore. We last spoke Women wear multiple hats at work and to Dr. Cheryl Ngo for the at home, while continuing to make an CAKE 06 “Radio Show” impact in the lives of their families — as cover story, where we asked well as in the field of ophthalmology. for her insight into some of Celebrating women in ophthalmology ophthalmology’s keeps talented women working, while most crucial inspiring those around them to continue industry managing a successful career and happy issues — and family at the same time. now, she’s back to discuss #3: What is your proudest another critical professional achievement? issue: the struggles women still face in Opening my own ophthalmology ophthalmology. practice!

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#4: If you could wave a magic wand to improve one thing for women, what would it be? Achieving a work-life balance with flexible hours, shared parental duties, equal opportunities and remuneration for women.

#5: What does your perfect day off look like? This is the easiest question to answer — a cool day at the beach with my family, and a glass of champagne in hand.

Dr. Dee Stephenson, Florida, USA Dr. Dee Stephenson is the founder and director of Stephenson Eye Associates in Venice, Florida, USA. We last interviewed Dr. Stephenson for our CAKE 07 “Back to the Future” cover story, where she shared her thoughts on the evolution and future of cataract surgery. Now, we welcome her back to shed her perspective on the difficulties women face in medicine.

#1: Do women face additional challenges compared to men in ophthalmology? Dr. Stephenson: Women in medicine, not just ophthalmology, face additional challenges compared to men: We are paid less and are just as well trained, if not better trained than some of our male counterparts.

“We are paid less and are just as well trained, if not better trained than some of our male counterparts.” — Dr. Dee Stephenson #2: Why is it important to celebrate women in ophthalmology? We have babies and still manage to bring our “game face” to work every day. Celebrating women in ophthalmology is a must — we need to lift each other up and celebrate our colleagues’ accomplishments and milestones. We are better as a united front than we will ever be alone.

#3: What is your proudest professional achievement? My proudest professional achievement is the ability to pass down my knowledge to younger women in ophthalmology; to share my experiences, empathy and techniques with the hope of helping other women to better themselves, and maybe make their paths a little easier.

#4: If you could wave a magic wand to improve one thing for women, what would it be? That women would be appreciated more — that we are unique, and we can do any job a man can do — and we deserve to get paid (at least) equally.

#5: What does your perfect day off look like?

— the main child carer. Hence, women in ophthalmology juggle many tasks, including their career, children, family elders, etc. It is very challenging for them if they have big families. However, the families are also understanding and the grandparents and extended family often come forward to help. For me, I couldn't have managed without my wonderful parents, Mdm. Boey Chooi Kheng and Mr. Raymond Alan Bastion — they came over often to pick up the kids on days when I couldn't, for example during OT days or private clinic days, and kept an eye on the domestic help.

Prof. Dr. Bastion and her family also enjoy traveling. In Dec. 2019, they visited Cappadocia, Turkey, to witness the hot air balloons take flight. Pictured are Prof. Dr. Bastion and her husband, Dr. Wong Yiing Cheong, and their children.

A perfect day off is when I can cook a great meal from scratch and share it with my daughter, son-in-law and my mom — without being rushed or having to answer the phone!

Prof. Dr. Mae-Lynn Catherine Bastion, Malaysia We always like a good crossover — so here, we took the chance to not only hear from female ophthalmologists from around the world … but also from across the eyeball globe! Prof. Dr. MaeLynn Catherine Bastion is a professor of ophthalmology (vitreoretina) and senior consultant ophthalmologist at the Department of Ophthalmology, Faculty of Medicine, Universiti Kebangsaan Malaysia (UKM) and UKM Specialist Centre.

#1: Do women face additional challenges compared to men in ophthalmology? Prof. Dr. Bastion: Yes definitely. In our Asian society, women are still seen to be — and willingly take on the role of

#2: Why is it important to celebrate women in ophthalmology?

It is important to celebrate women because they have overcome these challenges — and some have emerged as top ophthalmologists, highly respected in their field. Add the challenge of taking on academic roles in the university … and then add administration, research and formal teaching to the clinical tasks. Certainly, women in ophthalmology with their nurturing roles should be celebrated.

“In our Asian society, women are still seen to be — and willingly take on the role of — the main child carer.” — Prof. Dr. Mae-Lynn Catherine Bastion #3: What is your proudest professional achievement? My proudest achievement would have to be my promotion to professor of ophthalmology (vitreoretina) at the Universiti Kebangsaan Malaysia in

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2015. I have continued to serve and endeavored to deserve this title and distinction. I have also tried to help deserving colleagues pursue their academic dreams to reach the same achievement.

#4: If you could wave a magic wand to improve one thing for women, what would it be? It would be to allow them to have the support they need to pursue their dreams and ambitions while enjoying that close relationship with their loved ones.

#5: What does your perfect day off look like? My perfect day off would be spent with my children, enjoying our pets, followed by an action movie at the cinema, play gym and shopping.

Contributing Doctors

WOMEN IN OPHTHALMOLOGY

Dr. Cathleen McCabe serves as Chief Medical Officer at Eye Health America. She is one of the foremost eye surgeons today, specializing in bladeless laser cataract surgery and LASIK at The Eye Associates in Sarasota, Florida. Dr. McCabe has performed over 45,000 cataract surgeries and more than 17,000 LASIK procedures. She has a keen interest in advancing the field of ophthalmology and has participated in numerous clinical trials, including innovations in intraocular lenses, perioperative medications, medications and devices to treat glaucoma, dry eye treatments and presbyopia correction. She is passionate about giving back to her local community, profession and globally and participates in charitable giving and volunteer efforts both at home and abroad. She is a board member of several charitable foundations in ophthalmology, including One World Global Health/ Vision Quest, OOSS Gives, and others. Dr. McCabe received her medical degree from the Medical College of Wisconsin and received her residency training at the prestigious Bascom Palmer Eye Institute at the University of Miami’s School of Medicine. cmccabe13@hotmail.com

Prof. Dr. Mae-Lynn Catherine Bastion is a professor of ophthalmology (vitreoretina) and senior consultant ophthalmologist at the Department of Ophthalmology, Faculty of Medicine, Universiti Kebangsaan Malaysia (UKM) and UKM Specialist Centre. She is the chairperson of the Vitreoretinal Chapter for the College of Ophthalmologists @ Academy of Medicine Malaysia and a fellow at the Academy of Medicine, Malaysia. Prof. Dr. Bastion is also the honorary treasurer of the Malaysian Society of Ophthalmology (MSO) and the vice-chairperson for the Malaysian Advocacy for Myopia Prevention (MAMP), Paediatric Special Interest Group @ MSO. Her interests include vitreoretinal surgery, diabetic retinopathy and diabetic wound healing, along with stem cell therapy for hereditary retinal diseases and optic nerve diseases. mae-lynn@ppukm.ukm.edu.my

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Dr. Cheryl Ngo is a consultant and medical director at the Adult & Child Eye Clinic in Singapore. She completed her specialist ophthalmology training in Singapore, holds a Master of Medicine (ophthalmology), and received a medal for her fellowship examination in ophthalmology. Dr. Ngo is currently a fellow of the Royal College of Surgeons of Edinburgh. She also completed a prestigious subspecialty fellowship training at the Hospital for Sick Children, Toronto, Canada. She is the immediate past head of Pediatric Ophthalmology and Strabismus in the National University Hospital Singapore (NUHS) from 2014 to 2019, as well as the research director and an assistant professor of the Yong Loo Lin School of Medicine. She remains as a visiting consultant to NUHS and an adjunct assistant professor at the Yong Loo Lin School of Medicine, NUS. drcherylngo@adultchildeye.com

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Dr. Chelvin Sng, BA, MBBChir, MA(Cambridge), MRCSEd, FRCSEd, MMed, FAMS, is the Medical Director of Chelvin Sng Eye Centre at Mount Elizabeth Novena Hospital. She is also an Adjunct Associate Professor at the National University of Singapore (NUS), a Visiting Consultant at the National University Hospital, Singapore, and an Adjunct Clinician 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 an open access book on "Minimally Invasive Glaucoma Surgery", 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 (currently known as the "Paul Glaucoma Implant"), which was patented in 2015. Dr Sng has received multiple international awards, including the Asia Pacific Glaucoma Society Young Investigator Award and the Asia Pacific Academy of Ophthalmology Achievement Award. When not working, Dr. Sng can be found volunteering in medical missions in India and across Southeast Asia.

chelvin@gmail.com Dr. Dee Stephenson, MD, FACS, is the founder and director of Stephenson Eye Associates in Venice, Florida. Dr. Stephenson has been recognized by numerous institutions and journals for her expertise and contributions to cataract surgery and premium IOLs. She was listed as one of the 250 in Premier Surgeons of Leading Innovators, and more recently was named in the Ocular Surgery News Premier Surgeon 300 and Who’s Who in Ophthalmology. Dr. Stephenson shares her knowledge with ophthalmologists worldwide, and to ophthalmology residents, as an associate professor at the Morsani College of Medicine Department of Ophthalmology at the University of South Florida in Tampa. She is on the editorial board of CRST, editor of the cataract section for AAO Focal Points, a founding member of AECOS, and CEDARS/ASPENS. eyedrdee@aol.com


ASCRS 2022

CONFERENCE HIGHLIGHTS

Pearls for Calculating IOL Power by Joe Schreiber

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here were plenty of pearls this year at the American Society of Cataract and Refractive Surgery (ASCRS 2022). Enough that if they were the real thing, we could provide plenty of free cataract surgeries to those in need around the world — the exact number depends on which part of the Earth’s circulatory system they come from, this writer just discovered. Just like real pearls, these pearls of wisdom hold their value. But unlike real pearls, they’re ready to be passed down to the next generation now. No need to wait for your grandmother to have a bout of generosity. Today, we present to you a talk by Dr. Helga Sandoval, the director of clinical research at US Eye and an affiliate faculty member of the OphthalmologyMedical University of South Carolina in Charleston. The presentation was called My Top 5 Pearls for Calculating IOL Power. On a side note, have a bonus pearl: I highly recommend Charleston if you need a quick weekend getaway. Dr. Sandoval started her talk by noting that to her, “calculating intraocular lenses (IOLs) is like an art. It’s not one size fits all. Every patient is different and they want different things.” She is a particularly great artist in the world of IOLs, and her practice has been said to have the highest refractive accuracy in the world.

Pearl #1: Ocular surface optimization Dr. Sandoval said that ocular surface optimization “is key to a good measurement prior to the surgery” and the appropriate management before the biometry is “key to improve the outcomes as well as patient satisfaction.” The keys to having a healthy ocular surface include pre-op optimization,

surface protection during surgery, and quality post-op treatment.

Pearl #2: Validation criteria She cited the recent guidelines for IOLMaster (Carl Zeiss Meditec AG, Jena, Germany) and Lenstar (Haag-Streit, Köniz, Switzerland) measurements of Dr. Warren Hill, the long-serving medical director of East Valley Ophthalmology in Mesa in Arizona. Dr. Hill proposed many guidelines that are followed, but there are quite a few and Dr. Sandoval highlights the four most common. The difference in the axial length should be consistent between both eyes, the Lenstar being 0.3 and the IOLMaster being 0.33. “And if there is a difference, then we just confirm that difference,” she said. Next, we have the K readings. Consistency between the K1 and K2 should be within a quarter diopter with both the IOLMaster and Lenstar. The K power should also be 1.2 in the IOLMaster and 0.9 in the Lenstar. “The difference between the mean case between the two eyes,” Dr. Sandoval added. Use both the Lenstar and IOLMaster to confirm the results, making sure measurements are performed correctly and the axis is correct. Compare multiple results before proceeding. She said: “If you do the test and it matches, proceed. If they don’t match, repeat, but you have to repeat after the surface has been treated.” Don’t just repeat immediately, wait a week or two to make the differences pop.

Pearl #3: IOL calculation formulas Dr. Sandoval noted that “it’s key to use more formulas to get better outcomes.” There are a lot of formulas out there and

be sure to find what feels good to you. A lot of them are online calculators, so it is very important that you are careful not to enter what Dr. Sandoval — and our editors — call “typos” or your results could be way off. Modern formulas that the presentation mentioned are Barret Universal II, Kane and Ladas. Other formulas and calculators include Emmetropia Verifying Optical (EVO), Nallasamay, Hoffer QST, PEARL-DGS, K6 and VRF.

Pearl #4: A-constant optimization Dr. Sandoval and her team compared post-op information prior to optimization. They started with patients who were around -0.4 and were closer to planar after optimization. They found that the “number of patients within a half-diopter improved from 64% to 90% and 100% within 1 diopter.”

Pearl #5: Cataract surgery planning software With a new software, you can skip data entry and simply use the formulas that are listed and compare to check for a difference. But don’t be lazy. Don’t depend on it. She said: “This is just a tool. This is not going to tell you what to do.” As with anything else, perform your own analysis and decide what will work best for you and your patients.

Editor’s Note: ASCRS 2022 was held on April 22-26 as a physical show in Washington DC, USA. Reporting for this story took place during the event.

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CONFERENCE HIGHLIGHTS

ASCRS 2022

A Marvelous Look into Corneal Melts Highlights from ASCRS 2022

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veryone has their own favorite workplace story to tell. In the case of this particular Media MICE writer, that story happens to revolve around corneal melting. When he started out working for the world’s funkiest ophthalmology collective, he covered the ESCRS Winter Meeting in 2021 and wrote a report about a case study involving a 31-year-old Portuguese patient with severe Crohn’s disease. So severe, in fact, that it had not only caused gangrene and multiple recurring perianal abscesses (yes, really)… but it also caused corneal melting to the extent that the patient’s pupil appeared to bleed out of the patient’s eye.

Normally, the reaction received for this little story is abject revulsion (and shock) that this is medically possible. We in the ophthalmology community of course know better, so when a chance came around to write about corneal melts again, the editor naturally took the chance to assign the article to yours truly again. Thank goodness for Dr. Julie Schallhorn, an associate professor of ophthalmology at the University of California, San Francisco, for her presentation Differentiating and Treating Inflammatory Melts.

Pucker up for PUK Given during the American Society of Cataract and Refractive Surgery (ASCRS 2022) annual meeting in Washington D.C. earlier this year, Dr. Schallhorn’s presentation was marvelously melty and monstrously fact-filled. It began with an outline of the most common causes of scleritis and peripheral ulcerative keratitis (PUK) at the presentation stage. She reported that these are infections in 7% of cases;

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by Andrew Sweeney

autoimmune issues in another 37% of cases; and in the remaining 66%, no cause could be defined. However, in the final category, up to 50% of patients will be diagnosed with an autoimmune disease within a 90-month period. Going into a little more detail about the infections that most commonly cause corneal melts, one can find the usual suspects like bacterial and fungal issues, but also syphilis, a certain writer’s favorite topic. Many autoimmune conditions were listed by Dr. Schallhorn as causing scleritis and PUK, including Crohn’s in the form of inflammatory bowel disease, as well as other less suspected causes like hepatitis and polyangiitis. Rather ironically given that our correspondent was writing this article from Istanbul, Turkey, the incredibly rare Behcet’s disease was also listed, a rather nasty condition that causes inflammation in the blood. We’ve covered reports from other conferences about how to effectively communicate with patients and that was a trend picked up by Dr. Schallhorn, too, specifically about the subtle risk factors for corneal melts. So, if your patient comes to your clinic and also exhibits non-ocular warning signs, ranging from oral and genital ulcers to arthritis and blood in the stool, talk to them about their medical background. You may well find that they have other risk factors for scleritis and PUK.

Mesmerizingly melty melts Once you’ve got all of that out of the way, you’ve established a melty diagnosis and are ready to crack on with actually treating the cornea.

| Sept/Oct 2022

Dr. Schallhorn had a number of other recommendations, too. She said that the endpoint has to be the complete epithelialization of the defect, along with a quiet sclera. Furthermore, she emphasized that treatment must depend on etiology and that one should engage with rheumatology, infectious disease, and uveitis specialists when required. Dr. Schallhorn described how she prefers to take a conservative approach as much as possible, and that one should not be too eager to resort to patching. In fact, she said that in cases where the melt is small, surgery is not the answer, and that it is better to focus on treating the underlying cause of the problem. Her mantra could be summed up as “only patch when you must.” However, when it comes down to patching, Dr. Schallhorn was happy to share how she aims at getting those patches perfect, starting with smaller ones where she tends to use a < 4-5 mm circular punch. For larger areas, she said you’ll want to use a > 5-6 mm crescentic graft instead. Here again, however, she emphasized the importance of a conservative approach and only intervening when necessary. In summary, we can say a few things, firstly that we really enjoyed this presentation — so, if you didn’t make it to ASCRS 2022, you certainly missed out on this one! Dr. Schallhorn, in her concluding remarks, added that one should use “glue if perforated, patch if necessary” in treating corneal melts, and that conjunctival resection can be a useful adjuvant. As for our writer, he’s just happy he’s got another corneal melt story to tell…

Editor’s Note: ASCRS 2022 was held on April 22-26 as a physical show in Washington D.C., USA. Reporting for this story took place during the event.


C&PE 2.0

CONFERENCE HIGHLIGHTS

ICYMI: Highlights from CAKE & PIE Expo 2.0 This hybrid show took place in Da Nang, Vietnam, from August 20-21. Here are some highlights from the scientific talks, exhibition floor and Orbis Fundraising Party.

| Sept/Oct 2022

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