CAKE Issue 21 - Cataract & Refractive Issue

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From AI-assisted diagnosis to robotic solutions, how is digital technology reshaping the future of phacoemulsification and cataract surgery? P12

Letter to Readers

Beyond Marginal Gains Every so often, do advances turn what was once slim pickings into the new low-hanging fruit? Dear Readers,


o. Because...” was going to be my answer, and then I reconsidered as I reflected on what I had witnessed this week. So, I changed my mind and wrote this column on the latest advancements in corneal, cataract and refractive surgery. Last week, I watched a couple of procedures that, while not world firsts, were the first in my adopted country of Switzerland. The surgeons, Feri and Emilio, the man from Ziemer, Fabian, and my—and if you also knew him, your—favorite optometrist, Léo, were all in our OR to do the first all-femto corneal allogenic intrastromal ring segment (CAIRS) procedure in Switzerland. Isaac Newton said that he stood on the shoulders of giants; in this case, our surgeons stood on the shoulders of Soosan Jacob, who invented CAIRS, and Shady Awwad, who brought the femtosecond laser into the equation – and coined the name. We had two patients that afternoon, both of whom went under the laser and had corneal tunnels created, followed by the insertion of custom-cut tissue from a human donor cornea into those tunnels. Quickly performed, they posed for pictures with their thumbs up and walked away quite happily after the usual post-op conversations and advice sessions. A lot of parts—and people—had to synchronize together to make sure it worked. As is always the case with a first, adrenaline levels were as high as the expectations (or at least mine were). Implanting actual human corneal tissue into a previously cross-linked ectatic cornea instead of a polymethylacrylate one is another example of “marginal gains” I’ve written about many times before in this column. From my (perhaps naïve, non-surgeon) perspective, why would you not use this approach to rehabilitate the shape of the cornea instead of the plastic rings, if all else was equal (more biocompatible, should have a lower chance of erosion, etc.)? But the big step was made with the rings in the first place: A large reshaping of the cornea, which, in many people’s eyes, remains there fine, and has given them a great deal of visual quality back since the procedure. But sometimes changes aren’t marginal gains. For example, there’s been a lot of noise regarding accommodative IOLs in the past couple of years, and I remember reading recently that Jorge Alió was suggesting that, rather than relying on the ancient bag


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and the ciliary muscles to move the lens in the bag, the better location would be to implant the lens in the sulcus. He’s seen 1 to 3 diopters of pseudophakic accommodation with the Lumina lens, and that’s certainly a sign of the technology moving in the right direction. When it comes to the cornea, we’re also witnessing the development of products that could make a big difference in treating corneal epithelial defects—large-scale production of standardized stem cell-derived growth factors showing great promise in early-phase trials. The work done to not only grow these stem cells, isolate the factors, and then scale up to manufacture and commercialize this stuff is phenomenal. When I graduated from university for the first time—nearly 25 years ago now—this was unimaginable. You might have heard me complaining that all the low-hanging fruit was picked 20 years ago, but these developments make me wonder whether the new tools we have are beginning to bear new fruit. Or has it simply raised our levels so that what was once high in the tree is the new “low-hanging”?

Cheers, Mark Hillen, PhD

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

In This Issue...

Matt Young CEO & Publisher


Anterior Segment




Hannah Nguyen COO & CFO Gloria D. Gamat Chief Editor Mapet Poso Editor Matt Herman Associate Editor Maricel Salvador Graphic Designer Writers April Ingram Chow Ee-Tan Hazlin Hassan Nick Eustice Tan Sher Lynn Ruchi Ranga Society Relations & Conference Manager International Business Development Brandon Winkeler Robert Anderson Sven Mehlitz

Cataract Surgery: What’s Hot in 2024? From AI to adjustable lenses, discover what’s steering cataract surgery toward unprecedented levels of precision and care

Eyeing Glaucoma Dynamics Experts at the APVRS 2023 Symposium shed light on the impact of IOP and GCC thickness on glaucoma progression

All About Patient Satisfaction Study unveils the revolutionary impact of multifocal IOLs on cataract patients’ vision and satisfaction

Cover Story


Beyond the Scalpel From AI-assisted diagnosis to robotic solutions, how is digital technology reshaping the future of phacoemulsification and cataract surgery?





A Pioneering Spirit From an unexpected love affair with neuro-ophthalmology to championing gender equality, Prof. Helen Danesh-Meyer is a trailblazing figure in ophthalmology


The Lens Chronicles Dr. Boris Malyugin shares insights into the crucial role of patient selection in achieving transformative postoperative outcomes Taking the Road Less Traveled Stories of resilience, adaptation, and the pursuit of fulfilling careers in the ever-evolving landscape of medicine

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Conference Highlights


The Intricacies of Aging Challenges and adaptations faced by ophthalmologists as they navigate the inevitability of aging in the industry


The Myopia Enigma Experts decode the best practices of myopia management at

We are looking for eye docs who can contribute articles to CAKE magazine. Interested? Let's talk! Send us an email at To place an advertisement, advertorial, symposium highlight, video, email blast, or other promotion in CAKE magazine, contact

Advisory Board Members

Dr. Harvey S. Uy

University of the Philippines; Peregrine Eye and Laser Institute, Manila, Philippines

Dr. Boris Malyugin

S. Fyodorov Eye Microsurgery Institution Moscow, Russia

Dr. Chelvin Sng

Chelvin Sng Eye Centre, Mount Elizabeth Novena Hospital, Singapore

Prof. Jodhbir S. Mehta

Singapore Eye Research Institute (SERI); Singapore National Eye Centre (SNEC) Singapore

Society Friends

Arunodaya Charitable Trust (ACT)


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Dr. George H.H. Beiko

University of Toronto; McMaster University, Ontario, Canada

Dr. William B. Trattler

Center For Excellence In Eye Care Miami, Florida, USA

Industry Update

100% Optical Hosts CPD Sessions in Dedicated Ophthalmology Hub


rganizers of 100% Optical recently announced the launch of its continuing professional development (CPD) education program sessions—which is now open for bookings. The world-class education program features over 100 hours of CPD sessions across 12 diverse hubs, including the all-new Ophthalmology Theatre. It will once again be orchestrated at ExCeL London from February 24 to 26, 2024, in collaboration with the Allied Ophthalmic Personnel (AOP), the event’s longstanding education partner. The show’s five key CPD areas are Main Stage, AOP Lounge, Future Practice Hubs sponsored by SpaMedica, New Medica and Alcon, Dispensing Workshop and Optical Academy sponsored by Sense Medical | Canon. This year, the UK’s largest optical exhibition also announced a new feature: The debut of 100% Ophthalmology as a co-located event. This addition offers visitors a number of opportunities to network and connect with other parts of the optical community. With a tailored education program in store for them, ophthalmic surgeons and their teams can attend the event for free. In addition, the exhibition will feature the latest equipment and instruments from renowned brands such as ZEISS, Heidelberg Instruments, Sense Medical | Canon, TopCon and many more.

Within the dedicated ophthalmology program, numerous seminars and sessions are scheduled to take place at the Ophthalmology Theatre throughout the three-day event. On the first day of the event, a total of five sessions are scheduled, including a seminar titled How to Access Research Funding-Experiences from the Inside Track. This seminar aims to encourage the audience to consider applying to Fight for Sight and other similar vision charities and addresses ways to overcome perceived barriers within the research community that prevent them from applying. The panel will share experiences and insights while interacting and engaging with the audience, as well as responding to queries, if any. On the second day of the event, six sessions are scheduled. One of which is titled Guilty Til Proven Otherwise!, a pictureled quiz-like presentation on eyelid tumors conducted by Rachna Murthy, consultant ophthalmic surgeon at Face Restoration, and Jonathan Roos, consultant ophthalmic plastic surgeon.

On the third and final day, the Ophthalmology Theatre will conclude with a debut appearance titled Widefield OCT Angiography with Tariq Aslam, consultant ophthalmologist at Manchester Royal Eye Hospital. This last session will explore the research and clinical opportunities that have become possible with the advent of wide-field optical coherence and tomography angiography (OCT-A). The session will discuss the principles of wide-field OCT-A imaging and how it is set to make a major impact, particularly in the diagnosis and management of diabetic retinopathy and other retinal vascular disorders. The event marks the 10th edition of 100% Optical—Europe’s fastest-growing optical event, which attracts over 10,000 optical professionals from across the globe. A must-attend occasion for all those in the optical industry, the event will bring together optometrists, ophthalmologists, dispensing opticians, distributors and wholesalers—providing a valuable platform for networking and learning. The show offers free admission and features over 200 well-known and independent eyewear brands. Attendees can expect a world-class education program, a unique venue for makers and crafters, a dispensing workshop and a lineup of key industry speakers. The Studio, an ultracool industrial space sponsored by Nikon Menswear UK, adds a unique element to the event. Not but not least, the show also boasts the highly anticipated Love Eyewear Awards and daily live catwalk shows. To register or to view the full seminar program, visit

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Cataract Surgery:

What’s Hot in 2024? From AI to adjustable lenses, discover what’s steering cataract surgery toward unprecedented levels of precision and care

by Hazlin Hassan

The year 2024 is beginning to unfold as a pivotal period for cataract surgery innovations. Let’s take a look at some of the groundbreaking technologies that are shaping the landscape —providing a glimpse into the ever-evolving domain of precision and patient care.


s Thomas Jefferson once said: “I like the dreams of the future better than the history of the past.” Unlike him, however, we won’t need to dream, for 2024 promises to be a great year. Expect a number of exciting innovations in the field of cataract surgery, boosting patient safety and improving visual outcomes. Cataract surgery is one of the most commonly performed procedures worldwide. In this issue, we interviewed three cataract surgeons to unveil their top picks for the latest and hottest technologies in the cataract space for 2024.

Light Adjustable Lens The Light Adjustable Lens from RxSight (California, USA) could be one of the best things since sliced bread: The first intraocular lens (IOL) that can be adjusted after cataract surgery. Made from a photosensitive material that changes the shape and power of the implanted lens in response to ultraviolet (UV) light, this innovation results in customized refractive outcomes. Surgeons implant the lens using a standard cataract procedure and make adjustments with a light delivery device during follow-up clinic visits. Precise UV light treatments


change the shape and prescription of the lens. Depending on the desired visual outcome, the power of the lens can be adjusted up to three times until the optimal refractive result is achieved, followed by two “lock-in” treatments to prevent further changes. “This is easily the most exciting technology [these days]. It’s been growing like wildfire,” said Dr. William Trattler, a refractive, corneal, and cataract eye surgeon at the Center For Excellence In Eye Care in the US. “We can basically perform cataract surgery to get as close as possible to our target. During the postoperative period, we can further adjust the vision to get people to 20/20 or even 20/15 vision,” he elaborated.

Adaptive Cataract Treatment System The ALLY Adaptive Cataract Treatment System from Lensar (Florida, USA) is the first platform to

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combine top-notch imaging and nextgeneration dual-pulse femtosecond laser in a single system. Capable of performing a completely sterile femtosecond laser-assisted cataract surgery (FLACS) procedure, it can significantly reduce surgery time and enable precise corneal incisions. Furthermore, the seamless transition from femto to phaco, performed in a sterile environment, will enable the phaco to be pre-primed and the patient prepped prior to the procedure. According to Dr. Trattler, its technology dramatically increases the speed of the laser. “The whole treatment time is about a minute, compared to three minutes previously—effectively reducing the treatment time. It makes our workflow faster, which benefits patients because it becomes a shorter procedure,” he shared. The technology’s threefold reduction in the process reduces the likelihood of patient movement and provides better consistency and accuracy. In addition, the ALLY also features an augmented reality imaging system that creates a 3D view of the eye. This system guides surgeons in designing a tailored treatment plan for the cataract procedure, ensuring precise surgery and IOL positioning. “Patients have been really happy with the technology. It significantly contributes to positive outcomes for both the procedure and the patients,” enthused Dr. Trattler.

Premium intraocular lenses Premium intraocular lenses (IOLs) are the hottest thing since, well, hot cakes. These include multifocal and accommodative IOLs that provide clear vision at both near and distant focal points without relying on spectacle correction, along with toric IOLs for astigmatism correction.

Indeed, these are a convenient solution for today’s busy lifestyles. According to Dr. Noor Aniah Azmi, medical director and consultant refractive surgeon at Ikonik Eye Specialist and General Health Centre in Malaysia, there is currently a prevailing preference among the majority of patients for premium IOLs. “These lenses offer a judicious compromise and are particularly beneficial for individuals who are not suited for monovision,” she highlighted. Dr. Noor Aniah also pointed out that the escalating demand for cataract surgery is further propelled by an aging demographic. By 2030, the mean age of patients who will have to undergo cataract surgery is expected to drop from 73 to 68. “The cataracts removed will be softer, reflecting a shift in the patient demographic undergoing this surgery. Of significance is the heightened expectation among patients for a superior quality of vision postoperatively, with a prevailing desire to achieve freedom from reliance on spectacles,” she explained.

Extended depth of focus IOLs “This year will be an exciting year for cataract surgeons as we see more innovations in our field,” shared Dr. Lee Mun Wai, consultant ophthalmologist and retinal surgeon at LEC Eye Centre in Malaysia. In particular, non-diffractive extended depth of focus (EDOF) IOLs are expected to feature prominently as more choices become available. “Intraocular lens technology continues to evolve, and we will see a bigger uptake of enhanced monofocal IOLs, which can offer a better range of vision to correct presbyopia without some of the dysphotopsia issues seen in traditional multifocal IOLs,” Dr. Lee explained. Aside from EDOF IOLs from key IOL manufacturers like Alcon (Geneva, Switzerland), Johnson & Johnson (California, USA), and Bausch + Lomb (Quebec, Canada), Dr. Lee

expects to see innovations from other manufacturers, such as Medicontur (the ELON; Geneva, Switzerland) and Teleon (Acunex Vario; Spankeren, The Netherlands), which will provide more options for surgeons to deliver presbyopiacorrecting IOL technology to their patients. The ELON uses proprietary wavefront linking technology to provide functional vision from far to intermediate distances. On the other hand, the Acunex Vario uses less photopic disturbances compared to conventional multifocal lenses, providing vision at far and intermediate distances.

Artificial intelligence Penetrating nearly every aspect of our lives, the incorporation of artificial intelligence (AI) into the cataract diagnostic and surgical pathway is, of course, inevitable. “We already have AI-based IOL calculation formulae, such as the Hill RBF. The use of AI in this aspect has been further enhanced by the European Society of Cataract and Refractive Surgery (ESCRS) calculator, which uses web-scraping technology to allow the user to have instant access to different IOL formulae,” Dr. Lee noted. The Hill-RBF method uses pattern recognition based on AI and sophisticated data interpolation to deliver highly accurate IOL power predictions. Thanks to data from participating surgeons worldwide, this technology is constantly evolving. The ESCRS’ free online tool consolidates major online IOL calculators into one site, allowing surgeons to compare the results of up to seven calculators, including the Barrett Universal II, Cooke K6, Evo, Hill-RBF, Hoffer QST, Kane, and Pearl GDS. AI algorithms will also allow the integration of the preoperative, intraoperative, and postoperative cataract pathways, enhancing safety and ensuring seamless patientcentered care, concluded Dr. Lee.

Contributors Dr. William Trattler completed his ophthalmology residency at the University of Pennsylvania, USA, before undergoing subspecialty training in cornea and refractive surgery at the University of Texas Southwestern Medical Center. He is the past US President of the American-European Congress of Ophthalmic Surgery (AECOS). He has participated in more than 70 clinical trials and is the author of more than 50 peer-reviewed publications. A father of four, Dr. Trattler is an avid skier and basketball enthusiast. He reports financial disclosures with Lensar and RxSight.

After completing medical school in Egypt in 2010, Dr. Noor Aniah Azmi pursued a Master of Ophthalmology in Malaysia in 2018, followed by a post-graduate diploma in Cataract and Refractive Surgery in the United Kingdom in 2022. The mother of four is active on social media, where she shares the daily challenges of managing both professional and family responsibilities, aiming to empower women.

Dr. Lee Mun Wai, a graduate of the University of Manchester, started his ophthalmic training in the UK before completing his advanced training in Singapore. He underwent a vitreoretinal fellowship at Lions Eye Institute, Australia. Currently serving as the medical director at LEC Eye Centre, Malaysia, Dr. Lee is also the chair of the Malaysian Society of Cataract and Refractive Surgery.

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All About Patient Satisfaction Study unveils the revolutionary impact of multifocal IOLs on cataract patients’ vision and satisfaction by Nick Eustice

A recent multicenter study explored the correlation between multifocal intraocular lenses (IOLs) and patient satisfaction, revealing significant improvements in visual acuity across various distances. With real-world insights from renowned cataract surgeon Dr. William Trattler, the study highlights the exceptional results of modern multifocal IOLs while emphasizing the importance of patient counseling and managing expectations for a truly life-changing experience.


ince their introduction 75 years ago, IOLs have evolved considerably. As lens technology has advanced, so has the diversity of available IOLs, with each new generation designed to cater to a broader set of specific visual needs. Today’s multifocal IOLs represent a revolutionary stride in the field of ophthalmology, offering a dynamic solution to address presbyopia and reduce dependence on reading glasses. Since their inception, these innovative lenses have garnered increasing attention for their ability to provide clear vision at varying distances. Unlike traditional monofocal lenses, multifocal IOLs incorporate advanced optical designs that allow individuals to seamlessly transition between near, intermediate and distance vision. The current generation of IOLs represents the most significant


achievement in combined visual range ever available to cataract patients. Nevertheless, no IOL is perfect. Side effects persist, and while correction for middle and far-field vision has made significant strides, it still isn’t as good as a dedicated lens. Cataract surgeons still need to spend a fair bit of time counseling patients on what to expect from their new lenses. Although patients are usually

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very satisfied with the procedure, often describing their improved vision as miraculous, ophthalmologists need to manage expectations to ensure patients aren’t expecting literal miracles.

Crunching the numbers on patient satisfaction Just how satisfied are these cataract patients with multifocal IOLs, though? And what is the correlation between these lenses and other factors that influence patient satisfaction, specifically their cataract grade? A recent study has delved into this question, reviewing data across a wide range of patients.* This multicenter comparative study involved feedback and testing data from 164 patients who underwent cataract surgery, receiving identical bilateral implantation of five of the most popular multifocal IOLs. Beyond assessing these patients’ visual performance, the study incorporated the National Eye Institute Refractive Error Quality Of Life Instrument (NEI-RQL 42) scoring questionnaire in order to gauge the impact on patients’ quality of life. The Sirius Scheimpflug Analyzer (SCHWIND eye-tech-solutions GmbH; Kleinostheim, Germany) was also employed to evaluate the posterior cornea and any aberrations therein. Additionally, the study explored the association of patient satisfaction with the Pentacam Cataract Grading Scale (PCGS) and Lens Opacities Classification System (LOCS III). Using these diverse criteria and methodologies, the study brought together a unique sampling of data to reveal how well these lenses worked following implantation, and how the patients found their quality of vision had been improved. The study revealed a notable subjective improvement in uncorrected far, near (40 cm), and intermediate (60 cm) visual acuity across all five groups of multifocal IOLs, with significant P values < 0.001. Mesopic and photopic

contrast sensitivity showed a significant difference between Symfony (Johnson & Johnson Vision; California, United States), Trinova (VSY Biotechnology; BadenWurttemberg, Germany), and AT LISA (Carl Zeiss Meditec; Jena, Germany) at the spatial frequency of 12 cycles per degree, favoring Symfony (P < 0.001). PanOptix (Alcon; Geneva, Switzerland) users exhibited considerably lower mean coma values (P < 0.001), while AT LISA users had lower mean spherical aberrations (P = 0.009) compared to other groups. In addition to these positive findings, these lenses all reflected a sterling safety record. All five of the popular IOLs evaluated in the study showed that there were no additional safety concerns recorded related to IOLs. Furthermore, the study unveiled a high correlation between mean satisfaction and LOCS and Pentacam Nuclear Staging (PNS) in each lens group. For example, the correlation coefficient and P values for AT LISA were r = 0.99, P < 0.001, and r = 0.97, P = 0.004, respectively. These imaging results indicate that the severity and location of cataract opacity within the patient’s preoperative lens have a strong bearing on their eventual anterior segment health and visual satisfaction. This information could prove valuable in selecting the most appropriate intraocular lens for implantation during cataract surgery. While some variation occurred between the lens results, all of them had exceptionally positive results.

Real-world clinical applications To understand how this information applies in day-to-day clinical practice, we consulted a thought leader in the world of cataract surgery. Dr. William Trattler, based in Miami, Florida, USA, is a globally recognized figure in the field, and he only had good things to say on the subject. “This is a great study,” he said, right off the bat. “It essentially shows that, in general, the range of vision modern IOLs of all types can provide results in excellent patient satisfaction.” From years of experience in cataract

surgery, Dr. Trattler’s enthusiasm echoed the findings of the study: The best lenses available in cataract surgery today provide exceptional results. Dr. Trattler continued: “At 3 years, the vast majority of patients were happy with their vision, regardless of the specific lens type,” he said. “In my experience, my patients have been very happy with the technologies available in the US. I have experience with both the PanOptix and Symfony Optiblue, and both have performed well with high patient satisfaction.” These real-world applications verify the data compiled in the study: The multifocal IOLs currently available for implantation represent a significant advance in cataract medicine and deliver a very high level of patient satisfaction. But as the study pointed out, patient satisfaction is closely tied to the stage at which the lenses are implanted. Patients who recognized the need for treatment at an earlier stage had a significantly higher rate of satisfaction in their overall results than those who waited longer to address their medical needs. In addition, the presence of contemporaneous ocular illness has a tremendous bearing on how satisfied a patient will be with their IOLs. Dr. Trattler’s experiences strongly support this finding. “The key is, of course, the preoperative evaluation,” he said. “I strive to offer these two technologies only to patients who have a normal corneal shape on topography and a healthy macula on optical coherence tomography (OCT).”

The art of patient counseling Other factors in a patient’s optical health can indeed have a significant impact on their satisfaction with their overall improvement in visual acuity. As Dr. Trattler rightly noted, every IOL comes with its own share of drawbacks in addition to its benefits for a patient’s vision. “It is critical to set patient expectations,” he concluded, “including the risk of glare or halos

at night, as well as the limitations of these technologies.” While today’s multifocal IOLs represent a (very) high point in the development of ophthalmological technology, it is crucial to counsel patients seeking relief through cataract surgery. A key takeaway from this study is that even though the lenses available today are not quite equal to natural perfection, they are truly life-changing for millions of satisfied patients worldwide.

Reference * Niazi S, Gatzioufas Z, Dhubhghaill SN, et al. Association of Patient Satisfaction with Cataract Grading in Five Types of Multifocal IOLs. Adv Ther. 2024;41(1):231-245.

Contributor Dr. William B. Trattler 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.

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Eyeing Glaucoma Dynamics Experts at an APVRS 2023 symposium shed light on the impact of IOP and GCC thickness on glaucoma progression by Hazlin Hassan

At a Glaucoma Symposium held on the final day of the 16th Congress of the Asia-Pacific Vitreo-retina Society (APVRS 2023) in Hong Kong last year, experts from around the region gathered to discuss the intricacies of intraocular pressure (IOP), macular ganglion cell complex (GCC) layer thickness, and their impact on glaucoma.


rom insights into the significance of lower mean IOP in treating primary angleclosure disease to groundbreaking studies on innovative diagnostic techniques like retinal nerve fiber layer optical texture analysis, the APVRS 2023 Glaucoma Symposium highlighted advancements in


at The Chinese University of Hong Kong (CUHK), a key takeaway was that, even within the ‘normal’ IOP range in treated primary angleclosure disease (PACD) eyes, a lower mean IOP was associated with slower glaucoma progression. There may be justification to aim for a lower target IOP, such as in the low teens, particularly in cases of advanced and/or progressive primary angle-closure glaucoma (PACG). Results from the ongoing CUHK PACG Longitudinal (CUPAL) study of patients with PACD showed that IOP fluctuation was a significant and independent predictor for subsequent visual field (VF) deterioration in eyes with PACD. “Both high mean IOP and high IOP fluctuation had the most rapid VF loss over time,” Prof. Tham noted Questions arise over whether reducing IOP fluctuation could provide additional benefits, in addition to IOP lowering, in slowing down the progression of PACD. Additionally, there were also questions whether different treatment options have varied effects on modulating IOP fluctuation. Risk factors for IOP fluctuations in PACG include higher baseline IOP, more IOP-lowering drugs, a previous trabeculectomy and smoking

glaucoma research with global implications.

The benefits of being random

Lowering mean IOP: A key strategy

Prof. Christopher Leung from the Department of Ophthalmology at The University of Hong Kong shared about an ongoing glaucoma screening project that is offering free comprehensive eye screening

In a presentation by Prof. Clement Tham, chairman of the Department of Ophthalmology and Visual Sciences

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services to over 3,000 randomly selected Hong Kong residents aged 50 or above, who live in public rental housing. “Screening is beneficial when the disease is serious, when early treatment is more effective than delaying treatment until symptoms appear, and also when the prevalence of the disease is relatively high,” he noted. He added that a good screening test should be inexpensive, easy to administer, reliable, and cause minimal discomfort. Macular damage in glaucoma is difficult to detect using conventional clinical tests. What sets this project apart is the use of retinal nerve fiber layer (RFNL) optical texture analysis (ROTA), a patented technology developed by a research team from the Faculty of Medicine at HKU ROTA outperforms current clinical standards and detects glaucomarelated optic nerve damage with 15% to 28.4% more accuracy than traditional methodologies.

glaucoma than screening with optic disc photography? Is glaucoma screening cost-effective? What is the prevalence of glaucoma in HK? What is the prevalence of undiagnosed glaucoma in HK? What is the prevalence of blinding eye disease in HK? What are the risk factors for glaucoma and other blinding eye diseases in HK

“Screening is beneficial when the disease is serious, when early treatment is more effective than delaying treatment until symptoms appear, and also when the prevalence of the disease is relatively high.”

preperimetric glaucomatous damage. Findings from the paper indicate that the GCC thickness generally tends to thin with age, with all GCC thickness subfields being highest in the age group of less than 39 years old. On the other hand, they were thinnest in the over 70-year-old age group. While GCC thickness decreased with age, male subjects exhibited thicker GCC than females. Subjects who smoked, did not have diabetes, and had lower HbA1c showed thicker GCC. During the presentation, it was explained that the spectrum of diseases causing blindness is changing due to the rapid socioeconomic development of China and the accelerated aging of the population. A population-based cohort study helps in understanding the impact of urbanization and aging on blinding eye diseases, thus contributing to the prevention and treatment of blindness in China.

When age and gender matter

The Handan Eye Study aimed to establish the normal GCC thickness profile in the general population using spectral domain-OCT in different macular sectors. Additionally, it sought to determine the systemic and ophthalmic factors associated with GCC thickness and identify potential risk factors.

A group of researchers in China has found that the thickness of the macular ganglion cell complex (GCC) layer is closely associated with age and gender, among other factors.

The study provides normative profile data of GCC thickness, distribution patterns, and correlated systemic and ocular parameters in a middle-aged cohort of rural populations in China.

It is hoped that the project, running until May 2024, will identify undiagnosed patients with glaucoma and provide insights into the prevalence and risk factors of glaucoma in Hong Kong. Additionally, ROTA is expected to benefit patients worldwide, as two multinational OCT manufacturers have obtained licenses to integrate ROTA into their clinical OCT systems. At present, over 1,000 participants have been examined.

In a paper by Jian Wu, Peilun Shi, and Ningli Wang from Tongren Hospital and Capital Medical University, China, the researchers demonstrated an association between GCC thickness and age, gender, hypertension, diabetes, SE and BCVA. “The associations between age are strong and therefore need to be considered when using GCC to make clinical decisions of glaucoma and other optic neuropathies characterized by the loss of retinal ganglion cells,” the investigators reported.

The researchers did not find GCC thickness to be an independent parameter associated with gender, BMI, IOP, and AL. Further studies are required to further investigate the factors underlying the GCC.

Questions to be answered include the following: Is screening with ROTA more effective in identifying

The average GCC thickness and its related parameters represent a reliable biomarker in detecting

This method allows for the direct visualization of nerve fibers on the retina in high resolution using standard optical coherence tomography (OCT) scans, significantly improving the accuracy of early detection of optic nerve damage within and beyond the macula caused by glaucoma. ROTA also increases diagnostic sensitivity by up to 40% for detecting early glaucoma compared to the current standard using OCT retinal nerve fiber layer thickness analysis.

— Prof. Clement Tham

Editor’s Note The 16th Asia-Pacific Vitreo-retina Society Congress (APVRS 2023) was held from December 8 to 10, 2023, at the Hong Kong Convention and Exhibition Centre, Hong Kong. Reporting for this story took place during the event.

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Cover Story

From AI-assisted diagnosis to robotic solutions, how is digital technology reshaping the future of phacoemulsification and cataract surgery? by April Ingram

In the last decade, technological advances, digitization, and the application of artificial intelligence (AI) have significantly impacted cataract surgery—aiming to make it more efficient and safer. In this article, we explore the role of AI in intraocular lens calculations, the use of robotics in cataract surgery, advancements in phacoemulsification platforms, and its integration in postoperative care— showcasing how these innovations are reshaping the landscape of cataract surgery.


dvanced technology has seamlessly integrated into various aspects of our daily lives that we hardly notice anymore. We rely on smartphone and smartwatch apps to manage our finances, store our memories, unlock our vehicles, and even call for assistance during emergencies. However, would you trust technology enough to allow a robotic arm to administer your intravitreal injections, perform cataract removal, and select and fit you with the optimal intraocular lens based on its judgment?

Revolutionizing cataract surgery through AI Cataract surgery is one of the most frequently performed surgical


procedures in the world. Multiple factors contribute to a successful surgery, including the surgical technique, skill and precision of the surgeon, phacoemulsification and aspiration devices, intraocular lenses and associated calculations, and, of course, the importance of post-op care. In the last decade, there have been extensive technological advances, digitization, and the application of artificial intelligence (AI) in these areas—all aimed at achieving more efficient and safer surgeries with the best achievable outcomes. Dr. Douglas D. Koch is a professor of

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ophthalmology and the Allen, Mosbacher, and Law chair in ophthalmology at The Cullen Eye Institute, Baylor College of Medicine. He and his colleagues have considerable experience in the evaluation and implementation of AI within ophthalmology, recognizing its considerable advantages. “We are already experiencing the impressive benefits of AI in ophthalmology, with examples

“Examples include the ZEISS (Jena, Germany) AI IOL calculator, which generates 500,000 ray-traced eye images to train a dataset and define the limits of the network when presented.”

“We are already experiencing the impressive benefits of AI in ophthalmology, with examples ranging from interpretation of optical coherence tomography (OCT), retinal vasculature, and visual fields, among others.”

Dr. Koch and colleagues at Baylor recently published their study on the efficacy of segmented axial length and AI approaches to IOL power calculations in short eyes. They reported that the ZEISS AI outperformed Barrett, Pearl-DGS, and Kane.1

— Dr. Douglas D. Koch

As larger datasets are developed, the applications to screening and therapeutics across eye care will be incredibly valuable. “Generating models to supplement available data will play a growing role in ophthalmology, and they will bring new insights in many areas,” Dr. Koch added. Dr. Koch is exactly right—AI technologies have proven extremely useful in the screening and diagnosis of cataracts for both adults and children. This is particularly evident in circumstances where face-toface consultations are hindered by limited access to specialist care, as exemplified during the pandemic. that represents ground truth.”

ranging from interpretation of optical coherence tomography (OCT), retinal vasculature, and visual fields, among others,” said Dr. Koch. “AI can be classified based on the type and complexity of the neural network processing data. The obvious application of AI is machine learning, where the AI is trained on a dataset

An application that has become more mainstream and is at a comfort level of those who may be a little apprehensive about fully embracing AI in the clinic is its use in intraocular lens (IOL) calculations. We asked Dr. Koch where he sees AI having the greatest impact. “AI shows great promise in providing new diagnostic and therapeutic progress through more complex neural networks, often involving the generation of new images or data,” he explained.

AI-assisted telemedicine programs facilitate preliminary screening and diagnosis of cataracts. These AI networks have achieved over 86% accuracy in determining lens characteristics and grading the severity of cataracts. Patients are also encouraged to submit photographs of their eyes, taken with their smartphones. This enables referrals to appropriate healthcare professionals, as needed.

Harnessing AI for surgeon skill enhancement As the demand for cataract surgeries continues to rise, surpassing the

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current global annual count of 26 million, the need for well-trained surgeons is reaching a critical level. Dr. Shameema Sikder is the L. Douglas Lee and Barbara LevinsonLee professor of ophthalmology at the Wilmer Eye Institute-Bethesda. She’s also the director of the Center of Excellence for Ophthalmic Surgical Education and Training (OphSET) at the Johns Hopkins University School of Medicine.

for skill optimization and elevate standards of surgical care globally. Dr. Sikder highlighted that she anticipates seeing AI-enhanced surgeon training becoming mainstream very soon. “The team recently received a Maryland Innovation Initiative Award to commercialize Circlage,” she enthused, sharing the good news.

Dr. Sikder recognizes the challenges ahead and is actively working to address them. “A global challenge is the shortage of highly trained ophthalmologists who can perform sight-saving surgeries. We are aiming to implement AI to influence and enhance how surgeons are trained in the future,” she said.

The Bausch + Lomb Stellaris (Quebec, Canada) also enhanced its fluidics to prevent postocclusion surge and introduced flow restrictions with its tapered microphaco needle. The small lumen also improves visualization. Moreover, there are features designed to improve ergonomics and overall surgeon experience. These include redesigns of the traditional footswitch and footbed, allowing surgeons to modify and customize the positions that work best for them. Other enhancements include larger touchscreen interfaces, voice feedback, and more options for language selection.

Dr. Sikder is at the forefront of an NIH-funded initiative, leading a team that is developing AI solutions to analyze surgeons’ performance using surgical videos and provide feedback. She explained the importance of AI in addressing the shortage of surgeons. “AI is expected to shorten the time surgeons take to acquire skills and reduce variation in skill across surgeons who are in training and in practice,” she said. “We have received additional support from a ‘Microsoft for Startups’ grant, which we used to develop a cloudbased platform, Circlage. Surgeons can use Circlage to apply AI analytics to acquire specific skills.” In addition, the team from OphSET, led by Dr. Sikder, has collaborated with the Malone Center for Engineering in Healthcare and the Whiting School of Engineering. Together, they are now working on harnessing the power of AI to provide surgeons with personalized feedback


The latest versions of phacoemulsification platforms have harnessed technology to improve intraocular pressure (IOP) control and advanced fluidics. Notably, there is a buzz about Alcon’s Centurion (Geneva, Switzerland) with its Active Sentry handpiece, which provides IOP-sensing technology right at the tip of the handpiece. This innovative feature helps prevent post-occlusion surge, ensuring an important safety measure.

Next-gen phacoemulsification platforms As AI continues to train more surgeons and perform IOL calculations with precision, we explored the integration of these technological advances into the operating room. The latest phacoemulsification platforms come with a broad range of innovative and more intuitive features, all aimed at improving safety and optimizing patient outcomes.

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The upgraded EVA system from the Dutch Ophthalmic Research Centre, which was recently acquired by Zeiss (Jena, Germany) also features a dual-linear wireless footswitch, providing surgeons with independent control and the ability to quickly switch between aspiration and phacoemulsification.

Robotic solutions in cataract surgery Robotic technology in cataract surgery is not designed to replace the surgeons that Dr. Sikder and others are working so hard to train. Instead, it aims to address the limitations that we, as humans, face when trying to precisely manipulate the tiniest of tissues. These aspects of our humanity that we need to contend with include

natural hand tremors, inadequate spatial resolution and depth perception of microstructures, and the sensory detection of the required force to complete an action.2 Additionally, the reaction time of a human is, on average, 300 times that of a robot. Jean-Pierre Hubschman and his research team at UCLA have been advancing robotics in cataract surgery for nearly a decade. In 2018, they published an evaluation of an OCT system integrated into their intraocular robotic interventional surgical system (IRISS) robot. This system successfully demonstrated semiautomated OCT-guided lens removal in pig eyes, achieving this without any capsular rupture or damage.3 More recently, the group has showcased the capabilities of this OCT-guided surgical robot in polishing the posterior capsule and removing lens fragments.4,5 The IRISS utilizes a master/slave design featuring a master controller equipped with two joysticks and a slave manipulator. The slave manipulator consists of two independent arms that hold the necessary surgical instruments. Each arm has an independent pivot point and 7 degrees of freedom, allowing it to replicate the precise motion required to perform surgical maneuvers. Surgeon input is processed by robotic technology, enabling real-time refinement or correction of force and movements. Currently, femtosecond laserassisted cataract surgery (FLACS) offers a more automated alternative to conventional cataract surgery. It utilizes a computer-guided laser linked to an imaging system, such as an OCT, and performs the corneal incision, capsulotomy, and lens fragmentation steps. Surprisingly, the robotic step of this type of cataract surgery is completed in less than 30 seconds!

“AI is expected to shorten the time surgeons take to acquire skills and reduce variation in skill across surgeons who are in training and in practice.” — Dr. Shameema Sikder

Academy of Ophthalmology, they concluded that FLACS and conventional phacoemulsification cataract surgery were both safe and had excellent outcomes, but FLACS was less cost-effective. However, they noted that FLACS might be advantageous in certain complex cases. The Centre for Sight in Delhi promotes ‘Robotic Cataract Surgery’

to potential patients, emphasizing the benefits of high precision, perfect lens placement and alignment, laser-assisted correction, better visual outcomes, and faster recovery.

AI and telehealth synergy Recently, LENSAR (Florida, USA) announced FDA clearance for ALLY, their adaptive cataract treatment system. It uses adaptive intelligence to automatically determine cataract density and optimize fragmentation patterns and energy settings. In addition, it incorporates advanced astigmatism management technology. The ALLY was designed to minimize the overall energy delivered to perform the cataract procedure more efficiently, contributing to quicker visual recovery and better patient outcomes. While some may not be entirely convinced that robotics should take over cataract surgery, they might be open to allowing advanced technologies to manage some of the post-operative care. Using predictive

Phacoemulsification Market Size, Growth & Statistics7,8 It is anticipated that by 2025, there will be over 35 million cataract surgeries performed globally. Overall, the cataract surgery market was valued at $6.77 billion (USD) in 2022, projected to reach $12.57 billion by 2030, with a compound annual growth rate (CAGR) of 8.04%. The segments of this market include femtosecond laser equipment, intraocular lenses, ophthalmic viscoelastic devices, and phacoemulsification equipment.

Between 2023 and 2028 the phacoemulsification devices market is estimated to grow by $622.54 million. That represents a CAGR of 5.36% over the same period. North America is expected to contribute to 40% of this anticipated growth. Phacoemulsification consumables make up an even larger proportion of the market share than the platforms themselves—estimated to be $988.24 million in 2018.

In a review published by the American CAKE MAGAZINE | February 2024


Cover Story

models, AI platforms have been able to identify patients at higher risk for postoperative complications. They can then stratify when follow-up needs to be scheduled and with what type of specialty care. This combination of telehealth and AI-powered risk prediction can serve as a valuable tool in improving the allocation of medical resources. Researchers in the United Kingdom have proposed the use of Dora agent, Ufonia’s (Oxford, England) autonomous voice conversational agent, an AI-enabled autonomous telemedicine call for the detection of postoperative cataract surgery patients who require further assessment.6 They aim to demonstrate that conversational technology can be used to conduct an accurate assessment, that it is acceptable to different populations with different backgrounds, and how this

technology can be integrated into existing platforms.

Digitization at the forefront At every ophthalmology conference, there is a launch of some type of digitization or advanced technology. While some may take time to achieve smooth integration into daily practice, the goals remain consistent. These innovations aim to alleviate the burden on healthcare resources, provide optimal training experiences for current and future surgeons, and automate surgeons’ treatment plans to enhance safety and outcomes, among others—all while improving efficiency and workflow. The recognized benefits also extend to surgeons, ophthalmic staff, and patients alike.

References 1. Kenny PI, Kozhaya K, Truong P, Weikert MP, Wang L, Hill WE, Koch DD. Efficacy of segmented axial length and artificial intelligence approaches to intraocular lens power calculation in short eyes. J Cataract Refract Surg. 2023;49(7):697-703. 2. Nuzzi R, Brusasco L. State of the art of robotic surgery related to vision: brain and eye applications of newly available devices. Eye Brain. 2018;10:13-24. 3. Gerber MJ, Hubschman JP, Tsao TC. Robotic posterior capsule polishing by optical coherence tomography image guidance. Int J Med Robot. 2021;17(3):e2248. 4. Shin C, Gerber MJ, Lee YH, Rodriguez M, Pedram SA, Hubschman JP, Tsao TC, Rosen J. SemiAutomated Extraction of Lens Fragments via a Surgical Robot Using Semantic Segmentation of OCT Images with Deep Learning - Experimental Results in ex vivo Animal Model. IEEE Robot Autom Lett. 2021;6(3):5261-5268. 5. Chen CW, Lee YH, Gerber MJ, Cheng H, Yang YC, Govetto A, Francone AA, Soatto S, Grundfest WS, Hubschman JP, Tsao TC. Intraocular robotic interventional surgical system (IRISS): Semiautomated OCT-guided cataract removal. Int J Med Robot. 2018;14(6):e1949. 6. de Pennington N, Mole G, Lim E, Milne-Ives M, Normando E, Xue K, Meinert E. Safety and Acceptability of a Natural Language Artificial Intelligence Assistant to Deliver Clinical Follow-up to Cataract Surgery Patients: Proposal. JMIR Res Protoc. 2021;10(7):e27227. 7. TechNavio. Phacoemulsification Devices Market Analysis North America, Europe, Asia, Rest of World (ROW) - US, Canada, Germany, UK, China - Size and Forecast 2024-2028. Available at Accessed on January 17, 2023. 8. Global Information Inc. Global Cataract Surgery Devices Market by Product, End-User - Cumulative Impact of COVID-19, Russia Ukraine Conflict, and High Inflation - Forecast 2023-2030. Available at html. Accessed on January 17, 2023.


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Contributors Dr. Douglas D. Koch, MD, is a professor of ophthalmology and serves as the Allen, Mosbacher, and Law Chair in ophthalmology at The Cullen Eye Institute, Baylor College of Medicine. His primary clinical and research interests lie in cataract and refractive surgery. Dr. Koch has taught over 250 residents and fellows, authored over 200 articles and book chapters, and given 33 named lectures, including the Jackson Memorial Lecture and the Kelman Innovators Lecture. In addition, he is editor emeritus of the Journal of Cataract and Refractive Surgery and past president of the American Ophthalmological Society, ASCRS, and the International Intraocular Implant Club. Dr. Shameema Sikder, MD, is the L. Douglas Lee and Barbara Levinson-Lee associate professor of ophthalmology at the Wilmer Eye Institute, Johns Hopkins University. Specializing in corneal disorders and complex cataracts, she served as the founding medical director of the Wilmer-Bethesda clinic, where she maintains a busy surgical practice. Dr. Sikder is also the founding director of the Johns Hopkins Center of Excellence for Ophthalmic Surgical Education and Training. With a faculty role at the Johns Hopkins Malone Center for Engineering in Healthcare, she is committed to advancing surgical training. In addition, Dr. Sikder conducts innovative research funded by NIH and Microsoft, focusing on novel AI technologies for assessing surgical skills. Outside of her professional pursuits, Dr. Sikder enjoys spending quality time in Washington DC with her husband and boy-girl twins.

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“After completing my fellowship training, I returned to Auckland as an associate professor at the University of Auckland,” shared Prof. Danesh-Meyer. “I was later promoted to professor, assuming the Sir William and Lady Stevenson chair in ophthalmology.” In fact, she made history as the first female professor of ophthalmology in New Zealand. Today, Prof. Danesh-Meyer is now a renowned clinician-scientist, dedicating half of her time to clinical practice and surgery and the other half to research.

Trailblazing achievements in ophthalmology

A Pioneering Spirit From an unexpected love affair with neuro-ophthalmology to championing gender equality, Prof. Helen Danesh-Meyer is a trailblazing figure in ophthalmology by Chow Ee-Tan An internationally acclaimed authority in glaucoma and neuro-ophthalmology, Prof. Dr. Helen Danesh-Meyer’s career has been marked by groundbreaking achievements and a commitment to gender equality. From her early days in medical school to becoming the first female professor of ophthalmology in New Zealand, she shared her inspiring story of serendipity, challenges and triumphs.


n expert in glaucoma and neuro-ophthalmology, Prof. Helen Danesh-Meyer boasts an impressive resume, establishing herself as one of the most highly regarded authorities in her field. A medical graduate of Otago University on the South Island of


New Zealand, Prof. Danesh-Meyer completed her registrar training in Dunedin, Christchurch, and Auckland. She continued her training with fellowships at Wills Eye Hospital in Philadelphia, specializing first with Peter Savino in neuro-ophthalmology and second with George Spaeth in glaucoma.

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Prof. Danesh-Meyer has achieved numerous firsts as a New Zealand ophthalmologist. She holds the honor of being the first female professor of ophthalmology in New Zealand and the Sir William and Lady Stevenson chair in ophthalmology and head of Academic Neuro-ophthalmology and Glaucoma. Other firsts include being the first member of the International Glaucoma Research Society from New Zealand, where membership is determined by research contribution to the field; the first Kiwi ophthalmologist to be Visiting Professor at Harvard Fall Festival; the first Australian or New Zealand ophthalmologist to be appointed to the American Academy of Ophthalmology Basic Clinical Science Course; the first female chair of the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Scientific Programme Committee; and the first New Zealand ophthalmologist to serve on the editorial board of the American Journal of Ophthalmology and Ophthalmology. She was also the youngest appointed professor at the University of Auckland Faculty of Medical and Health Sciences and one of the few women professors in a surgical specialty. In her role, she delivers lectures to undergraduate science, medical, and optometry students. Additionally, she teaches postgraduate optometry and ophthalmology, both nationally and internationally.

Serendipity in medicine Contrary to expectations, glaucoma was not Prof. Danesh-Meyer’s first love. She revealed that neuroophthalmology holds that special place in her heart—and still does to this day.

“It never dawned on me that being a neuroophthalmologist might limit my career as a surgical ophthalmologist. So, I decided to pursue a surgical subspecialty as well.” “I think much of where we end up is shaped by luck and serendipity. Throughout medical school, my interests gravitated towards the brain, and I could have easily pursued a path in neurosurgery or neurology,” she reflected. “However, the ophthalmology department, particularly Prof. Antony Molteno and Gordon Sanderson, for some reason, took me under their wing. Once I saw the view of the fundus through the indirect ophthalmoscope, I fell in love with the eye. It was beautiful!” At the end of her neuroophthalmology fellowship, Prof. Danesh-Meyer recalls being told that she must not like to operate if she loved neuro-ophthalmology so much. “It never dawned on me that being a neuro-ophthalmologist might limit my career as a surgical ophthalmologist. So, I decided to pursue a surgical subspecialty as well,” she said. This happened in 1999, when glaucoma was not yet recognized as a legitimate optic neuropathy and was primarily viewed as a disease related to high pressure. However, over time, these two sub-specialties have significantly converged.

As a clinician-scientist dedicating equal time to patient care, surgery and research, Prof. Danesh-Meyer serves as a director of the Eye Institute (Auckland, New Zealand) specializing in glaucoma and neuroophthalmology. In this capacity, she performs complex cataract and glaucoma surgery. When asked whether she has a preference and which role she thinks fits her better, she said she can’t choose—as both patient care and research are fulfilling in different ways. “Like most ophthalmologists, I feel privileged to be the caretaker of the most precious of all our senses—our sight,” enthused Prof. Danesh-Meyer. “Patients value their vision, and the trust they place in us is truly a gift and honor. Research, on the other hand, fulfills my intellectual restlessness and curiosity,” she admitted. As if she’s not busy enough, Prof. Danesh-Meyer also actively contributes to the wider community and has been awarded the Paul Harris Award by Rotary International for her service. She is also a founding trustee and chair of Glaucoma New Zealand, a charitable trust dedicated to preventing blindness from glaucoma.

Overcoming challenges and making strides With such an illustrious career, one might wonder about the challenges she faces, particularly as the first female professor in ophthalmology in her country. “When one talks about challenges, I think it is important to first acknowledge the support and encouragement we receive,” she said, paying tribute to her many mentors, whom she described as ‘amazing.’ Some of them include Prof. Charles McGhee, Peter Savino, George Spaeth, and Marlene Moster. All have provided her extraordinary support and guidance. “I will always be grateful to them for believing in me,” she shared. In terms of challenges for women, she noted that while there is still much to achieve, women ophthalmologists have undoubtedly come a long way “The challenges for women include implicit gender bias, which may come

from both men and women. Women often face greater commitments and responsibilities to family, making them more time-poor,” she added. “Also, I think it can be challenging for women to have their voices heard and taken seriously. So, it is important for women to have internal confidence to overcome self-doubt,” she advised Prof. Danesh-Meyer has been an astute and strong advocate, both nationally and internationally, for promoting equality, diversity, and inclusion in ophthalmology. Serving as the chair of Women in Ophthalmology for RANZCO, chair of Women in Vision NZ, and the regional representative for Women Ophthalmology Worldwide, she has played a key role in introducing innovative policies that have contributed to reducing inequities in clinical and scientific training.

“My view on gender differences in ophthalmology has evolved over the years. In my early years, I was reluctant to get involved or acknowledge that there were issues of gender equity.” It’s no surprise that Prof. DaneshMeyer has extensively published on topics related to gender differences in ophthalmology, as well as bullying, harassment, and sexual discrimination in the industry “My view on gender differences in ophthalmology has evolved over the years. In my early years, I was reluctant to get involved or acknowledge that there were issues of gender equity,” she admitted. “I wanted to prove I was as good as the boys. I never accepted a role or position if I thought I was being

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nominated primarily because of my gender. As I became more involved in mentorship, I would find myself outraged when I saw numerous examples of implicit gender bias or discrimination. It took witnessing such incidents happening to others for me to decide I needed to be an active part of the solution.”

Shaping policies through research Prof. Danesh-Meyer has published approximately 300 papers in glaucoma and neuro-ophthalmology and authored several textbooks and chapters. Not to mention the over $15 million in grant funding she has brought in. Several of her research findings have not only impacted clinical practice but have also been featured in prestigious publications, such as The New Scientist. Her impactful articles addressing gender biases faced in surgical training, published in professional journals, have provided an enduring evidence base to sustain campaigns for equity, which has resulted in policy changes at RANZCO. One of the recent publications she co-authored is a study in the American Journal of Ophthalmology (Vol 236 April 2022) titled “An Eye on Gender Equality: A Review of the Evolving Role and Representation of Women in Ophthalmology.” Prof. Danesh-Meyer said the review demonstrates that while women have made advances, there are still challenges in all arenas—research, academics, leadership, income, and promotions. There is not one area of professional life where women have completely conquered the issues.

Support on every front For Prof. Danesh-Meyer, the true highlights of her career revolved around ‘the many extraordinary women and men’ that she has had the privilege to train and support on their ophthalmology journey. “It is such a tremendous joy to watch their careers flourish,” she enthused. She has mentored over 20 clinical and research fellows and is actively engaged in teaching and education. Prof. Danesh-Meyer regularly lectures both nationally and internationally. She is one of the


international authors of the American Academy of Ophthalmology’s Basic and Clinical Science Course (Neuro-ophthalmology), has served as an examiner for the RANZCO examinations, and has developed a web-based glaucoma education program. Prof. Danesh-Meyer has received numerous awards and accolades throughout her career. Most recently, in the 2023 New Year Honors (New Zealand), she was appointed a Companion of the New Zealand Order of Merits (CNZM) for services to ophthalmology. She quipped that she felt deeply humbled by this recognition. As the saying goes: “Behind every successful woman is a supportive husband.” It’s no different in Prof. Danesh-Meyer’s case. She is happily married to Michael, a periodontist. They met during a chemistry lecture in their first year of medical school.

“For me, I thrive on multitasking and, fortunately, I do not need much sleep! However, as a professional mother, guilt and children often grow together.” “He was a huge support during my training and fellowship years,” shared Prof. Danesh-Meyer. “We have two daughters, Juliette and Emily. Both are exceptionally strong-minded, determined, effervescent young women now pursuing a career in medicine. I believe their main inspiration was my mother, their grandmother, who was one of the earliest female doctors in Iran.” Prof. Danesh-Meyer acknowledges that finding the right balance between work and family is a challenging decision for many career women.

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“For me, I thrive on multitasking and, fortunately, I do not need much sleep! However, as a professional mother, guilt and children often grow together,” she laughed.

Contributor Prof. Dr. Helen DaneshMeyer, CNZM, MBChB, MD, PhD, FRANZCO, is New Zealand’s first female professor of ophthalmology and holds the Sir William and Lady Stevenson Chair in ophthalmology and head of Academic Neuro-ophthalmology and Glaucoma. She was the youngest appointed professor at the University of Auckland Faculty of Medical and Health Sciences and one of two women professors in a surgical specialty. She has been included in the top 20 of the ‘Power List’ of top 100 influential ophthalmologists internationally, as well as the top 100 Most influential female ophthalmologists internationally. She has published approximately 300 papers, chapters and books in glaucoma and neuro-ophthalmology and authored several textbooks and chapters and raised over $15M in grant funding. Prof. DaneshMeyer is the only New Zealand Ophthalmologist to have been awarded the Paul Harris Award by Rotary for her service to the community. She is a Founding Trustee and Chair of Glaucoma New Zealand, a charitable trust to prevent blindness from glaucoma. She is also on the Executive Advisory Committee for Wolrd Glaucoma Association. She has also co-founded Vision Research Aotearoa, a charity established to support young dynamic New Zealanders. In 2022, she received the highest recognition of the College Medal for the Royal Australian and New Zealand College of Ophthalmologists for her enduring role in research, education, and community engagement. She has been made a Companion of the New Zealand Order of Merit (CNZM).


“Both the patient satisfaction results and depth of focus curves generated are excellent.” Prof Graham Barrett ©2024 Rayner Group, all rights reserved. Rayner and RayOne are proprietary marks of Rayner. All other trademarks are property of their respective owners. Rayner, 10 Dominion Way, Worthing, West Sussex, BN14 8AQ. Registered in England: 615539. EC 2023-30 AU 02/24

Industry Update

Rayner Acquires This AG, Firm Behind Sophi Phaco Machines “The phaco machine plays a central role in cataract surgery,” he said. “[This AG’s]’ machines are truly differentiated with breakthrough technology combined with stunning design, which makes them such a good fit for Rayner,” he said.


ayner’s multi-year shopping spree in the cataract space continued today with the acquisition of Swiss-based This AG, the company behind Sophi phacoemulsification platforms. The deal closed on January 17, 2024. Tim Clover, CEO of Rayner, lauded This AG’s technological prowess and provided some insight into the rationale behind the move.

The acquisition is just the latest in a stunning multi-year run by Rayner on companies encompassing the entire cataract surgery process. They have now acquired complete or partial stakes in a surgical tool manufacturer (HASA OPTIX, 2022), mydriatic agent (OMIDRIA, 2021), and now a phacoemulsification machine (This AG, 2024). All of these moves come on the heels of CVC Capital Partners’ (Luxembourg, Luxembourg) purchase of a majority stake in Rayner in 2021. These are the latest additions to the Rayner portfolio, which also

includes OVDs, digital tools, and pharmaceuticals. Thomas Koeppel, Founder and CEO of Sophi, echoed Mr. Clover’s sentiments and spoke about the common values underpinning the partnership. “Sophi was created by viewing things from a completely new perspective; to redefine the requirements of a perfect phaco system by focusing on the point of view of the surgeon and their team,” he said. “We saw the same philosophy in Rayner.” For the full press release and comments, visit A version of this article was first published on Check out an animated explanation of Sophi’s technology, produced by Media MICE.

CAKE MAGAZINE | February 2024




The landscape of premium lenses According to Dr. Boris Malyugin, the most widely used IOL is the multifocal/trifocal lens, which is available in different versions, such as the trifocal toric and regular trifocal. In recent years, EDOF lenses have also gained popularity. In addition to prominent manufacturers, the rise of smaller producers from India and Europe is expanding the market—potentially leading to more competitive and affordable pricing for these lenses in the future.

The Lens Chronicles Dr. Boris Malyugin shares insights into the crucial role of patient selection in achieving transformative postoperative outcomes by Tan Sher Lynn

Premium intraocular lens (IOL) technology has significantly improved postoperative visual outcomes and the quality of life for patients after cataract surgeries. However, the key to unlocking the full potential of these lenses lies in meticulous patient selection. Renowned Russian cataract surgeon Dr. Boris Malyugin shared invaluable insights to help ophthalmologists navigate the intricate process of IOL selection, ensuring optimal outcomes for cataract surgery.


remium IOLs, including multifocal, extended depth of focus (EDOF), and more exotic technologies like postoperatively adjustable lenses, have ushered in a revolution in cataract surgery outcomes. Designed to enhance


visual acuity at various distances, these lenses reduce or eliminate the need for glasses post-surgery. However, the key to achieving successful outcomes depends significantly on careful patient selection.

CAKE MAGAZINE | February 2024

“Multifocal lenses are considered mainstream because they provide good near vision and reasonable intermediate vision. When aiming for good near vision, trifocal lenses are our first choice. EDOF lenses, while not as effective for reading as multifocal lenses, are a viable alternative when multifocals are not suitable for the patient for various reasons,” shared Dr. Malyugin.

Components of patient selection Three critical components should be taken into consideration when matching patients with the right lenses. “Firstly, it is crucial to ensure that the patient has no ocular comorbidities discouraging the use of this technology. Secondly, consider the patient’s visual or lifestyle demands. And, thirdly, evaluate the patient’s financial capacity,” Dr. Malyugin explained. “Frankly speaking, I am quite conservative in my offering to my patients. Firstly, I would carefully rule out any possible comorbidity that will affect the results. Diseases like age-related macular degeneration, diabetic retinopathy, and glaucoma are strong contraindications to multifocal IOL technology. In such cases, EDOF lenses may be considered,” he continued. He added that EDOF lenses, which are not dependent on refraction and are less likely to cause halos and light dissipation, may be a viable option for these patients. “We are conducting studies on these lenses in individuals with glaucoma and epiretinal fibrosis, and the initial

results are promising. The studies are currently in progress, and we have received positive feedback and results from the participants,” Dr. Malyugin shared.

for a multifocal lens. A combination of both vision demands may lead to a multifocal lens choice, as such patients have good far vision and reasonable intermediate vision.

Meanwhile, in patients with retinal, optic nerve, and inflammatory comorbidities, monofocal lenses are more suitable due to potential light dissipation issues in multifocal lenses.

Dr. Malyugin also spoke about the VIVIOR Monitor (Vivior AG; Zug, Switzerland), an attachment that is worn on prescription glasses to measure how much time a person devotes to tasks requiring near, intermediate, and distance vision.

“In earlier versions of multifocal lenses, 17% of light coming into the lens is just dissipated. Current multifocals are more sophisticated, but still, up to 9% to 10% of light is diffracted and does not reach the macula. “Hence, when the macula is affected by the disease, or if the optic nerve is not working properly, even this 10% of light might be critical for the patient to obtain some useful vision,” Dr. Malyugin added—elaborating on why multifocals are not suitable for this segment of patients.

Assessing patient’s suitability The patient’s lifestyle is also an important factor that impacts visual demands. To gain a deeper understanding of his patient’s lifestyle and visual demands, Dr. Malyugin used a questionnaire, broadly categorizing those he would consider for premium IOLs into two groups—the hunter and the accountant. The hunter, desiring sharp distant vision, is suited for the monofocal lens. Meanwhile, the accountant, requiring the ability to read extensively, is a perfect candidate

The data collected allowed ophthalmologists to better understand the visual demands of their patients, which helps in the selection of the right lens for them. Additionally, a simulation monitor could demonstrate to the patient the potential unwanted effects associated with different types of lenses, such as halos when driving at night, ensuring that these effects do not come as a surprise to patients after the surgery. Furthermore, two eye conditions influence IOL selection, noted Dr. Malyugin. “Low myopes are not generally considered ideal candidates for multifocal lenses since they already have excellent near vision. On the contrary, patients with hyperopia are among the best candidates for multifocal lenses because they may struggle with both near and far vision,” he explained. “Also, patients with cataracts are generally happy with the results regardless of the lens suggested due to the low vision they had before surgery. On the other hand, presbyopic patients in their 50s with early nucleus sclerosis and wanting to be free of their glasses are

more demanding of the results,” Dr. Malyugin shared. “Essentially, the combination of the refractive status plus the visual habits of the patient is the factor that drives the satisfaction of the person with the multifocal technology,” he added. In conclusion, Dr. Malyugin emphasized that no optical technology is without side effects. Therefore, ophthalmologists should educate patients about the potential side effects, if any. He also cautioned against overpromising to patients. “Adhering to the principle of ‘under promise, over deliver,’ it is crucial not to make promises that cannot be fulfilled. In addition, patients need to be assured that while every technology has its drawback, the benefits far outweigh the potential issues in their specific case,” he said..

Contributor 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.

CAKE MAGAZINE | February 2024




navigate the challenges of taking on an entirely different field outside the clinical setting?

Navigating career crossroads Dr. Peter J. McDonnell opened the symposium by presenting a survey of over 1,200 doctors, which yielded some unexpected results. Surprisingly, as many as one-quarter of all doctors surveyed reported that they were seriously rethinking their careers in medicine.

Taking the Road Less Traveled Stories of resilience, adaptation, and the pursuit of fulfilling careers in the ever-evolving landscape of medicine by Nick Eustice

Beyond the conventional boundaries of clinical practice, ophthalmologists are embracing diverse pathways, ranging from industry collaborations to innovative side hustles. Experts at last year’s American Academy of Ophthalmology (AAO) Annual Meeting shared insights and experiences, offering a glimpse into the multifaceted world of ophthalmology and the varied trajectories shaping the future of medical careers.


eetings of the minds play a big part in the success of conferences, such as the AAO Annual Meeting, where diverse topics in ophthalmology are exchanged. There are tried-and-true subjects that are always rife with new material, including cuttingedge pharmacology, surgical pearls of wisdom, and advances in gene therapy. And then there are the less-common topics, such as


building a cooperative practice with optometry or patient education. Occasionally, there's a topic that completely stands out. At last year's AAO Congress, one symposium explored a question that ventured beyond the typical scope of ophthalmology: What happens when doctors transition out of ophthalmology? Or, even if they do continue to practice, how do they

CAKE MAGAZINE | February 2024

Taking a deeper dive into the survey’s results, Dr. McDonnell noted that of these respondents, a significant majority of the doctors who were interested in changing careers were primary care physicians. These doctors reported extremely high rates of burnout and dissatisfaction, with even higher numbers among women and young doctors. One significant motivator for this desire for change is COVID-19. Being on the frontline in treating this disease, physicians and other healthcare workers had among the highest rates of infection, especially in the early days of the pandemic. One case in every 16 reported was a healthcare worker. “Ophthalmologists certainly have a rationale for being impacted by the pandemic,” said Dr. McDonnell. “We all remember Dr. Li Wenliang, the ophthalmologist who first alerted us to this virus, was punished by his government for doing so, and tragically lost his life to the disease.” Dr. Wenliang was not an isolated case in his specialty. As Dr. McDonnell noted, ophthalmologists are among the top three specialists most affected by COVID-19. Since the pandemic has largely subsided, and the most imminent dangers of COVID have passed for the most part, physicians are now more frequently considering changing fields due to factors such as work-life balance, an increasing lack of autonomy, and bureaucracy protocols that continually erode the doctor-patient relationship. On the more positive end of the spectrum, many doctors leave their practice because they’ve invented a new

medical device, or discovered a talent for medical administration. “What about ophthalmology?” asked Dr. McDonnell. “Well let’s face it, among all medical specialties, we ophthalmologists chose the best one.” He explained that, comparatively speaking, ophthalmologists experience some of the lowest levels of burnout in all surveys and consistently report very high job satisfaction. “Even if we no longer operate,” Dr. McDonnell continued, “ophthalmologists find practice rewarding and ophthalmology fascinating.”

The growing world of medical side hustles As the symposium continued, the focus shifted somewhat away from leaving the profession altogether to exploring different paths within ophthalmology and the medical field in general. One of the most popular directions that many ophthalmologists choose is forging closer collaborations with industry. Doctors often find that their close working relationships with the companies providing their medical devices and pharmaceuticals lead them to work directly with those companies. Whether on a full- or part-time basis, partnering with the medical industry can be both lucrative and rewarding in many ways. Though the topic was covered by many presenters at the symposium, Dr. Constance Okeke’s presentation, titled Building an Industrial Presence in Ophthalmology stood out. Pointing

to her extensive list of financial disclosures, Dr. Okeke spoke about her extensive work in collaboration with industry. “There are different types of industry relationships you can be involved in,” she said. “But it first begins with an idea of where your strong interests lie. Where do you have keen experience and expertise? And where is your desire to express that idea of interest with others?” For Dr. Okeke, her involvement with industry sprang from an early interest in Trabectome (NeoMedix Corporation; California, USA) as a treatment for mild to moderate glaucoma. Although this approach was not very common, it led to networking within the industry. Dr. Okeke started speaking about the successes she had experienced with her patients. By branching out and sharing her results, she identified communication as the foundational step to working with industry. “Many opportunities are lost because of poor communication,” Dr. Okeke emphasized. “Companies don’t know where your interests lie, they don’t know where your expertise lies. You need to share your interests with them and approach them… let them know what you’re interested in and how you’d like to work with industry.” Following that first step, Dr. Okeke highlighted the importance of understanding contracts, particularly the first one. In this same vein, she pointed out that it is vital to understand your rate of pay when working in conjunction with industry. This, she said, is often in direct correlation to what’s included in

your CV, stressing the importance of keeping it up to date. Overall, Dr. Okeke stressed the importance of networking beyond the initial stages of working with industry and maintaining proactive communication. As one progresses on a path of consulting with industry, staying abreast of the state of technology is imperative. She concluded by saying, “Be a repeat consultant by being accessible, dependable, and constructive.”

Diverse ventures beyond ophthalmology Other speakers shared a wide array of experiences working in fields adjacent to ophthalmology. Some have partnered with insurance companies, while others have provided expert testimony in the legal field. Indeed, the different paths doctors have taken are as diverse as the interests that led them to pursue these opportunities. Whatever paths ophthalmologists choose to explore in addition to their practices, it is noteworthy, as Dr. Mc Donnell pointed out, that the vast majority find their work both rewarding and fascinating.

Editor’s Note The 127th American Academy of Ophthalmology Meeting (AAO 2023) was held on November 3 to 6, 2023, in San Francisco, California, USA. Reporting for this story took place during the event.

CAKE MAGAZINE | February 2024


Conference Highlights

AAO 2023

The Intricacies W of Aging Challenges and adaptations faced by ophthalmologists as they navigate the inevitability of aging in the industry by Nick Eustice

In ophthalmology, the aging process introduces complex considerations for practitioners. At the heart of this discussion is a recent American Academy of Ophthalmology (AAO) Symposium, where experts examined the statistical landscape and trends that challenge preconceived notions about aging doctors. From the average age of practitioners to the correlation between age and performance, the symposium explored the profession’s response to the inevitability of aging.

e all get older. And as we do, our bodies and minds lose some degree of the strength and quickness they once had. Though, in exchange, it can be said that we gain wisdom and experience, our society tends to place a lot of value on youth and vitality. Sometimes this is for good reason, as those in certain occupations such as firefighters and lifeguards need to be in peak physical condition to perform their jobs. Other times, however, we encounter the problem of ageism, discrimination against people of advanced years, in places where it doesn’t belong, and where it isn’t necessarily fair. But it’s not always easy to separate cases where discrimination takes place and where it doesn’t. We see this problem more and more in our public discourse, in positions of importance as great as that of the President of the United States. How old is too old to do the job? This question often depends as much on the person as it does on the job. Certainly, in ophthalmology, there are valid reasons to value both the steady hand of youth and the careful eye of experience. Navigating the challenges of this delicate balance was the subject of an insightful symposium at last year’s meeting of the American Academy of Ophthalmology (AAO) in San Francisco. Titled Professional Longevity: What Are the Essential Elements in Our Approach to This Emerging Challenge? and inspired by the New York Times guest essay entitled ‘How Would You Feel About a 100-Year-Old Doctor?’—this symposium set out to frankly and honestly address the elements of physical longevity within the profession.

The challenges of selfregulation One of the biggest challenges in addressing the issue of aging in ophthalmology, and in medicine in general, is figuring out when it may be time to step away from surgery, or from practicing altogether. In discussing this issue, panelist Dr. Tamara R. Fountain pointed out that


CAKE MAGAZINE | February 2024

having the freedom to make this decision without external pressures is a relatively fortunate one. “At some point, all of us are going to reach this fork in the road where we have to make some decisions,” Dr. Fountain said. “But I want to position this fork in the road as really a privilege because, most of the time, we have the choice of when to take this pathway. “For example, if you’re in the FBI or law enforcement, someone’s going to tell you when to retire. Similarly, the federal government tells our pilots they have to retire at 67 and our air traffic controllers at 56.” While she noted that these required retirement ages are quite young, Dr. Fountain added that this knowledge did make her feel more confident about getting on the plane to go home from the conference. Nonetheless, the point remains that ophthalmology is largely a selfregulated profession. Consequently, the decision of whether or not to continue practicing is usually left to the individual physician. For this reason, personal introspection and collegial peer discussion remain absolutely critical for each and every ophthalmologist. Dr. Fountain brought up two distinctly different examples of colleagues who recently decided to retire from the profession: One decided that it was the right time to retire in her mid50s, while the other, Dr. Fountain’s senior partner, transitioned out of active practice at the age of 85. In both cases, the doctors were highly capable surgeons. The determining

factor, simply put, was the age at which they decided to retire.

Do our abilities necessarily decline? It’s generally understood that our abilities, including focus and motor skills, will decline at some point in our lives. However, the timing of when that occurs is unique to each individual. Numerous factors can lead to an ophthalmologist needing to leave the profession relatively early in life, while others remain entirely vigorous until much later. In examining statistical data on ophthalmologists and aging, Dr. Flora Lum presented a number of figures gathered by the AAO on its members. Dr. Lum showed that significant changes had taken place among the organization’s membership over the past 20 years. Notable among these figures was that the average age of American ophthalmologists has increased by about four and a half years, from 50 to 54.5. In addition, members over the age of 60 now make up 37% of practicing ophthalmologists. Do these numbers indicate diminished performance? Happily, no. Dr. Lum’s statistics showed that older doctors typically demonstrated slightly better results and patient satisfaction than their younger colleagues. More experienced ophthalmologists also showed notably lower surgical fatalities than other age groups. Looking at the performance rates reported in the IRIS database, Dr. Lum also found good news. Success

rates across the board were virtually identical between younger and older doctors. Additionally, there was no correlation between age and the number of malpractice claims. Though these findings are very encouraging, Dr. George Bartley, the CEO of the American Board of Ophthalmology, presented somewhat more sobering figures later on in the symposium. Citing literature across medical specialties, Dr. Bartley said that declining abilities are an inevitability for us all and that doctors are frequently less capable of selfevaluating than they believe. Referring to an article reporting these findings, Dr. Bartley said: “It convinced me that I should sheathe my scalpel while I was at the top of my game, or at least when I perceived that I was at the top of my game, rather than being confronted with the cruel reality if or when a poor result occurred.”

Parting thoughts: Seek out peer evaluation While no one likes the thought of their abilities diminishing with age, Dr. Bartley rightly pointed out that staying aware helps to ensure that one doesn’t find out the truth once it’s too late. As a result, he advocates checking up on colleagues and participating in voluntary certification programs. “It’s up to each of us to regulate ourselves,” Dr. Bartley concluded. “I gently encourage you to be proactive… assess your knowledge and compare your results with your peers and colleagues.” He closed the symposium with sound advice, saying that it is up to the community of ophthalmologists to regulate itself to ensure the wellbeing of patients and colleagues, and the future of the profession.

Editor’s Note The 127th American Academy of Ophthalmology Meeting (AAO 2023) was held on November 3 to 6, 2023, in San Francisco, California, USA. Reporting for this story took place during the event.

CAKE MAGAZINE | February 2024


Conference Highlights

APMMS 2023

The Myopia E Enigma Experts decode the best practices of myopia management at APMMS 2023 by Nick Eustice and Gloria D. Gamat

“Myopia is not just a vision concern. It is a chronic, progressive disease that needs comprehensive management.” These words resonated at the core of the first session of the recently held 3rd Annual Asia-Pacific Myopia Management Symposium (APMMS 2023) in Taipei, Taiwan. Under the topical heading Reframing Myopia: A Disease Demanding Urgent Treatment, the morning session brought together thought leaders from around the world.


CAKE MAGAZINE | February 2024

xperts from various fields within eye care presented an array of lectures, each expressing the need for a fresh perspective on a condition that has long been dismissed as a mere refractive error—easily treated and forgotten. All the session’s moderators agree that this needs to change, especially in Asia-Pacific. The diverse panel of experts had each shone a light on a different area of myopia care throughout the world, collectively spearheading efforts to make a difference in the vision and eye health of millions of children worldwide.

Myopia care highlights – from lenses to atropine The session opened with Dr. Nicola Logan (United Kingdom), who presented a survey of global trends in treating myopia, reflecting the growing concern about the disease’s increasing prevalence in children throughout the world. “We are all here today because we have that special interest in myopia, but are we all doing something about it in our clinical practice? Regional

differences are affected by scope of practice and availability of options,” said Dr. Logan. Her presentation identified a number of key takeaways from a global trends survey in myopia management. While contact lenses are growing in popularity, single-vision spectacles remain the most popular myopia correction method.

“We are all here today because we have that special interest in myopia, but are we all doing something about it in our clinical practice? Regional differences are affected by scope of practice and availability of options.” — Dr. Nicola Logan

This is especially true among young myopes. Additionally, she pointed out that eye care professionals have begun to prescribe myopia management contact lenses much more frequently than soft singlevision lenses, which she said is certainly a step in the right direction. “Single vision spectacles are still (as first option) the most frequently prescribed optical correction to young myopes [4x more often than single vision contact lenses and orthokeratology lenses; over 3.5x more than soft contact lenses and 2.5x more than spectacles for myopia management purposes],” Dr. Logan reported. “It appears that the disparity between favoring spectacle over soft contact lenses seems to reduce when prescribed for myopia management purposes,” she explained. Currently, according to Dr. Logan, eye care professionals consider

a patient’s age to be the most important factor when deciding what intervention to use. “I would like to encourage you to consider lifestyle factors to be equally important in terms of choosing your intervention to use in every individual child you see in your practice. “I encourage everyone to be on board in making a difference in terms of what we are doing for young children with myopia and move away from that typical single vision correction to something that’s much more appropriate,” she concluded. Following Dr. Logan’s lecture, Dr. Seung-Hee Baek (South Korea) spoke about the evolution of myopia treatment in South Korea in the past decade. She noted that myopia development is especially high among young Korean patients, and appears to be advancing at a higher rate of progression in recent years. Dr. Baek reported on the growing use of low-dose atropine as a myopia treatment, which has shown encouraging results. She presented the results of several studies involving low-dose atropine in Korean children. “Results showed that treatment with 0.01%, 0.025% and 0.05% atropine solution inhibits myopia progression in Korean children in a dosedependent manner,” she shared. Based on these results, it is hoped that higher low-dose atropine may soon be available, as they may prove more effective. “The burden of myopia in Korea is substantial. Clinically, 0.01% atropine may not suffice in many cases. We are eager to have higher low-dose commercial atropine eye drops soon,” she concluded.

Early intervention is key – the axial length and genetic connection Dr. Tzu Hsun Tsai (Taiwan) took the podium next, presenting findings from the first comprehensive study of axial length among children in Taiwan. “We established the first Taiwanese population-based percentile curves of axial length in children, which may help in assessing an individual’s health status and predicting the probability of myopia,” said Dr. Tsai.

Specifically referencing change of axial length percentile as an indicator of myopia progression, Dr. Tsai reported that these factors can be useful in charting myopia progression throughout the young population. She noted, however, that these data points are population- and timespecific, and their use may not prove useful when applied generally. “The region-specific characteristics served as reference and helped in tailoring anti-myopia strategies,” she explained. Furthermore, Dr. Tsai added that in a cohort of orthokeratology lens users, axial length percentile change rate in addition to baseline spherical equivalent, best estimate myopia progression. Dr. Ninomiya Sayuri (Japan) and Dr. Pei Chang Wu (Taiwan), each focused on different aspects of childhood myopia development. Dr. Sayuri focused on the pathogenesis and mechanism of the condition, while Dr. Wu’s lecture was primarily concerned with risk factors and potential preventions. Dr. Sayuri posited that genetic components may underlie childhood myopia – pathological myopia—and that this may one day hold the key to finding a cure for the condition. Dr. Sayuri walked the audience through the three main areas for myopia control: optical, pharmacological and environmental control. Also, she brought some good news— that MiSight® [CooperVision’s 1 day soft contact lenses for myopia control] is finally undergoing clinical trials in Japan—the first on-label trial for myopia control in the country. “So, for me, prescribing single-vision glasses to myopic kids is like giving a poisonous apple to them. I feel guilty when I know there is a better option,” shared Dr. Sayuri. Dr. Wu spoke on the great importance of outdoor time for children as a preventative measure, as well as the correlation between other factors like physical activity and living environment, and myopia development. He also highlighted the prevalence of “quarantine myopia” during the COVID-19 pandemic, which was exacerbated by increase of screen time and lack of outdoor time.

CAKE MAGAZINE | February 2024


Conference Highlights

He went far back to the concept of pre-myopia – a state of low hyperopia reserve in children—to serve a poignant reminder to the audience regarding the critical role of the environment in influencing myopia progression. All of these speakers brought together one central theme—the critical importance of myopia care and prevention among young patients in order to control the condition.

“Why myopia? And why now?” It was with these two questions that Dr. Mark Bullimore (USA) opened his lecture at the latter part of the session. Dr. Bullimore discussed the undeniable correlation between the extent of each patient’s myopia progression and their likelihood of developing other, more critical visual impairments. “When I was studying in England 40 years ago, we regarded myopia as a benign, refractive condition—and we would correct it with spectacles or contact lenses, and more recently, refractive surgery,” Dr. Bullimore shared. What has changed? “Well, for one, there’s an increased prevalence. Beyond that, I would say the two most important factors are that— thanks to CooperVision and other leaders—we now have the ability to do something about it, coupled with a better understanding of the role that myopia plays in ocular disease and uncorrectable visual impairment,” he explained.

Clear signs of correlation Dr. Bullimore presented several papers supporting the relationship

APMMS 2023

between myopia and advanced visual conditions. The first showcased a logarithmic interpretation of data from five unique studies of myopic patients in different global regions and their development of myopic maculopathy (MM). It indicated that each additional diopter of visual impairment corresponded to a 67% greater likelihood of developing the condition.

“When I was studying in England 40 years ago, we regarded myopia as a benign, refractive condition—and we would correct it with spectacles or contact lenses, and more recently, refractive surgery.” — Dr. Mark Bullimore

The relationship between myopia and severe comorbidities became increasingly evident as Dr. Bullimore proceeded—along with myopia, and in proportion to its extent, other ocular conditions emerged. But what about myopia itself and the loss of vision that occurs directly as a result of the condition? Left unchecked, myopia often advances throughout a patient’s lifetime. The ongoing deformation in the eye’s axial length can frequently lead to diminished vision and, in some cases, to vision loss. While we have more

preventative options for myopia than ever before, vision loss due to myopia remains irreversible. And this threat is one that needs to be understood more thoroughly.

The continuum of myopia care To address the threat posed by myopia, Dr. Bullimore referred to what he calls the continuum of myopia care—an ongoing process wherein he encourages the profession to identify, diagnose, and treat myopia as early and as rapidly as possible—a sentiment shared by all the session’s speakers. Key to this approach is comprehending the risks posed by myopia to young patients and sharing this understanding with their parents. “We need to start communicating that risk and really predict the future: Talking to parents early so that they are primed to understand what the future holds for their children, and understanding the fact that we have the ability to envision a different future if we intervene early,” emphasized Dr. Bullimore. “We have the greatest opportunity to do something about it—by initiating treatment right away and not waiting for the myopia to progress,” he continued. “Of course, those treatments need to be evidencebased. And we’re here thanks to CooperVision, which offers some of the best evidence-based treatment interventions available to us,” concluded Dr. Bullimore. Long gone are the days when corrective lenses were the beginning and the end of the story of myopia. And with our increased ability to treat the condition comes an increased responsibility to take the condition seriously—and to act early to protect patients’ vision.

Editor’s Note

The panel of experts at the morning session of the 3rd APMMS held in Taipei, Taiwan on December 10, 2023.


CAKE MAGAZINE | February 2024

The 3rd Annual Asia-Pacific Myopia Management Symposium (APMMS 2023) was held in Taipei, Taiwan on December 10, 2023. Reporting for this story took place during the event.


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Industry Update

AAO Issues Warning on the Dangers of Eye Color-Changing Procedures


he American Academy of Ophthalmology (AAO) warns the public against two eye colorchanging surgeries that are trending on social media: Iris implant surgery and a laser surgery that inserts pigment into the cornea. Both of these surgeries carry serious risks for vision loss and complications. These risks and complications should be fully disclosed to patients. Patients contemplating these procedures for cosmetic reasons alone must weigh these serious risks against the potential gain. Iris implants have been FDA-approved for patients who are missing part or all of their iris due to injury or a birth defect. Surgery involves inserting an artificial iris made of silicone through a slit that has been cut into the eye at the edge of the cornea. Then the artificial iris is unfolded inside of the eye and adjusted to cover the natural iris.

Patients who have the procedure for medical reasons also risk complications from implant surgery, but the benefits of gaining an iris may outweigh their risks. Serious complications have been reported in patients receiving iris implants for cosmetic reasons, even requiring the removal of the implant. Potential complications of iris implant surgery include reduced vision or blindness, light sensitivity, elevated pressure inside the eye that can lead to glaucoma, cataract, injury to the cornea, and inflammation of the iris or areas around it—leading to pain, blurred vision, and tearing. Keratopigmentation, also referred to as eye tattooing, is surgery performed on the cornea itself. The natural cornea is crystal clear and shows the color of the iris underneath it inside the eye. Keratopigmentation involves using a needle or a laser to create space in the cornea itself, into which a color pigment

is injected, permanently changing the cornea from clear to opaque and covering over the natural iris color inside. Possible risks include damage to the cornea that can lead to cloudiness, warpage, fluid leakage and vision loss; light sensitivity; reaction to the dye, which can cause inflammation; uveitis; bacterial or fungal infection; uneven distribution of the dye; leakage of the dye into the eye; and color fading due to the dye moving or leaking into the eye. “Don’t think that these surgeries carry no risk,” said Dr. JoAnn A. Giaconi, MD, clinical spokesperson for the American Academy of Ophthalmology. “No surgery is free of risk. With purely cosmetic surgeries on the eye, it’s just not worth the risk when it comes to your good vision.” For more information about eye health and how to protect your eyes, visit www.

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