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ASIA-PACIFIC’S MOST DELICIOUS M AG A ZINE ON THE A N TERIOR SEGMEN T

01X ARVO 2019 Edition

Have a piece, and enjoy it, too!

March/April 2019 www.cakemagazine.org

Fresh Delivery

New One-Handed Revolving Technique for Soft Cataract Surgery Page

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Cookie-Cutter, Not

The Future Looks Bright for MIGS in Asia Page

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Cover Story

Steal a Taste of What’s Cooking in the Anterior Segment Page 18 Renowned Ophthalmic Editor Dr. Mark Hillen (pictured here) stole a taste too Page 04

THE WORLD’S SECOND FUNKY OPHTHALMOLOGY MAGAZINE


IN THIS ISSUE...

06 Matt Young

CEO & Publisher

Cataract 08

No Chopper Required: New One-Handed Revolving Technique for Soft Cataract Surgery

Patient Understanding: Key in Achieving Spectacle-Free Results

10 Anterior Segment 14 Saving Precious Sight: Cataracts in Infants

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Robert Anderson Media Director

Hannah Nguyen

Production & Circulation Manager

A Renaissance in Glaucoma Treatment: The Future Looks Bright for MIGS in Asia

Going Under-the-Flap to treat Early Ectasia with Hyperopic Refractive Error

Gloria D. Gamat Chief Editor

Brooke Herron Associate Editor

Mark Hillen

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Cover Story

Editor-At-Large

Ruchi Mahajan Ranga Project Manager

Something’s Cooking!

Alex Young

Publications & Digital Manager Graphic Designers

A Taste of What’s Baking in the Anterior Segment

Winson Chua Patalina Chua Writers

April Ingram Gerardo D. Sison III Hazlin Hassan Khor Hui Min Konstantin Yakimchuk Olawale Salami Sharon Kleiner Tan Sher Lynn Cover Art

Kudos 22

Restoring Vision with ‘Tooth in Eye’ Surgery

Prafulla Badgujar Published by

Media MICE Pte. Ltd.

6001 Beach Road, #19-06 Golden Mile Tower, Singapore 199589 Tel: +65 8186 7677 Fax: +65 6298 6316 Email: enquiry@mediamice.com www.mediaMICE.com

Society Friends

Asia-Pacific Academy of Ophthalmology

Unveiling the Great Masquerade

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The Importance of Focus, Passion, and Perseverance

28

Enlightenment

Conference Highlights

36

Spotting a Publishable Case (. . . And Working on It!)

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In Case You Missed It: Refractive e-Poster Highlights from AAO

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Attending International Conferences 101: Tips for Young Ophthalmologists

New Developments in Cataract Surgery Pharmacology from APAO

We are looking for eye docs who can contribute articles to CAKE magazine. Interested? Let's talk! Send us an email at enquiry@mediamice.com. Delhi Ophthalmological Society

To place an advertisement, advertorial, symposium highlight, video, email blast, or other promotion in CAKE magazine contact CEO Matt Young at matt@mediamice.com.


CAKE MAGAZINE Letter to Readers

Dear Reader,

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aunching a new magazine in ophthalmology is not an easy task. I know – I’ve been there and done that twice, first in Europe, and then in North America. Since ophthalmology is so varied, it was never hard to find something good to cover. As editor, I had the easy job. However, for publishers, it’s a difficult game, and it’s only getting harder. Advertising budgets are falling; print is apparently ‘dead’. And Facebook wants your content to sell its ads against. And yet today, you’re reading the newest magazine in the business: CAKE. Are the CAKE team mad? Are they real ‘whisk-takers’? Not at all. CAKE isn’t this team’s first take on eyecare publications. It’s not even their first take on bakinginspired magazine names. If you share a break-out room or a canteen with retina surgeons, you might be familiar with CAKE’s sister title, PIE (Posterior Segment, Innovation and Enlightenment), which came out of the oven two years ago (don’t worry, it’s still fresh!). The team behind both publications are seasoned pros. They know how to tell stories; and they believe that the secret ingredient behind it all is a disruptive approach. Therefore, CAKE takes a freshly-baked approach to covering eyecare, with a recipe that combines journalistic chops, in-depth interviews, fantastic features – all with that special secret ingredient. CAKE magazine stands for Cataract, Anterior Segment, Kudos and Enlightenment. So, if you’re involved in (or have an interest in) corneal, cataract, refractive, or glaucoma surgery, this magazine is for you. There’s a time and a place for continuing medical education (CME). However, there’s also a time and a place to be educated and entertained about your profession – and that’s when it’s time for some CAKE. The first two items in CAKE’s acronym (Cataract and Anterior Segment) mean that you work in one of the most rewarding subspecialties in ophthalmology. Most of your patients think that you’re a miracle worker! I work for a clinic where the chief surgeon deals with some of the most complicated cases in the continent – in the world, even – repairing the refractive surgeries that went wrong; and in patients with keratoconus, rescuing as much visual acuity as possible by stringing together CXL, Trans-PRK, and bespoke scleral lens fitting. I see the looks on these patients’ faces. It’s the same look you get with each patient that opens their eyes after any intervention that improves their vision: joy. And this field just gets better and better – improvements in the industry’s offerings mean that there’s a menu of ever-improving magical ingredients to sprinkle into the mix when planning and performing surgery.

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Moving on to Kudos and Enlightenment. Let’s face it, Anterior segment surgeons don’t have it easy, but they do it nevertheless. Kudos. These are the people who do the right thing, who work hard to improve the lives of their patients – be it day-in, day-out in the clinic – or by working in collaboration with huge teams to bring the next product to market. And these efforts deserve recognition and celebration. By covering this work, CAKE provide a platter on which this kudos can be served (and we all learn something valuable in the process). There’s also more to life than turning up to work and churning through long lists of patients before whisking yourself off home to rest, rinse, and repeat. This is where you need Enlightenment, and it takes many forms: from crumbs of wisdom that make you that little bit fitter, better or more productive, to choux-(s)topping stories from surgeons who have adopted practices like meditation or Tai-Chi to bring some mindfulness and balance to life. We hope to help you cool-whip your work-life balance back into shape! (Sorry about the puns, but if you can’t take the wheat, stay out of the kitchen.) But in all seriousness, I believe that CAKE has what it takes to succeed. CAKE is not pretending to be a journal of record. It’s not cover-to-cover advertorial. CAKE is something unique. It is lovable education: part professional, part lifestyle. It’s meant to be enjoyed. And so long as it’s enjoyable, it will be a success. Given the team’s pedigree, I expect what comes out of the oven in March to be more hot takes than half-baked; more content that pleases than hard cheeses. Enjoy! Dr. Mark Hillen Director of Communications ELZA Institute, Zurich, Switzerland Editor-At-Large CAKE Magazine

March/April 2019


CAKE MAGAZINE Advisory Board Members Dr. Jodhbir Singh Mehta, B.Sc. (Hons.), M.B.B.S., PhD, FRCOphth, FRCS(Ed), FAMS Dr. Mehta is head of Cornea External Disease and senior consultant in the Refractive Service at Singapore National Eye Centre (SNEC), deputy executive director at Singapore Eye Research Institute (SERI), as well as a professor at Duke-National University of Singapore. With a main interest in corneal transplantation, he completed a corneal external disease and refractive fellowship at Moorfields Eye Hospital in London and at SNEC. He has co-authored nearly 20 textbooks and 333 citations, and holds 16 patents, six of which have been licensed. A seasoned committee organizer, Dr. Mehta will be part of the World Corneal Organizing Committee in 2020, as well as the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS), Singapore, in the same year. He has won several awards from the American Academy of Ophthalmology (AAO) and the Association for Research in Vision and Ophthalmology (ARVO), among others, the latest of which was from the American Society of Cataract and Refractive Surgeon (ASCRS) in 2018. Dr. Mehta is also a favorite keynote speaker and presenter in several international conferences. [Email: jodmehta@gmail.com]

Dr. William B. Trattler, M.D. Dr. 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, suture-less cataract surgery; as well as laser cataract surgery. He has been an investigator for next generation technologies (like the Tetraflex accommodating intraocular lens) and procedures like corneal collagen crosslinking (CXL). His involvement in the FDA-approval study for CXL led to its approval in 2016. In addition to his private practice, Dr. Trattler is on the Volunteer Faculty at the Florida International University Wertheim College of Medicine, as well as the University of Miami’s Bascom Palmer Eye Institute. He is board certified by the American Board of Ophthalmology and has been an author of several articles and abstracts. In 2016, Dr. Trattler received the Catalyst Award in Advancing Diversity in Leadership from the Ophthalmic World Leaders (OWL), an association of interdisciplinary ophthalmic professionals dedicated to driving innovation and patient care by advancing diversity in leadership. [Email: wtrattler@gmail.com]

Dr. Chelvin Cheryl Agnes Sng, B.A., MBBChir, M.A., MRCSEd, MMed Dr. Sng is a consultant at the National University Hospital (NUH) and assistant professor at National University of Singapore (NUS). She is also an honorary consultant at Moorfields Eye Hospital, London, and adjunct clinic investigator at SERI. A pioneer of minimally invasive glaucoma surgery (MIGS), Dr. Sng was the first surgeon in Asia to perform XEN, InnFocus Microshunt and iStent Inject implantation. A coauthor of “The Ophthalmology Examinations Review”, Dr. Sng has also written several book chapters and publications in various international journals. She has received international grants and awards for her research accomplishments from the American Academy of Ophthalmology and the Australian and New Zealand Glaucoma Interest Group. Proficient in conventional glaucoma surgery and trained in complex cataract surgery, Dr. Sng co-invented a new glaucoma drainage device, which was patented in 2015. She has been invited as a reviewer for several international ophthalmic publications, and as a speaker in various international lectures and conventions. When not working, Dr. Sng can be found volunteering in medical missions in India and across Southeast Asia. [Email: chelvin@gmail.com]

Dr. Harvey Siy Uy, M.D. Dr. Uy currently serves as associate clinical professor at the University of the Philippines-Philippine General Hospital, consultant for Retina and Uveitis Services at St. Luke’s Medical Center, as well as medical director at Peregrine Eye and Laser Institute in the Philippines. Previously, he was a clinical fellow in Medical and Surgical Retina at St. Luke’s Medical Center, Philippines, and in Ocular Immunology and Uveitis at the Massachusetts Eye and Ear Infirmary at Harvard Medical School. In 2015, he co-invented the Modular Intraocular Lens Designs, Tools and Methods, which was patented with the United States Patent Office. Dr. Uy is a recipient of numerous awards and honors, including the Immunology Award, presented by the Ocular Immunology Service from the Massachusetts Eye and Ear Infirmary, Harvard Medical School (1998), and the Senior Achievement Award from the Asia-Pacific Academy of Ophthalmology (2017). He has also published more than 32 international peer-reviewed journals and 30 book chapters, and is a prominent speaker, presenting in various national and international conferences. [Email: harveyuy@yahoo.com]

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March/April 2019

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Cataract ATARACT IOLs

Patient Understanding

Key in Achieving Spectacle-Free Results

To optimize outcomes, physicians should ask patients about their hobbies when selecting an IOL.

by April Ingram s we know, not all lenses are created equal – and certainly, not all eyes are created equal. That leaves surgeons to balance the qualities, characteristics, and optics of each intraocular lens (IOL) with the ocular findings, expectations and lifestyle of the patient in order to deliver a predictable, spectacle-independent outcome. Cataract surgeons are excited about the range of options for presbyopia-correcting IOLs, which allow them to be more selective and specific to their patient’s needs than ever before. In addition, the developments in the design and technology supporting these lenses are creating more opportunities to deliver optimal outcomes to a broader range of patients. With more available options, surgeons need to be well-versed in all the factors that may influence the success of each particular lens for every individual patient. In addition, they need to know how to effectively communicate the potential and limitations of each IOL option. Patients, on the other hand, are arriving at their surgeons’ office with higher levels of expectation, having done a lot of their own ‘research’ as to what the outcomes ‘should’ be.

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Multiple Options with Multifocal Lenses

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Dr. Leonard Ang, medical director and senior consultant ophthalmologist at Lang Eye Centre at Mount Elizabeth Novena Hospital in Singapore, knows that he can deliver superior visual performance and a greater range of vision correction with the latest advancements in multifocal lens technology. According to him, “Multifocal lenses have given patients greater convenience by reducing the need for distance and reading spectacles. Most multifocal lenses are traditionally focused on correcting distance and near vision. Newer trifocal lenses are now able to provide patients with improved unaided distance, intermediate, and near vision to further reduce the need for spectacles.” Some of Dr. Ang’s favorite IOLs to consider include the AcrySof IQ PanOptix IOL (Alcon, Fort Worth, Texas, U.S.A.), built on Alcon’s proven AcrySof IQ platform. “The ENLIGHTEN Optical Technology provides an exceptionally high light utilization (88%) and less pupil dependence than previous generations of multifocal IOLs,” he shared. “It has an intermediate focal March/April 2019

point at 60cm, the distance for common intermediate vision activities, such as using a computer. It also has excellent rotational and axial stability.” For his patients, Dr. Ang has been pleased with the results achieved with the AcrySof IQ PanOptix lens, “It offers a comfortable and continuous range of near-to-intermediate vision without compromising distance vision,” he added. “I have been impressed with the visual performance of the lens and the level of patient satisfaction, which is why it is my preferred multifocal lens for patients who desire spectacle independence.”

The Importance of Patient Education Dr. Chee Soon Phaik of the Singapore National Eye Centre (SNEC) knows how important patient education is to the entire process. “I counsel patients on the different types of IOL, and they choose the type of IOL they want to receive,” she shared. After careful discussion with her patients and weighing all the factors, about half of Dr. Chee’s patients receive a trifocal IOL. “A significant number are turned away from a trifocal IOL because of previous refractive surgery, macular issues, glaucoma or severe dry eyes. For those patients who are intolerant to halos and glare, most would prefer to have monovision,” she said. When considering the patients’ tolerability to visual effects, monovision can be a great alternative to minimize the need for spectacles, especially for those that don’t require finely tuned depth perception for their daily activities. Dr. Chee explained: “Around one in every 20 of my patients chooses either both eyes for distance or combination of near and intermediate vision.” After considering patient history, need and preference, what does Dr.


Chee use most often? According to her, approximately 80% of eyes receive a toric IOL: “I use mostly the Alcon toric lens because of its rotational stability and refractive predictability.” When it comes to a trifocal IOL, Dr. Chee, like Dr. Ang, favors the Acrysof IQ PanOptix trifocal lens. “We note that they achieve a continuous spectrum of clear vision from 40cm to distance,” shared Dr. Chee. Some multifocal IOLs have resulted in reduced contrast sensitivity compared with monovision options. But as Dr. Chee has found, “the high light utilization results in a contrast sensitivity, which is within the normal band for photopic conditions and low levels of glare at six months tested binocularly.”

Understanding Patients Beyond Prescription Dr. Florian Kretz, from Eyeclinics AhausGreven-Raesfeld-Rheine in Germany, acknowledges the importance of getting to know your patient, understanding his specific needs and expectations, and then looking at all the available IOL options that will be best suited for him. “I work with most IOL companies as I like to choose the right one for the right patient. Patients are very demanding, but also, many of them have their specific needs,” Dr. Kretz explained. He added that some patients are more, and some are less accepting of dysphotopsia. “So, in these cases, I like using rotational asymmetric IOLs.” Dr. Kretz shared that the presbyopia-correcting LENTIS Mplus IOL (Berlin, Germany) from Oculentis is effective for those patients that are not accepting of dysphotopsia and added: “It comes with the limitation that they often need spectacles for near or (by German law) for driving, by performing a blended vision approach.” For those patients who really want true spectacle independence, Dr. Kretz often turns to the Zeiss portfolio of IOLs. “Currently my favorite option is to place an EDoF IOL (AT LARA, Carl Zeiss Meditec, Jena, Germany) in the distant dominant eye and a trifocal IOL

(AT LISA tri, Carl Zeiss Meditec) in the near dominant eye. That combination provides a full range of vision from distance to near, and a wide range of vision in different intermediate distances from 50 to 100cm. Dysphotopsia occurs less than with binocular trifocals, but still, happens a bit more when compared to rational asymmetric IOLs. “We achieve a high degree of patient satisfaction with that option and a really good outcome,” shared Dr. Kretz. He added that the only limitation to this option is, “if patients do binocular near work, it is difficult, as only the AT LISA tri provides near. In those situations, I like using binocular trifocals.” Dr. Kretz advised not to forget to ask your patients all about their hobbies and activities, because it will really make a difference in achieving a satisfactory result. For example, do they spend time on the glistening water? Or

do they like to be in bright sunlight, or skiing on snowy mountains? As Dr. Kretz has found: “For patients that perform a lot of watersports, like surfing or sailing, etc., I like to provide a trifocal from Belgium-based PhysIOL (trifocal hydrophobic IOL Pod F GF) as it has a blue light filter. And I feel that patients have less difficulties with the light reflections on the water.”

The True Art of Medicine All our experts agree that doing the detective work and figuring out the right IOL for the right patient takes on the true qualities of the art of medicine. Effectively communicating this knowledge to the patient is key to managing post-op expectations.

“There are a lot of options for our patients and we can individually select a lens for them to get the best possible outcome,” concluded Dr. Kretz.

About the Contributing Doctors Florian Kretz is the CEO and medical head of the Augentagesklinik Rheine and Augentagesklinik Greten in NRW Germany. His focus is on cataract and refractive surgery, but he is also treating patients for glaucoma and medical retina. He loves watersports, but his favorite hobby is his job, research and seeing his patients happy and satisfied after their treatments. He and his wife regularly go on philanthropy missions to support and offer free eye care where it is needed. As a medical board member of the Khmer Sight Foundation the couple is currently mainly working in Cambodia. Dr. Kretz’s greatest passion is living in a patchwork relationship with two children and his wonderful wife. [Email: s.wittenbernds@augenklinik.de] Dr Leonard Ang is the medical director and senior consultant ophthalmologist at Lang Eye Centre located at Mount Elizabeth Novena Hospital in Singapore. He has won more than 30 international and local scientific awards, including the Singapore National Academy of Science Young Scientist Award and the Singapore Clinician Investigator Award, and has written more than 90 scientific publications and book chapters. Dr. Ang’s achievements include pioneering new methods for cornea and stem cell transplantation and bioengineering of eye tissues for eye disease treatment. [Email: leopk12@gmail.com] Dr. Chee Soon Phaik is a senior consultant and head of both the Cataract Subspecialty Service and Ocular Inflammation and Immunology Service at the Singapore National Eye Centre (SNEC). She is also professor at the National University of Singapore and Duke-National University of Singapore Graduate Medical School. She serves as the group lead member of the cataract research team at the Singapore Eye Research Institute. She graduated from the National University of Singapore, obtained her master’s degree from the same university. Her research interests in cataract are in managing complicated cataracts such as the dense posterior polar cataract, subluxated cataract & IOL and IOL explantation. She has published over 200 peer reviewed scientific papers and is a member of several editorial boards, including Journal of Cataract and Refractive Surgery. [Email: chee.soon.phaik@singhealth.com.sg]

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Cataract ATARACT Surgery

No Chopper Required New One-Handed Revolving Technique for Soft Cataract Surgery by Konstantin Yakimchuk

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ver the years, cataract surgery has evolved from an original incision with a sharp blade to phacoemulsification and application of intraocular lenses. It has come to the point where several cataract surgical techniques co-exist and are applied, depending on the patient’s case or the surgeon’s individual preferences. A novel approach to soft lens dissection with a phaco tip has been reported in the recent issue of Clinical Ophthalmology1. Dr. Bu Ki Kim and coauthors at the Onnuri Smile Eye Clinic in Seoul, South Korea, have characterized their one-handed surgical method as a safe and effective technique to treat soft cataracts. The method has shown satisfactory results in a large cohort of patients and allowed significant reduction of potential side effects.

It’s All About the Phaco Tip Effective, though not impeccable, phacoemulsification technique is currently the primary choice for cataract removal. More importantly, the ability of a surgeon to divide the hard nucleus is crucial for surgery outcome. Being a standard surgical tool for phacoemulsification, a chopper may damage the anterior or posterior segment, leading to lens’ ptosis. The size of incision for this type of surgery has continuously reduced over time, with phacoemulsification having a small incision of 2.2 mm and even smaller. A smaller cut provides obvious advantages to both the patient and physician. These benefits include faster recovery and easier regulation of intraocular pressure. In addition, according to the authors of the study, the risks of astigmatism, a well-known postoperative condition caused by scleral incision, are significantly

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reduced by the one-handed technique. The literature search reveals several phacoemulsification methods for soft cataracts, which have recently been developed. One of them, a visco-fracture method, implies division of the nucleus and the corneal side port2. Meanwhile, the chip-and-flip technique requires a corneal side port for the second surgical instrument3. In contrast, the one-handed approach of Dr. Kim and co-authors requires only a phaco tip and the initial incision. As stated in the Clinical Ophthalmology report, the one-handed revolving technique for soft cataract extraction begins with an initial 2.8mm long corneal incision, followed by continuous curvilinear capsulorhexis and hydrodissection. The superficial cortex and the epinucleus are taken away after the insertion of the phaco tip into the anterior chamber. In the next steps, the endonucleus and the lens are removed by several rotations of the phaco tip. The remaining lens tissue can be effortlessly emulsified. After the residual tissue

is removed by the aspiration tip, the implantation of the intraocular lens completes the surgery.

No Chopper and Corneal Side Port, Thank You What is so unique about the described technique? In this report, the authors introduced an innovative approach, which both avoids the chopper and maintains high surgical efficiency. In particular, the one-handed revolving technique does not require a corneal side port. Furthermore, the operation does not depend on a second instrument, which might potentially destabilize the anterior chamber or damage the capsule. Avoiding a corneal side port brings several technical advantages for the phacoemulsification method. In particular, according to the authors, the surgeon is relieved from any deep manipulations within close proximity to the posterior capsule. This approach significantly decreases the chances of capsular damage. Besides, the

Could less hands mean more for cataract surgery?

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March/April 2019


researchers claimed that their method helps protect the corneal endothelium as the main surgery is done in the capsular bag. Moreover, astigmatism, as a side effect of phacoemulsification, is observed more often in two-handed methods4. Other studies have shown that in contrast to the two-handed cataract surgery, the one-handed method causes less damage to the cornea and improves clinical outcomes.

Safety and Effectiveness of the Procedure So, how safe is the one-handed revolving technique? Even a surgery with a small incision might have its complications. Among those side effects are corneal edema, rupture of the posterior capsule, moderate to severe iritis and endothelial cell loss. However, Dr. Kim and co-authors reported that their method excludes the risk of posterior capsule damage, since the physician is relieved from deep surgical manipulations close to the capsule. Remarkably, the one-handed technique guards endothelial cells in the cornea from harm, as the surgical procedure occupies the capsular bag. In the majority of phacoemulsification techniques, the nucleus is prolapsed into the anterior chamber. In contrast, the one-handed method does not implement the prolapse, and the nucleus is taken out with capsular support. How effective is the reported technique? Well, the successful surgeries speak for themselves. According to Dr. Kim and co-authors, they have performed more than 1,500 surgical operations and did not observe any noticeable complications.

A Welcome Option for Phaco Surgeons Could this method be considered a panacea for any type of cataract? The authors stated that their method is

The one-handed surgical method has shown satisfactory results in a large cohort of patients and allowed significant reduction of potential side effects.

– Dr. Harvey Uy, M.D., medical director at the Peregrine Eye and Laser Institute in Makati, Philippines primarily suitable for cataracts graded nuclear opalescence or nuclear color 3 or lower, according to the Lens Opacities Classification System III. They pointed out that not only soft, but also moderate and even hard cataracts can be effectively cured by this surgical approach. However, continuous curvilinear capsulorhexis less than 5mm or immobile lens were named as exceptions, which would require a different type of surgical intervention. Are there other advanced phacoemulsification methods that could compete with the reported method? Femtosecond laser-assisted cataract surgery has been shown to be superior to regular phacoemulsification5. In particular, the laser-assisted method has shown better capsular overlap, centration of intraocular lens and has demonstrated shorter effective phaco time.

Dr. Harvey Uy, medical director at Peregrine Eye and Laser Institute in Makati, Philippines, has commented on Dr. Kim and co-authors’ paper: “Their method is a welcome option for phaco surgeons treating less dense nuclei and will benefit those who prefer onehanded, coaxial techniques.” In his opinion, the technique seems easy to learn and has the added advantage of minimizing surgical instrumentation. “Overall, the soft cataract rotation technique appears promising and worth trying out,” concluded Dr. Uy. The development of both effective and safe techniques remains one of the greatest challenges in cataract surgery. Undoubtedly, Dr. Kim and co-authors’ one-handed surgical technique shows highly effective results and has the potential to become the method of choice for soft cataract surgery.

References

Kim BK, Mun SJ, Choi HT, et al. One-handed revolving technique for soft cataract extraction. Clin Ophthalmol. 2018; 12: 2423–2425. 2 Malavazzi GR, Nery RG. Visco-fracture technique for soft lens cataract removal. J Cataract Refract Surg. 2011;37(1):11-12. 3 Fine IH. The chip and flip phacoemulsification technique. J Cataract Refract Surg. 1991;17(3):366-371. 4 Kawahara A, Kurosaka D, Yoshida A. Comparison of surgically induced astigmatism between onehanded and two-handed cataract surgery techniques. Clin Ophthalmol. 2013;7:1967–1972. 5 Mamalis N. Femtosecond laser-assisted cataract surgery: Back to the future. J Cataract Refract Surg. 2019;45(1):1-2. 1

About the Contributing Doctor Dr. Harvey Uy, M.D., is a clinical associate professor of ophthalmology at the University of the Philippines, and medical director at the Peregrine Eye and Laser Institute in Makati, Philippines. He completed fellowships at St. Luke’s Medical Center and the Massachusetts Eye and Ear Infirmary and has been a pioneer in femtosecond cataract surgery, accommodation restoration by lens softening, modular intraocular lenses and intravitreal drugs. He has published over 30 peer reviewed articles and is on the editorial board of American Journal of Ophthalmology Case Reports. He is a former President of the Philippine Academy of Ophthalmology and current council member of the Asia Pacific Vitreo Retina Society. [Email: harveyuy@yahoo.com]

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Cataract ATARACT Pediatric Assessing visual acuity can be difficult in young (and crying) patients.

Saving

Precious Sight:

Cataracts in Infants

by Hazlin Hassan

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ften, cataracts are associated with elderly patients. However, infants can get them, too. In fact, congenital cataract is the most common cause of treatable blindness in children. Both pediatric cataracts and cataracts from aging can cause blurry vision or blindness from a clouding of the lens... but the similarity ends there. One main difference? Treatment. In adults, surgery can often be postponed for years without any ill effects. But in infants, if a cataract is not removed during the first year, the child’s vision will never be fully regained. Children’s eyes continue to develop until around the age of eight to 10 years old, so untreated cataracts can have serious long-term effects on their vision.

Early detection and prompt treatment have significant roles in the restoration of a child’s vision. Otherwise, amblyopia, also known as lazy eye, can occur. This can then lead to other eye problems, such as nystagmus, strabismus, and an inability to fix their gaze upon objects. Ultimately, the condition can have an impact on the child’s learning ability, personality, and even appearance – affecting his or her life forever. In treating infants, it is important to correct aphakia as soon as possible after removing the cataract. Treatment usually involves surgery; and it is imperative that babies with aphakia undergo surgery as soon as possible because their eyes develop very quickly.

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Microphthalmia: Treating Small Eyes Microphthalmia is another eye abnormality that arises before birth, where one or both eyes are abnormally small. In some cases, the eye may appear to be completely missing, but even in these cases, remaining eye tissue is generally present. Severe microphthalmia should be distinguished from another condition called anophthalmia, where no eyeball is formed. Although microphthalmia may or may not result in significant vision loss, patients with microphthalmia may have other eye abnormalities, like cataracts.


Microphthalmia is estimated to occur in 14 per 100,000 infants. Unlike adults with full-sized eyes, treatment of children with microphthalmia requires specialized surgical instrumentation and techniques. A cross-sectional study* entitled “Outcomes of cataract surgery in microphthalmia” was conducted at Al-Ibrahim Eye Hospital, in Karachi, Pakistan, from January 2016 to August 2017, to find out the outcomes of cataract surgery with microphthalmia in children less than two years old. The study included 30 microphthalmic eyes of infants with visually significant cataracts who had cataract surgery without intraocular lens (IOL) implantation. Thirteen had bilateral cataract and four had unilateral cataract. Two patients had posterior synechiae, where the iris adheres to the lens, after three months. “Pediatric cataract surgery is always more challenging than its adult counterpart,” explained Dr. Saima Majid, assistant professor at the Isra Postgraduate Institute of Ophthalmology, Karachi, Pakistan, one of the doctors who conducted the study. “Safety issues arise from the anesthesia to the surgical procedure,” she said. “Regarding safety concerns in microphthalmia, I found them similar as any cataract surgery, and we always weigh the risk against the benefits.” However, Dr. Majid cautioned that there are more chances of synechiae formation and angle closure. “So, formation of anterior chamber and good anterior vitrectomy is required,” she said. “We usually avoid placement of IOL in primary surgery to avoid glaucoma.”

Avoiding Post-Operative Complications The aim of the study was to preclude the development of expected stimulusdeprivation amblyopia because of cataracts, and to avoid major postoperative complications, which can warrant long-term vision surveillance.

[

Microphthalmia is estimated to occur in 14 per 100,000 infants. Unlike adults with full-sized eyes, treatment of children with microphthalmia requires specialized surgical instrumentation and techniques.

“Congenital glaucoma is a relative contraindication, but we usually have to plan surgery due to risk of development of amblyopia,” added Dr. Majid. The study noted that conducting an objective visual acuity assessment was impossible due to dense cataract, young age and poor cooperation of patients preoperatively and postoperatively. Vision was checked using the “central, steady, maintain (CSM)” approach. A dilated fundus examination was done with 20 diopter and indirect ophthalmoscope to rule out post segment abnormalities. For patients with hazy fundus view, ultrasonography was used. The procedure was done using anterior continuous curvilinear capsulorhexis (CCC) by capsulotomy needle; the lens was aspirated with a simcoe cannula. After that, high magnification posterior capsulorhexis was completed with an automated cutter, and anterior vitrectomy was performed. Dexamethasone was injected intracamerally. The results of the study showed no complications during surgery. Patients were prescribed topical steroids postoperatively and called for followups on first and seventh days and at one-month, and three-month intervals. Parents were also counseled about

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corneal suture removal after one month, and IOL implantation at the age of two years. Development of secondary glaucoma after pediatric cataract surgery is an important postoperative complication to consider. It is very difficult to diagnose and treat aphakic glaucoma because these children can remain asymptomatic. In this study, intraocular pressure was taken preoperatively and postoperatively under general anesthesia. The author noted that visual acuity could not be assessed preoperatively due to dense cataracts and early age. “There is a need for longer followup of microphthalmic eye complications after secondary IOL implantation,” shared Dr. Majid. In conclusion, the study suggests that “cataract surgery in microphthalmia is a safe and successful option in smaller eyes and results in better vision after surgery”. It also poses fewer complications such as glaucoma, post synechiae, and visual obscuration. These results led the authors to conclude that “patients with even small eyes should opt for cataract surgery”. *Majid S, Ateeq A, Bukari S, Hussain M. Outcomes of cataract surgery in Microophthalmia. Pak J Med Sci. 2018;34(6):1525-1528.

About the Contributing Doctor Dr Saima Majid is an eye specialist practicing in Karachi, Pakistan, and an assistant professor at the Isra Postgraduate Institute of Ophthalmology. She is a fellow of the College of Physicians and Surgeons Pakistan, and has 13 years of experience. She is also a member of the Pakistan Medical & Dental Council. [Email: doctor.saim@gmail.com]

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March/April 2019

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Cataract NTERIOR SEGMENT Ectasia

Going Under-the-Flap to treat

Early Ectasia with Hyperopic Refractive Error

by Olawale Salami Our early results in combining “femto-LASIK with under-the-flap CXL to treat hyperopic refractive errors in early keratoconus were very encouraging in terms of corneal biomechanical stability and achieving the target refraction. – Dr. Elias Jarade

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n aircraft, flaps are a type of high-lift device used to increase the lift of an airplane wing. They provide the additional lift needed to get the aircraft off the ground. Just like an aircraft, patients want to get up and go following LASIK surgery. After the treatment, they expect to have improved vision and to be able to go back to their daily routine. They don’t want to be held down by postoperative complications. In this regard, surgeons need to help them find their flaps, so to speak. While a recent systematic review of patient-reported outcome of satisfaction after LASIK concluded that majority of patients were satisfied with the result of their LASIK surgery1, a small subset of patients develop postoperative complications; some of which may have significant impacts on vision and quality of life. Although rare, post-LASIK ectasia is a sight-threatening complication2 (occurring in 0.004 to 0.6% of postLASIK patients), in which surgical weakening of the cornea induces thinning and an outward bulging. The bulging is a result of significant alterations in the mechanical structure of the cornea. The result is a cornea that cannot withhold intraocular pressure, and cone formation ensures. Functionally, patients may either experience a myopic or hyperopic shift in spherical equivalence.

In a bid to restore emmetropia in patients with post hyperopic LASIK ectasia, several treatment options have been tried, and there is a shifting interest in the field toward early treatment3. Dr. Elias Jarade and his colleagues at the Beirut Eye Specialist Hospital in Lebanon have discovered a new way of working ‘under the flap’ to restore emmetropia and corneal stability in hyperopic post-LASIK ectasia. In a retrospective study, they assessed the safety, efficacy, and early results of a new combinational treatment for early corneal ectasia with hyperopic refractive error. Their findings were recently published in the Journal of Ophthalmology in a paper entitled “Under-the-Flap Crosslinking and LASIK in Early Ectasia with Hyperopic Refractive Error”4. In this study, the authors included cases with early corneal ectasia plus a major hyperopic component of refractive error (hyperopia, hyperopic astigmatism, and mixed astigmatism), a good corrected distance visual acuity (CDVA), and a clear cornea in a relatively good condition. They also included patients with keratoconus, diagnosed by a combination of computed slit-scanning videokeratography of the anterior and posterior corneal surface, keratometric

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Post-LASIK, patients are eager to get up and go!

March/April 2019

readings, and corneal pachymetry. A total of seven eyes of four consecutive patients (median age 21.5 years: all male) were included in the study. According to Dr. Jarade, “myopic refractive errors in early and moderated keratoconus cases are often addressed by combining photorefractive keratectomy (PRK) with corneal collagen crosslinking (CXL) or by intracorneal ring segment implantation (ICRS), with or without CXL. These two treatment modalities are not applicable in case of hyperopic refractive errors (peripheral ablation with PRK often leads to regression and corneal scar, and ICRS leads to more hyperopic shift). As such, hyperopic refractive errors in keratoconus can solely be addressed either by eyeglasses-contact lenses or by phakic intraocular lens, which are not much desired in case of relatively low refractive errors and relatively shallow anterior chamber in hyperopic cases.” The study results were remarkable. In all eyes treated, ectasia showed no progression over the follow-up period, which ranged from six to 15 months (mean 11.25 months), and uncorrected distance visual acuity (UDVA) improved substantially, changing significantly from 0.35 ± 0.18 logMAR to 0.05 ± 0.07 logMAR (p = 0.017), while CDVA remained relatively stable.


What are the major implications of this study within the current landscape of treating post-LASIK ectasia with hyperopic shifts? Dr. Jarade and colleagues proposed a novel approach toward treatment of mild to moderate hyperopic refractive errors in early stage of keratoconus. “Formerly, such a condition was only to be corrected with eyeglasses or contact lenses, often limiting the patient in his daily life – for example, certain occupations require the individual to be free of eyeglasses and contact lenses, and mainly, if the patient is intolerant to contact lenses.” What about the risks associated with keratectomy? Dr. Jarade noted: “Published clinical results of combining PRK+CXL have demonstrated that the early keratoconus cornea can tolerate a significant amount of central tissue ablation (often limited up to 50 to 60 microns) once combined with CXL.” In addition, he explained that underthe-flap CXL has been proven effective in maintaining corneal biomechanical stability in case of high myopic ablation. “Hence, combining femtolaser-assisted LASIK procedure with under-the-flap CXL seemed to be a safe approach to correct hyperopic refractive errors in early hyperopic keratoconus,” he stated. Femtosecond-assisted flap is more homogenous than the mechanical one and can attain a regular-thin flap in most cases. Estimate central stromal ablation after femto-flap creation is around 50 microns (similar to the amount of central tissue ablation in PRK+CXL), and hyperopic ablation is a peripheral one that does not affect the central stromal thickness. Dr. Jarade added: “Our early results in combining femto-LASIK with under-the-flap CXL to treat hyperopic refractive errors in early keratoconus were very encouraging in terms of corneal bio-mechanical stability and achieving the target refraction. However, cases of epithelial ingrowth were encountered, which most likely were attributed to hyperopic ablation and extended time of flap lifting during the under-the-flap CXL procedure.”

Dr. Jarade provided some important tips for all surgeons who would like to use this technique. He advised them to “exclusively use femtosecond laser to create the flap in order to avoid any irregular flap cut and perhaps a thick area of flap thickness that would imply a deep stromal tissue cut”. He continued, stressing that “using the ‘accelerated’ CXL technique is perhaps better than the conventional method in order to avoid extended time of flap lift to minimize the risk of epithelial ingrowth”. An alternative approach, according to Dr. Jarade, may include repositioning the flap after thorough irrigation of the interface then applying the UV light through the flap, to minimize the risk of epithelial ingrowth and possibly decrease the effectiveness of UV light at deeper tissue under the flap. Furthermore, for surgeons who are willing to adopt this technique, Dr. Jarade highlighted the importance of rigorously following the limitation of central ablation and flap thickness after confirming an appropriate patient inclusion criterion as mentioned in their method section. “We further advise to remain aware of the limitation of the follow-up time. Longer follow-up times will be published soon,” he noted.

The key clinical implication of our study for patients with early keratoconus with hyperopic component is that, if long-term results remain promising, a surgical solution for their refractive error can be proposed, leading to excellent vision without any glasses or contact lenses.

– Dr. Elias Jarade

As Dr. Jarade continues his work “under-the-flap”, he remains hopeful that this new technique will improve patient care in the future. “The key clinical implication of our study for patients with early keratoconus with hyperopic component is that, if longterm results remain promising, a surgical solution for their refractive error can be proposed, leading to excellent vision without any glasses or contact lenses,” he stated.

References

Solomon KD, Fernández de Castro LE, Sandoval HP, et al. LASIK World Literature Review. Quality of Life and Patient Satisfaction. Ophthalmology. 2009;116(4):691-701. 2 Bromley JG, Randleman JB. Treatment strategies for corneal ectasia. Curr Opin Ophthalmol. 2010;21(4):255-258. 3 Kanellopoulos AJ, Binder PS. Management of corneal ectasia after LASIK with combined, same-day, topography-guided partial transepithelial PRK and collagen cross-linking: The Athens protocol. J Refract Surg. 2011;27(5)323-331. 4 El-Khoury S, Abdelmassih Y, Amro M, Chelala E, Jarade E. Under-the-Flap Crosslinking and LASIK in Early Ectasia with Hyperopic Refractive Error. J Ophthalmol. 2018;15:4342984. 1

About the Contributing Doctor Dr. Elias F. Jarade, M.D., is the director of the Corneal, External Disease, and Refractive Surgery Services at Beirut Eye Specialist Hospital. He is a graduate of the Lebanese University Medical School and carries two certificates of fellowship in cornea and refractive surgery from the Eye Center and Eye Foundation for Research, and The Massachusetts Eye and Ear Infirmary, Harvard Medical School. Dr. Jarade is heavily involved in the practice and research of cornea, cataract, refractive surgery for the past 15 years, with main interest in keratoconus. He has more than 50 peer-reviewed scientific papers and chapters. He is also a presenter and an invited faculty in the field of cornea and refractive surgery at international meetings, as well as board member for the Journal of Refractive Surgery, International Journal of Ophthalmology, and International Advisory Board for the Saudi Journal of Ophthalmology. [Email: ejarade@yahoo.com]

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March/April 2019

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Cataract NTERIOR SEGMENT MIGS

A Renaissance in Glaucoma Treatment

The Future Looks Bright for Minimally Invasive Glaucoma Surgery in Asia by Hazlin Hassan

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laucoma is often caused by a buildup of pressure inside the eye, or intraocular pressure (IOP), which causes damage to the optic nerve. Most patients have no early symptoms or pain – but if left untreated, it can cause total permanent blindness within a few years. Sometimes, glaucoma can also be caused by a blunt or chemical injury to the eye, severe eye infection, blocked blood vessels inside the eye or other inflammatory conditions. On rare occasions, an unrelated eye surgery can also cause glaucoma.

A Revolution in Glaucoma Surgery Some of the treatments for glaucoma include prescription eye drops and laser surgery to reduce eye pressure and halt any damage to the optic nerve. Previously, there were limited surgical options for patients with mild to moderate glaucoma, but with the latest minimally invasive glaucoma surgery (MIGS) procedures available today,

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there are a wider range of treatment alternatives for patients. MIGS involves creating a tiny incision to implant a microscopic-sized device, which reduces IOP and slows the progression of glaucoma. The procedure is often touted as much safer, as it causes fewer complications compared to conventional surgeries, and involves a shorter recovery time than more invasive techniques. Some doctors like to start with medications, but early laser surgery or microsurgery may actually work better for some patients, like in babies, for instance, where the cause of congenital glaucoma is a very distorted drainage system. Dr. Chelvin Sng, a consultant at the National University Hospital in Singapore, said she uses a variety of MIGS devices in her practice. These include both iStent trabecular microbypass stent and the iStent Inject from Glaukos (San Clemente, California, U.S.A.), the XEN Gel Implant from Allergan (Dublin, Ireland), and the InnFocus Microshunt from Santen (Osaka, Japan).

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March/April 2019

All About iStent The iStent is a tiny snorkel-like device that bypasses the blockage in the trabecular meshwork to lower and control pressure within the eye. “The iStent has a very high safety profile but is more modest in terms of efficacy, with the IOP-lowering effect limited by the episcleral venous pressure,” explained Dr. Sng. “Hence, it is more appropriate as a phaco-plus procedure in patients with mild-to-moderate glaucoma controlled on medications, who would like to decrease their medication burden after the surgery. The target IOP of these patients should be in the mid-to-high teens. In general, trabecular bypass procedures are not suitable for patients with very advanced glaucoma who are on multiple medications,” she said. Elaborating further on the various options she uses, Dr. Sng said: “These MIGS devices differ in terms of efficacy, anatomical location and safety profiles making them appropriate for different types of patients.”


XEN Implant vs. InnFocus Microshunt

Breakthroughs and Innovation

The XEN Gel Implant and InnFocus Microshunt both use tiny, microscopicsized tubes that can be inserted into the eye and drain fluid from inside the eye to underneath the outer membrane of the eye (conjunctiva). According to Dr. Sng, the most distinctive feature of the XEN implant is that it is implanted ab-interno (from the inside of the eye) through a clear corneal incision, without requiring conjunctival peritomy. “This results in a shorter surgical duration, faster recovery and less complications... for example, bleb leak,” she noted. On the other hand, without conjunctival peritomy, the implant may be frequently occluded by Tenon’s capsule, hence the postoperative needling rate is high, at approximately 30 percent in her practice. In contrast, the InnFocus Microshunt is an ab-externo (from outside the eye) subconjunctival MIGS device, which requires conjunctival peritomy and sub-Tenon’s dissection. Early results have suggested that it can potentially be used for advanced glaucoma, and a randomized controlled study comparing the InnFocus Microshunt with trabeculectomy is currently underway. “In general, subconjunctival MIGS devices are more effective in lowering the IOP compared with trabecular bypass procedures and are able to achieve lower postoperative IOP. However, they are associated with a higher risk profile with potential blebrelated complications, and the surgeon would need to be skilled in postoperative bleb management.” “Appropriate patient selection is key to the success of any glaucoma surgery, and the surgeon must weigh the importance of safety versus efficacy in each patient and select the most appropriate MIGS device,” advised Dr. Sng.

The future looks bright with more breakthroughs to be expected for MIGS. According to Dr. Sng: “There is currently a renaissance in glaucoma surgery, with many novel and innovative devices introduced in recent years. I anticipate that this momentum in innovation will persist, and we will have access to even more devices with better predictability, efficacy and safety profiles in the future.” “Besides new surgical devices, I anticipate that there will also significant progress made in the area of drug delivery, with sustained-release glaucoma medications available which can be administered in the clinic. Such developments will greatly improve patient compliance and quality of life,” she concluded.

Could the Future be XEN? Dr. Cameron Hudson, international director for XEN at Allergan, said that XEN has a number of differentiating properties compared to other glaucoma procedures and devices, and remains the only ab-interno procedure capable of providing subconjunctival outflow. XEN is recommended for the management of refractory glaucomas, including cases where previous surgical

treatment has failed or in pigmentary glaucoma with open angles that proved unresponsive to maximum tolerated medical treatment. “For patients failing on existing therapy, XEN offers powerful and sustained IOP reduction without the need for significant dissection of the conjunctival and other ocular tissues,” explained Dr. Hudson. “Evidence shows favorable visual rehabilitation in patients who have received the XEN device, and compatibility with future treatment options is an area of current investigation where we expect to see further merit of the procedure,” he added. “With the advent of recent devices, XEN included, it’s clear that industry and professional partners share a common goal to make glaucoma surgery safer.” He said that safety is an important goal because around one in five glaucoma patients is poorly served by medical therapies and is progressing due to inadequate IOP control, or is burdened by adverse side effects of drops. What’s clear is that for patients with glaucoma, lost vision can’t be restored. However, lowering eye pressure can help preserve the remaining vision. With the latest in cutting-edge technology in MIGS, patients can look forward to easier, better and safer treatments than ever before.

About the Contributing Doctors Dr. Chelvin Sng is a consultant at the National University Hospital in Singapore, and assistant professor at the National University of Singapore. She graduated from Gonville and Caius College in Cambridge University with triple First Class Honours and Distinctions. A recipient of the Academic Medicine and Development Award, Dr. Sng completed her glaucoma fellowship at Moorfields Eye Hospital, U.K. She has a special interest in the use of glaucoma drainage devices. She is among the first surgeons in Asia to be accredited in the use of several novel micro-invasive glaucoma surgery (MIGS) devices. She was awarded a grant to study the outcomes of MIGS in Asian patients, and has conducted training courses on MIGS at ESCRS and APAO meetings. She is the co-inventor of the Paul Glaucoma Implant, which has attained CE mark and is in clinical use. [Email: chelvin@gmail.com] Dr. Cameron Hudson is the international director for XEN at Allergan. He earned his bachelor’s degree in Optometry at Cardiff University, Wales, U.K., in 2001, and obtained a PhD in Glaucoma at the same university in 2007. He has served on the U.K. national committee of Optometry Giving Sight, a global fundraising initiative that specifically targets the prevention of blindness and impaired vision due to uncorrected refractive error. Allergan plc, headquartered in Dublin, Ireland, is a global pharmaceutical company, which focuses on developing and manufacturing pharmaceutical, device, biologic, surgical, and regenerative medicine products for patients. [Email: Cameron.Hudson@allergan.com]

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March/April 2019

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Cataract NTERIOR SEGMENT Corneal Infections

Unveiling the Great Mas by Gerardo D. Sison III

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he cornea and the eye in general can be a playground for infections. These infections can often go unnoticed, sometimes masquerading as other irritations from different causes. As a persistent public health challenge and source of more serious complications, corneal infections remain a valid concern. Clinically meaningful treatment practices are critical in the fight against rare corneal infections. While discussing various infections and sharing modes of treatment, notable experts assembled at the recently concluded Asia-Pacific Academy of Ophthalmology (APAO) 2019 congress, held in Bangkok, Thailand, for an in-depth review.

Based on a presentation by Dr. Lingyi Liang, Zhongshan Ophthalmic Center Sun Yat-sen University, Guangzhou, China, on “Ocular Demodicosis: Myth or Reality?”

reported mostly in systemic immunecompromised patients,” reported Dr. Liang. “Among the cases of those non-immunosuppressed pediatric eyes, one-third of them had a past history or present illness of chalazion.”

Dr. Lingyi Liang opened up the discussion with ways to evaluate and treat ocular demodicosis, a potentially serious infection. “The Demodex folliculorum mite is, by far, the most common ectoparasite and has been implicated in ocular surface inflammation in adults,” said Dr. Liang. She noted that the infestation of Demodex is largely age dependent, with most infections occurring in the elderly. In line with an epidemiology study reviewed by Dr. Liang based on populations in the Huadu and Zengcheng Districts in China, the prevalence of Demodex infection in children less than 15 years old is 16.3 percent. One question that arose in the study, however, was whether demodicosis plays a role in the evaluation of chalazion. “Pediatric skin demodicosis has been

Demodex Pathogenicity and Infection

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The pathogenicity of Demodex is often debated due to affected patients exhibiting very little or no signs or symptoms. Although ocular demodicosis is often clinically associated with other conditions such as chalazion and meibomian gland dysfunction (MGD), there is no ultimate indication of causation. Furthermore, Dr. Liang shared that humans are the only host of Demodex. Therefore, animal models have not been established for greater assessment. While the pathogenesis of Demodex remains unclear, there are other implications in mechanical damage and immune response. “The mites may act as a vector carrying bacteria, including staphylococci and streptococci,” Dr. March/April 2019

Liang said. “According to an ocular surface study, there were significant changes in bacterial and fungal diversity when comparing Demodex-affected patients and control groups.” Dr. Liang concluded that Demodex infestation is certainly implicated in ocular surface inflammation. “Because Demodex infestation is associated with significant changes in ocular surface microbiota, it can further promote an inflammatory response.” Dr. Liang closed her discussion by cautioning that the interaction between microbiota and Demodex infestation warrants further investigation.

Based on a presentation by Dr. Ka-Wai Kam, Prince of Wales Hospital, Hong Kong, on “Cytomegalovirus Infection of the Anterior Segment” According to a brief overview by Dr. Ka-Wai Kam, cytomegalovirus (CMV) was first identified as inclusion bodies in stillbirths. It was then later discovered in organ transplant recipients and AIDS


squerade

patients with immunocompromised states. Despite these clinical associations, Dr. Kam pointed out that there are several factors that can contribute to an ocular CMV infection. In those with latent CMV from a prior exposure, local reactivation can occur from a variety of triggers. These triggers include the use of topical steroids, topical prostaglandin analogues, ophthalmic surgery, or other drugs, such as cyclosporine, which can cause immunosuppression. Because these triggers are all linked with a less-than-optimal immune state, they can all contribute to serious infection of the anterior segment. “When the virus load exceeds a certain threshold, it may even lead to end organ damage,” Dr. Kam said. “Steroids, especially, can cause disease by lowering the viral load threshold required.”

Prevalence and Treatment of CMV CMV has a higher prevalence in Asian countries due to greater genetic susceptibility and pathogenic strains.

However, between these countries, according to Dr. Kam, clinical features may vary. For instance, clinical features of CMV in Hong Kong are different from those in Japan with a more atypical presentation and greater predominance in females. Diagnosis includes looking for signs such as keratic precipitates and corneal edema usually with an absence of synechiae and epithelial/ stromal keratitis. “CMV anterior segment infection is emerging among immunocompetent adults,” said Dr. Kam. “Therefore, early anterior chamber tap is important for suspicious cases to aid in early detection and management.” He advised that specials can better utilize specular microscopy to document early endothelial destruction. Currently, there is still no consensus on treatment for ocular CMV. In his practice, Dr. Kam recommends topical ganciclovir as a preferred initial treatment because of good tolerability, efficacy, lack of systemic side effects, and lower cost.

Based on a presentation by Dr. Kendrick Shih, Department of Ophthalmology at Li Ka Shing Faculty of Medicine, Hong Kong, on “Management of Non-tuberculous Mycobacterial Keratitis: The Great Masquerade” Nontuberculous mycobacteria (NTM) make up a group of more than 150 species that are broadly distributed in the environment, primarily in soil and water. While human-to-human spreading is rare, infection from NTM is often due to environmental exposure. NTM keratitis encompasses only 0.24 percent of all infectious keratitis. However, it represents up to 47 percent of all post-LASIK keratitis, according to Dr. Kendrick Shih. “What makes NTM dangerous is its rapid growth rate in combination with resistance to standard anti-tuberculous (TB) medications,” added Dr. Shih.

“Rapid growers such as M. fortuitum and M. abscessus account for almost 70 percent of reported cases of NTM keratitis.” He also indicated that those with a history of recent surgery, trauma and/or corneal foreign body, or contact lens and steroid use, are particularly at risk for NTM infection.

NTM Diagnosis and Treatment Strategy Dr. Shih advised watching out for the classic ‘cracked windshield’ appearance with radiating lines from a central infiltrate. However, NTM can also appear as other signs of microbial keratitis, such as infiltrates with irregular outlines and satellite lesions (fungal) or dendritic epithelial defects with stromal infiltrates (herpetic). After a positive result from a corneal scraping or biopsy, Dr. Shih suggested medical treatment with at least two types of antibiotics as first line therapy. These antibiotics can include a combination of an aminoglycoside, macrolide, or fourth-generation fluoroquinolone in topical or systemic form. Although there is no standardized protocol for management in terms of therapeutic agents, duration and mode of delivery, Dr. Shih explained that treatment could continue for up to 30 weeks before resolution. “NTM keratitis of the eye is a rare but potentially devastating disease with variable prognosis due to delayed diagnosis or initial misdiagnosis,” explained Dr. Shih. “Delayed or incorrect treatment and drug resistance can also promote poorer outcomes.” He concluded that a high index of suspicion, timely diagnosis and proper treatment have been shown to be vital in achieving positive visual outcomes. Editor’s Note: The APAO 2019 Congress was held in Bangkok, Thailand, on March 6-9, 2019. Reporting for this story also took place at APAO 2019. Media MICE Pte Ltd, CAKE Magazine’s parent company, was the official media partner at APAO 2019.

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COVER STORY

Something’s Co A Taste of What’s Baking in the Anterior Segment by Brooke Herron

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AKE (magazine) stands for Cataract, Anterior segment, Kudos and Enlightenment, but let’s be honest – the first thing that comes to mind whenever someone mentions ‘cake’ is the kind that we usually get for dessert. As it turns out, CAKE and cake may have more in common than meets the eye. Cake recipes – just like anterior segment surgeries – are complex and precise, following set guidelines and requiring specific ingredients and measurements. For us at the magazine, this delicious similarity is just icing on our proverbial cake. Below, experts from across Asia-Pacific weigh in on the new ingredients and updated baking procedures that are heating up today’s anterior segment surgery recipes.

Fresh Ingredients in DED Treatment

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Conveniently enough, eyes and cake do have one thing in common: No one likes either of them dry. However, resolving the issue of dryness is much simpler with CAKE. Often described as a vicious cycle, dry eye disease (DED) generally involves three key mechanisms: tear film instability or deficiency, hyperosmolarity, and inflammation. While global prevalence rates vary by study, most agree that people of Asian descent experience higher rates of the disease. In fact, the TFOS DEWS II study1 reported a global prevalence ranging from 5% to 50%, finding that “Asian ethnicity was mostly a consistent risk factor”. March/April 2019

Dr. Louis Tong, senior consultant, Cornea and External Eye Disease Service at Singapore National Eye Centre (SNEC), specializes in the ocular surface. He offers dry eye clinics twice weekly, and notes that there’s generally about 20 to 30 patients visiting each clinic. For patients suffering from DED, the disease can have quite an impact on their quality of life. Psychological and physical discomfort aside, there is also an economic burden caused by both medical costs and a loss of work productivity. And when many are suffering from DED, this impact can extend into the community. Treatment is key – however, there is currently no standardized guideline (or foolproof recipe) to reduce signs and symptoms of DED. For many, including


Dr. Tong, treatment for DED begins with artificial tears. However, for moderate to severe cases, additional therapy might be required. Fortunately, now there are additional treatment options to help those patients. For example, to reduce inflammation, topical cyclosporine, diquafosol and lifitegrast eyedrops have shown beneficial results in reducing signs and symptoms of DED. Dr. Tong also mentioned autologous platelet-rich plasma (PRP) treatment, which a recent study found to be effective as monotherapy to reduce signs and symptoms in patients with moderate to severe DED2. During the 2017 study, 368 patients underwent monotherapy treatment with autologous PRP. After six weeks, the investigators found that DED symptoms improved in 322 (87.5%)

Refractive Surgery’s Better Batter

cases. In addition, 280 (76.1%) patients had a decrease in corneal fluorescein staining (CFS), and 106 (28.8%) patients’ best corrected visual acuity (BCVA) improved at least one line. According to Dr. Tong, another ingredient to watch are scleral contact lenses (SCL). A prospective, interventional case series from 2016 found SCL treatment to have a positive impact on tear osmolarity van Bijsterveld score, as well as improvements in the patients’ BCVA, DED symptoms, and overall quality of life3. With more and varied treatment options, comes more potential for relief for DED patients. Depending on whether the case is mild or severe, or if it’s associated with other conditions (like graft versus host disease), it is up to physicians to determine which components to include in the treatment of each patient... or bake the perfect cake.

In the end, they found that “individualized topography-based crosslinking treatment centered on the ectatic cone has the potential to improve the corneal shape in keratoconus with decreased spherical refractive errors and improved visual

Just as different cake recipes vary, so do treatment options and strategies in refractive surgery. CAKE-appointed baker Dr. Jodhbir Mehta, head of Cornea External Disease and senior consultant in the Refractive Service at SNEC, chimes in on some of the fresh ingredients that are spicing up refractive surgery. One is topography-guided cross linking, which – according to a 2016 study – can decrease spherical refractive errors and increase visual acuity4. In this openlabel, randomized clinical trial, investigators assessed the refractive improvements and the corneal endothelial safety of an individualized topography-guided regimen for corneal crosslinking in progressive keratoconus in 50 eyes of 37 patients.

Cooking!

acuity, without damage to the corneal endothelium.” Dr. Mehta is optimistic about this procedure: “While I don’t personally have experience with it, I think it has some potential and should be watched,” he said. Another refractive recipe that’s causing quite a stir is small incision lenticule extraction – or SMILE as it’s commonly known. “There’s a lot of development with SMILE,” said Dr. Mehta. According to a 2018 article published in Clinical Ophthalmology, SMILE or “refractive lenticule extraction is becoming the procedure of choice for the management of myopia and myopic astigmatism owing to its precision, biomechanical stability, and better ocular surface.” While SMILE has a steeper learning curve than conventional flap-based procedures, it shares similar safety, efficacy, and predictability as LASIK and is associated with better patient satisfaction5. In addition, Dr. Mehta shared: “I think over the next few years, we’ll see other players coming into the arena with different machines... and I think that will really ‘spice’ things up.”

The Icing on the Cataract Flour is to cake as intraocular lenses (IOLs) are to cataract surgery – both are ‘essential ingredients’. According to Dr. Harvey Uy, medical director at Peregrine Eye and Laser Institute in

Another ingredient to watch are scleral contact lenses (SCL). A prospective, interventional case series from 2016 found SCL treatment to have a positive impact on tear osmolarity van Bijsterveld score, as well as improvements in the patients’ BCVA, DED symptoms, and overall quality of life.

– Dr. Louis Tong

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COVER STORY the Philippines, trifocal and extended depth of focus (EDOF) IOLs are rapidly becoming the preferred ingredient for presbyopia correction. “Over the past five years, we’ve seen a shift in our premium IOL usage from 100% bifocal IOL implantation to more than 80% implantation of trifocal and EDOF IOL,” he shared. Dr. Uy said there are multiple reasons for this trend. For example, the increasing use of digital devices (like smartphones and tablets) has created a need for optics tailored for intermediate distance viewing. Other reasons include the need for better trifocal optics that minimize multifocal IOL visual disturbances, improved trifocal optical design, and IOL materials that maximize light utilization and visual quality. “Bifocal IOLs will continue to have a niche market, but our operating room ‘pantries’ will have a growing inventory of trifocal and EDOF IOLs,” said Dr. Uy. In baking, adding a new ingredient can cause quite a stir. And in ophthalmology – specifically in the quest for perfection in refractive cataract surgery – Dr. Uy said that two ‘not-so-secret’ sauces have been added to the mix: the incorporation of posterior corneal astigmatism (PCA) during IOL calculation and the use of femtosecond lasers for astigmatism correction. “There is increasing acceptance of PCA measurements for IOL power and position calculations,” said Dr. Uy, explaining that currently, doctors use both 4th generation formulas that account for the effect of PCA (e.g., Barrett and Abulafia-Koch formulas), as well as PCA measurements from biometry devices, like Pentacam (Oculus, Wetzlar, Germany) and IOL Master 700 (Carl Zeiss Meditec Inc., Jena, Germany). “These formulas help minimize postoperative errors of refraction and are very easy to incorporate into daily practice,” he added.

According to Dr. Uy, about one-third of patients have significant astigmatism. To help reduce postoperative astigmatism and improve refractive outcomes, he suggested adding femtosecond laser-assisted cataract surgery (FLACS) topographyguided astigmatism correction. “We currently use the Streamline IV software on a LENSAR (Orlando, FL, USA) machine,” he explained. “The system allows us to directly import topography data from several topographers, and then calculates incision length and location for arcuate incisions that reduce astigmatism.” In addition, the software can also create toric IOL alignment marks (either on the cornea or on the anterior capsule) that the surgeon can follow, which eliminates the need for inkbased marking. “In a recent series, we determined that this system consistently allows us to achieve the predicted amount of residual astigmatism using toric IOL calculators – we save time and achieve spectacular results,” added Dr. Uy.

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Bifocal IOLs will continue to have a niche market, but our operating room ‘pantries’ will have a growing inventory of

trifocal and EDOF IOLs. – Dr. Harvey Uy

Complex Concoctions (and Sophisticated Soufflés) Some cakes are simple, while others (like wedding cakes or a chocolate soufflé, for example) are more sophisticated and difficult to master. The same could apply to surgical procedures. Dr. Mehta detailed one such recipe, which involved the explantation of KAMRA (CorneaGen, Seattle, WA, USA) inlays from three patients. In a March/April 2019

case series published in 2018, Dr. Mehta and colleagues reported that patients developed visual symptoms from the inlays three to six years after KAMRA inlay implantation6. “There are patients who in the past had KARMA inlay insertion under flaps – most of them were performed during clinical trials from 2008 to 2009,” said Dr. Mehta. “Some of these patients have developed a haze around the implants.” All patients reported a decline in distance vision. “To treat these patients and remove some of the haze, we did a double excimer PTK ablation, treating the flap and the base, after implant removal,” shared Dr. Mehta. According to the paper, “six months following explantation, all patients reported improvement in visual symptoms.” “So far, the cases we have done have worked well,” he added. “Hopefully, we won’t have too many with such bad haze!” Dr. Uy also shared his experience with a complicated case: performing FLACS in eyes with small pupils. “We recently encountered a patient with Fuch’s endothelial dystrophy, a brunescent cataract and 3 mm non-dilating pupil. Our plan was to perform FLACS with use of a pupil expansion device,” said Dr. Uy. In addition to standard PHACO surgical instrumentation, he mentioned that they also employed the Beaver Visitec International I-Ring and a FLACS (LENSAR) laser. Just like in baking, this cataract procedure also requires several steps. First, intracameral Shugarcaine, synechiolysis, mechanical stretching and viscodilation were performed. Then, according to Dr. Uy: “If there’s still inadequate pupil dilation, insert the BVA I-Ring via a 2.4 mm clear corneal incision (CCI) into the anterior chamber, then apply to the pupil margins to achieve a dilation of 7 mm.” The ophthalmic viscosurgical device (OVD) is then removed by irrigation and aspiration and replaced


with balanced saline solution (in order to mimic the normal refractive index of the anterior chamber). A safety suture is placed on the CCI. “At this point, the patient is docked to the FLACS machine and the eye is scanned,” said Dr. Uy. Next, a 5.0 mm pupil centered capsulotomy is planned. “It is important to center the capsulotomy on the pupil instead of the optical axis to create a complete capsulotomy,” he added. After laser anterior capsulotomy and lens fragmentation, the eye is brought back to the operating room. The safety suture is removed and PHACO is performed. “The lens softening helps lessen ultrasound energy used in these complicated cases,” noted Dr. Uy. These complicated cases – just like making a soufflé or baking a wedding cake – require precision and skill. And each recipe here needs to be exquisitely executed. From these positive outcomes, to all the emerging and evolving treatment options, the future is certainly looking sweet for both patients and doctors. [Editor’s note: We know we made you think about cake. A lot. We apologize in advance for any broken diets or waistbands.]

References

Stapleton F, Alves M, Bunya VY, et al. TFOS DEWS II Epidemiology Report. Ocul Surf. 2017;15(3):334-365. 2 Alio JL, Rodriguez AE, Ferreira-Oliveira R, Wróbel-Dudzińska D, Abdelghany AA. Treatment of Dry Eye Disease with Autologous Platelet-Rich Plasma: A Prospective, Interventional, Non-Randomized Study. Ophthalmol Ther. 2017;6(2):285-293. 3 La Porta Weber S, Becco de Souza R, Gomes JÁP, Hofling-Lima AL. The Use of the Esclera Scleral Contact Lens in the Treatment of Moderate to Severe Dry Eye Disease. Am J Ophthalmol. 2016;163:167-173. 4 Nordström M, Schiller M, Fredriksson A, Behndig A. Refractive improvements and safety with topography-guided corneal crosslinking for keratoconus: 1-year results. Br J Ophthalmol. 2017;101(7):920-925. 5 Titiyal JS, Kaur M, Shaikh F, Gagrani M, Brar AS, Rathi A. Small incision lenticule extraction (SMILE) techniques: patient selection and perspectives. Clin Ophthalmol. 2018;12:1685-1699. 6 Ong HS, Chan AS, Yau CW, Mehta JS. Corneal Inlays for Presbyopia Explanted Due to Corneal Haze. J Refract Surg. 2018;34(5):357-360. 1

Even More New Baked Goods in Cataract

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n the next five years, according to Dr. Uy, cataract surgery could consistently achieve outcomes similar to laser refractive surgery. And there are certain “baked goodies” that could help optimize results. Treats like improved IOLs made from glistening-free material and with advanced optics will be used to maximize light usage and minimize visual disturbances; while trifocal and EDOF optics will provide good vision at all distances. Multicomponent IOLs with exchangeable optics also look promising: “If there is multifocal optic intolerance or significant refractive error, the optic can be removed and replaced with the optic with the correct dioptric power,” shared Dr. Uy. An IOL that isn’t positioned properly is like a cake baked at the wrong temperature: no good. Dr. Uy said FLACS lasers could optimize toric placement: “Optimal placement

would be based on topography data, which can reduce potential astigmatism from gaps in toric IOL power intervals. Intraoperative surgical guidance can also close the refractive error gaps.” And with wavefront aberrometry, it is important to provide real time intraoperative guidance for IOL selection and positioning. “Postoperative wavefront aberrometry can also be used to guide touch-ups for remaining astigmatism,” he noted. In addition, Dr. Uy said advanced biometry devices could use OCT, total corneal measurements, advanced IOL calculation formulas and artificial intelligence to learn from each refractive outcome. There could also be a sweet spot in error correction: “It may be possible for femtosecond lasers to noninvasively change the refractive index of previously implanted IOLs to correct past and future refractive errors. This exciting research work is being carried out,” he concluded.

About the Contributing Doctors Professor Louis Tong, MBBS(S’pore), FRCS(Ed), DM(Nott), FAMS, PhD(S’pore), is a senior consultant for the Corneal and External Eye Disease Service at Singapore National Eye Centre (SNEC). He also holds adjunct appointments at the Yong Loo Lin School of Medicine, National University of Singapore and the Dukes-NUS medical school, as well as several appointments at the Singapore Eye Research Institute (SERI), heads the Research Training and Development, and the Ocular Surface Research Group. [Email: louis.tong.h.t@singhealth.com.sg]

Dr. Jodhbir Singh Mehta, B.Sc. (Hons.), M.B.B.S., PhD, FRCOphth, FRCS(Ed), FAMS, is head of Cornea External Disease and senior consultant in the Refractive Service at SNEC, as well as deputy executive director at SERI. He is also a professor at Duke-National University of Singapore. [Email: jodmehta@gmail.com ]

Dr. Harvey Uy, M.D., is a clinical associate professor of ophthalmology at the University of the Philippines, and medical director at the Peregrine Eye and Laser Institute in Makati, Philippines. He completed fellowships at St. Luke’s Medical Center and the Massachusetts Eye and Ear Infirmary and has been a pioneer in femtosecond cataract surgery, accommodation restoration by lens softening, modular intraocular lenses and intravitreal drugs. He has published over 30 peer reviewed articles and is on the editorial board of American Journal of Ophthalmology Case Reports. He is a former President of the Philippine Academy of Ophthalmology and current council member of the Asia Pacific Vitreo Retina Society. [Email: harveyuy@yahoo.com]

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UDOS OOKP

Restoring Vision with

‘Tooth in Eye’ Su by Sharon Kleiner

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f you were permanently blind, would you give up a healthy tooth for a functioning eye to be able to see again? Although this may sound like a hypothetical question from the field of science fiction, a complex multi-stage surgical procedure called osteo-odontokeratoprosthesis (OOKP) can actually restore vision in specific patients with severe forms of corneal blindness. Also known as the ‘tooth in eye’ surgery, this procedure may be a suitable choice for patients who are otherwise not candidates for corneal transplantation or other surgical options.

depression, loss of productivity, and a reduction in quality of life. It is often accompanied by an array of social and psychological challenges that place a vast burden on the patients and their families.3-5,17 Hence, the importance of seeking, implementing and improving therapeutic solutions for all forms of corneal blindness cannot be overrated.

Treatment Options

Corneal diseases are one of the leading causes of blindness globally and are among the major causes of irreversible visual impairment.1,2,8,16 Corneal blindness affects people of all age groups and is a considerable ophthalmic public health problem, especially in developing countries.1-3,9 Acquired loss of vision is generally associated with disability,

For patients with irreversibly damaged corneas, corneal transplantation is often the only available treatment for restoring vision. In keratoplasty (KP), the diseased cornea is replaced with corneal tissue from a dead donor, and it remains the treatment of choice for most cases of severe corneal disease. Ideally, KP would be performed in a larger number of patients. Nevertheless, a main problem with corneal transplantation remains the scarcity of good quality corneal grafts.9,11-13 In addition, the varied and complex epidemiology of corneal diseases means that a substantial number of patients with corneal blindness are not amenable to KP.

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The degree of damage to the ocular surface is an important prognostic factor. In eyes with a severely damaged ocular surface, KP failure is considered almost inevitable, as a damaged surface cannot provide sufficient support for the graft. In these patients, using keratoprosthesis (KPro) is the only treatment with a potential of restoring functional vision.1,6,10,16 In KPro, the diseased cornea is replaced with an artificial cornea. Various types of synthetic corneas have emerged and undergone multiple tests and revisions over the past few decades with different rates of success, though the Boston KPro (type I and II) and the OOKP remain the principal models used in practice worldwide.1,6, 14,15 KPro can be divided into two main categories based on the status of the ocular surface, tear film and dryness level of the eye:1,14 KPro designed for eyes with normal ocular surface, intact tear film, eyelids and blink mechanism (i.e., Boston KPro type I); and KPro designed for eyes with severe ocular surface disease, severe dryness or incomplete blink (i.e., Boston KPro type II, OOKP). Main indications for KPro: ff Bilateral corneal blindness ff History of one or multiple corneal transplantation failures with poor prognosis for further donor corneal grafting ff Eye conditions that predict high risk for KP failure ff Patient’s lack of access to donor corneal tissue


Stage 1 of OOKP surgery includes two parts:

urgery

Stage 1A hh The entire ocular surface is removed. hh A full thickness buccal mucosa membrane graft is harvested and prepared. hh The buccal graft is placed over the corneal and sclera surface and then sutured onto the sclera. Stage 1B hh A single-rooted tooth is harvested along with the surrounding intact alveolar bone from the patient’s jaw.

Most KPro devices consist of a transparent central optic held in a cylindrical frame, as a replacement for the diseased cornea. The optical cylinder is supported by a peripheral non-biological skirt, made of an opaque, either porous or hard material (for example, polymethylmethacrylate [PMMA] or titanium in the Boston KPro), which enables fibroblasts cells ingrowth of the host tissue. This design promotes stability through the integration of the surrounding tissue with this part of the prosthesis.14,16

A Tooth for an Eye Osteo-odonto-keratoprosthesis or OOKP is a unique type of keratoprosthesis with a biological skirt, in which an autologous tooth root and alveolar bone are prepared to form a disc-like structure that serves as a carrier for a PMMA optical cylinder. It was pioneered by the Italian ophthalmologist Benedetto Strampelli in 1963, and was later modified by Dr. Giancarlo Falcinelli. Among all models of keratoprosthesis, OOKP is reserved for a minority of patients with bilateral corneal blindness as a result of autoimmune or other end-stage inflammatory ocular surface diseases, for example: StevensJohnson syndrome, Lyell syndrome, mucous membrane pemphigoid, trachoma and massive chemical or thermal burns. This category of eye conditions is characterized by severe chronic dryness and limbal stem cells deficiency that make the management and visual rehabilitation in these patients extremely challenging and difficult.

hh The osteo-odonto lamina is prepared and a hole is drilled for the optical cylinder. hh The PMMA optical cylinder is inserted into the hole and cemented to the dentine of the tooth root. hh The ready OOKP lamina is implanted into a subcutaneous or a submuscular pocket in the contralateral infraorbital area, where it remains for two to three months for vascularisation and integration. Stage 2 is performed two to four months after stage 1, when the buccal graft is well established and vascularised. hh The implanted osteo-odonto lamina is explanted from the subcutaneous or submuscular pocket together with the fibrovascular tissue that formed around it. hh The buccal graft is reflected inferiorly and the cornea is exposed. hh Central trephination of the cornea is performed. hh Iris, lens, and anterior vitreous are removed. hh The implant is sutured over the cornea. hh The buccal mucosa graft is replaced and repositioned over the lamina with a central trephination to expose the optical cylinder.

The efficacy of OOKP in the treatment of severe forms of corneal blindness resides in the unique combination of its components: osteo (bone) – odonto (tooth) – kerato (cornea) – prosthesis (artificial device). As an autologous biologic model of keratoprosthesis, OOKP has the advantage of good biocompatibility with a higher chance for biointegration, long-term anatomic retention and overall functional success. The entire complex is covered by autologous oral mucosa that provides further anchoring and protection and reduces the risk for extrusion and infections. In addition, OOKP does not require the use of systemic immunosuppressive drugs, which can be associated with certain risks and complications.1,7,16,18,19

The multi-stage surgery is performed by a multidisciplinary team of ophthalmologists, oral surgeons and radiologists. Thorough preoperative ophthalmological and oral assessments are necessary in order to evaluate the potential success of the procedure in each patient.1,20,21 Routine post-surgical assessments of the eye are essential to detect any changes or complications, especially laminar resorption, loosening of the optical cylinder, glaucoma, retinal detachment, endophthalmitis or extrusion of the implant. OOKP recipients must commit to lifelong follow-up visits and refrain from activities that can imperil the prosthesis.1,19,21

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UDOS OOKP A Case of a 70-year-old Woman in Israel In 2018, an OOKP surgery was performed in Israel for the first time, at the Rabin Medical Center, Petach Tikva. The patient is a 70-year-old woman who was blind for eight years. She lost her eyesight in both eyes due to severe ocular surface disease resulting from a life-threatening episode of StevensJohnson syndrome. The surgical team included Dr. Eitan Livny (cornea and anterior segment surgeon), Dr. Iftach Yassur (oculoplastic surgeon and the head of the Oculoplastic Service Unit), Dr. Dror Allon (maxillofacial surgeon), and Prof. Irit Bahar (cornea specialist and the head of the Ophthalmology Department). “Our interest in OOKP arose when we had several blind patients who were not amenable to keratoplasty or any other transplantation options,” shared Dr. Livny. Since the procedure has never been done in Israel, the team traveled together to Switzerland several times whenever an OOKP surgery was being performed there in order to learn this unique surgery. According to Dr. Livny: “I traveled together with my colleagues Dr. Yassur and Dr. Allon to Basel, Switzerland, where we studied the technique from our teachers Prof. David Goldblum (ophthalmologist), Prof. Christoph Kuntz and Dr. Isabelle BritBerg (both maxillofacial surgeons), who have years-long experience with OOKP.” The team knew what was required to make the surgery successful. “This is a multi-stage surgical procedure; every stage takes many hours and requires utmost accuracy and focus. It was important for us to gain as much proficiency in every part of the surgery. Our teachers from Switzerland came to Israel to assist and participate in our first surgery in Israel,” added Dr. Livny. So, what is the main advantage of using tooth and alveolar bone tissue to anchor the optical cylinder,

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Although a bone can be used as a biological anchoring substance, the risk of laminar resorption is greater in comparison to dentin found in the tooth – thus using a tooth when available is preferred over a bone. – Dr. Eitan Livny

as compared to using other autogenic tissues such as tibia bone? Dr. Livny explained that it is possible to use any hard biological tissue that would successfully anchor the artificial optical cylinder to its place. “However, the best option is a tissue that can provide a long-term anatomic retention and will last for the lifetime of the patient,” he shared. “Although a bone can be used as a biological anchoring substance, the risk of laminar resorption is greater in comparison to dentin found in the tooth – thus using a tooth when available is preferred over a bone. Whenever a tooth is not available, using bone is an option. A tooth root is a hard and stable tissue and the alveolar bone attached to it integrates well with the soft tissue around the implant, giving the best overall long-term outcomes.”

Pushing Boundaries While Managing Expectations OOKP is a demanding surgical procedure both for the medical team and the patient, and is performed only in a small number of specialized centers in the world. Kudos to the doctors who opt for this surgery because it certainly requires high surgical skills, meticulous preoperative preparation, well-synchronized team

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work, and the ability to tackle predicted and unpredicted complications in a timely and efficient manner. In the same manner, kudos to the patients, too, who must be physically and mentally able to withstand the long process with good attitude and patience, and have realistic expectations of the outcomes. In the end, when all conditions are met, the results can be pleasing and even life-altering for these patients. By regaining the ability to perform activities of daily living independently, recognizing faces, reading signs and experiencing the surrounding sights – a significant improvement in their quality of life can be expected.1,17,19 “In OOKP we aim to reach good functional vision that will allow the patient to perform daily activities without assistance, look after their personal hygiene, watch TV, read and write, recognize faces etc.,” explained Dr. Livny. “We plan in advance to obtain some degree of myopia (minus spectacles) that will increase the peripheral vision. Eyeglasses are prescribed after the surgery.” Almost one year after the OOKP surgery performed on their 70-year old patient, Dr. Livny shared that the patient is doing generally well. “The visual acuity in the operated eye is ~0.3, she is able to watch TV, read and write, recognize faces and perform activities of daily living. She suffered from epiretinal membrane (ERM) accompanied by macular edema about six months after the OOKP surgery, which is a serious complication that can develop following major eye surgeries. This condition required another retinal surgery. But our posterior segment specialist, Dr. Rita Ehrlich, was able to treat it successfully and without any impact on the visual acuity in this eye.” With the success of the surgery, are they planning to perform more OOKP surgeries in Israel in the future? “Yes, we already plan the next surgery to take place in the summer this year,” confirmed Dr. Livny.


Contribution of OOKP in the Ophthalmic World More than 50 years after its first appearance, OOKP remains the KPro of choice for restoring vision in patients with severe forms of corneal blindness not amenable to penetrating KP or other surgical options. Falcinelli’s further modifications and improvements of the original technique (referred to as the ‘Rome-Vienna Protocol’) became the gold standard, as far as visual and long-term anatomical outcomes are concerned. During several decades of clinical experience and follow-up, the superiority of OOKP over other KPro approaches has been supported by numerous clinical and histological studies.1,7,18,20,21 “Without this surgical option we could not offer these patients any therapeutic solution to restore their vision,” confirmed Dr. Livny. “Even though other surgical options do exist, they do not work as well in this specific category of patients. OOKP is still a very complex, long and risky surgical procedure; it is expensive and requires the full commitment of the entire surgical team. While taking these limitations into account, it is currently the most promising surgical option with the best long-term functional and anatomical outcomes for patients with bilateral corneal blindness due to limbal stem cell deficiency accompanied by severe ocular dryness.” Strampelli’s technique presented a creative, complex yet achievable solution for a very challenging medical problem. His innovative, multidisciplinary approach paved the way for ample research in this field and inspired researchers worldwide to investigate and develop alternative biocompatible materials to successfully replace the tooth and alveolar bone in the future.

References

Kaur J. Osteo-odonto keratoprosthesis: Innovative dental and ophthalmic blending. J Indian Prosthodont Soc. 2018;18(2): 89-85. 2 Robaei D, Watson S. Corneal blindness: a global problem. Clin Exp Ophthalmol. 2014;42(3):213-214. 3 Gupta N, Tandon R, Gupta SK, Sreenivas V, Vashist P. Burden of Corneal Blindness in India. Indian J Community Med. 2013;38(4):198-206. 4 Moschos MM. Physiology and psychology of vision and its disorders: a review. Med Hypothesis Discov Innov Ophthalmol. 2014;3(3):83-90. 5 Welp A, Woodbury RB, McCoy MA, Teutsch SM. Making Eye Health a Population Health Imperative: Vision for Tomorrow. Washington (DC). National Academies Press (US); 2016. 6 Liu C, Paul B, Tandon R, et al. The osteo-odonto-keratoprosthesis (OOKP). Semin Ophthalmol. 2005;20(2):113-128. 7 Sarode GS, Sarode SC, Makhasana JS. Osteo-odonto-keratoplasty: A Review. J Clin Experiment Ophthalmol. 2011;2:188. 8 World Health Organisation Visual Impairment and Blindness 2010. Available at: http://www.who.int/blindness/data_maps/VIFACTSHEETGLODAT2010full. pdf. 9 Wong KH, Kam KW, Chen LJ, Young AL. Corneal blindness and current major treatment concern - graft scarcity. Int J Ophthalmol. 2017;10(7):1154-1162. 10 Al-Swailem SA. Graft failure: II. Ocular surface complications. Int Ophthalmol. 2008; 28(3):175-189. 11 Gain P, Jullienne R, He Z, et al. Global Survey of Corneal Transplantation and Eye Banking. JAMA Ophthalmol. 2016;134(2):167-173. 12 Lambert NG, Chamberlain WD. The structure and evolution of eye banking: a review on eye banks’ historical, present, and future contribution to corneal transplantation. J Biorep Sci Appl Med. 2017;5:23-40. 13 Williams AM, Muir KW. Awareness and attitudes toward corneal donation: challenges and opportunities. Clin Ophthalmol. 2018;12:1049–1059. 14 Salvador-Culla B, Kolovou PE. Keratoprosthesis: A Review of Recent Advances in the Field. J Funct Biomater. 2016;7(2):13. 15 Iyer G, Srinivasan B, Agarwal S, et al. Keratoprosthesis: Current global scenario and a broad Indian perspective. Indian J Ophthalmol. 2018;66(5):620-629. 16 Moussa S, Reitsamer H, Ruckhofer J, Grabner G. The Ocular Surface and How It Can Influence the Outcomes of Keratoprosthesis. Curr Ophthalmol Rep. 2016;4(4): 220-225. 17 Seybold D. The psychosocial impact of acquired vision loss—particularly related to rehabilitation involving orientation and mobility. Int Congr Ser. 2005;1282:298-301. 18 Ciolino JB, Dohlman CH. Biologic keratoprosthesis materials. Int Ophthalmol Clin. 2009;49(1):1-9. 19 Tan A, Tan DT, Tan XW, Mehta JS. Osteo-odonto keratoprosthesis: systematic review of surgical outcomes and complication rates. Ocular Surf. 2012;10(1):15-25. 20 Falcinelli G, Falsini B, Taloni M, Colliardo P. Modified osteo-odontokeratoprosthesis for treatment of corneal blindness: long-term anatomical and functional outcomes in 181 cases. Arch Ophthalmol. 2005;123(10):13191329. 21 Hille K, Grabner G, Liu C, Colliardo P, Falcinelli G, Taloni M. Standards for modified osteoodontokeratoprosthesis (OOKP) surgery according to Strampelli and Falcinelli: the Rome-Vienna Protocol. Cornea. 2005;24(8):895-908. 1

About the Contributing Doctor Dr. Eitan Livny currently serves as the head of the Cornea Service Unit at the Department of Ophthalmology at the Rabin Medical Center in Petach Tikva in Israel. He is a senior ophthalmic surgeon with expertise in lamellar corneal transplantation procedures (DMEK, DSAEK), cataract surgery and refractive surgery. He graduated from medical school with honors in 2006 at the Semmelweis University in Hungary. He then completed his internship at the Sheba Medical Center in Israel, and later his residency in Ophthalmology at the Rabin medical center, Israel. He did a fellowship in corneal diseases and transplantation at the Netherlands Institute for Innovative Ocular Surgery with Dr. Gerrit Melles. He has authored and coauthored multiple refereed scientific papers related to cornea and anterior segment research. His works and contributions have acclaimed recognition internationally from honorable ophthalmology experts. [Email: eitanlivny@gmail.com]

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UDOS Women in Ophthalmology

The Importance of

Focus, Passion, and Perseverance Medipol University in Istanbul, Turkey, shared her experiences as a woman ophthalmologist in a largely maledominated industry.

Taking Chances, Breaking Barriers

by Khor Hui Min

A

lthough ophthalmology still largely remains a man’s world, women have been gaining ground in the past decades. Diversity in ophthalmology, not just in gender, but also in race and ethnicity, is encouraged and promoted to reduce disparities in eye care. To truly advocate and empower diversity in ophthalmology, Ophthalmic Women Leaders (OWL) – a non-profit organization for the professional development and advancement of men and women in the eye care industry – has been recently renamed

as Ophthalmic World Leaders. OWL aims to promote and develop diverse leadership to advance ophthalmic innovation and patient care. OWL hosted its annual Signature Events and Awards ceremony at the recent American Academy of Ophthalmology (AAO) 2018 annual meeting, in conjunction with the PanAmerican Association of Ophthalmology (PAAO), at McCormick Place, Chicago, USA. In a session on perspectives in international leadership, Dr. Aylin Kilic, a refractive and cataract surgeon and associate professor of ophthalmology at

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To move forward, and to grow personally and professionally, all it often takes is effort and ability. Sometimes, all it takes is to say ‘yes’ to an opportunity to do something different. According to Dr. Kilic, to be a good clinician, education is very important. “However, if you take a risk, you will learn from experience,” she shared. After she graduated from Hacettepe University, Turkey, in 1998, Dr. Kilic decided to pursue her residency at a private eye clinic instead of a government hospital, as suggested by her family – because, according to her, there she would have the chance to familiarize herself with the latest technology. And she was right. After 10 years, she moved to another state, another risky decision because she had to leave all her cases behind. She started from scratch all over again and began seeing new patients. Two years later, she joined the university so that she could share her knowledge and experiences with a new generation of ophthalmology students. Dr. Killic is a shining example of someone who pursues her passion – a


trait that’s essential for a clinician and researcher. As in every industry, it’s important to keep a balance between the relationships with companies and the obligations to patients. And Dr. Kilic has learned early on to draw a clear line between them. “We should always strive to be positive and honest. If I say something negative, it is because it is necessary to support the industry. But I will say it in a good way. Open discussions are healthy and beneficial for the industry,” added Dr. Kilic.

The Right Focus Can Make All the Difference Dr. Kilic, who has completed more than 55,000 procedures, certainly knows a thing or two about focus. Whether she is working in Turkey or with the International Society of Surgery, there are times she is so focused on what she’s doing that she doesn’t realize

she’s the only woman in the group. “Sometimes, I don’t notice that I’m the only woman in the group, until I see the group photos. I think there is really no difference,” she shared. Her candid sharing was greeted with cheers from among the audience. With her focus solely on work, and not on her gender, in a largely maledominated area of expertise in her country, Dr. Kilic was able to achieve phenomenal professional growth and success. “In my center, I had a good data pool, and I was able to analyze this data and publish papers. Working in a private center made it easier for me to manage the data,” she said, adding that she has also educated her staff to record data from patients. She added that most of the time, people were expecting a Turkish man as the author of the papers she wrote, and they were surprised to learn that she’s

a woman. Dr. Kilic has since published many articles and delivered more than 200 presentations, both nationally and internationally. “They had to choose someone from Turkey. With my published papers and experience, I was selected. Maybe that’s why I didn’t feel different as a woman,” added Dr. Kilic. Dr. Kilic has published multiple books, and has garnered multiple awards, including the Achievement Award from the AAO in 2010, Lans Award in 2016, ISRS Recognition Award in 2017, and the Senior Achievement Award in 2018. Editor’s Note: The Ophthalmic World Leaders (OWL) Signature Event and Awards Ceremony at the American Academy of Ophthalmology (AAO) was held on October 28, 2018, in Chicago, Illinois. Reporting for this story also took place at the AAO 2018.


NLIGHTENMENT Case Publication

Spotting a Publishable

(. . . And

by Tan Sher Lynn

C

ase reports have been published in medical literature for decades. By providing new ideas in medicine – and with a high sensitivity for detecting novelty – case reports remain a cornerstone of medical progress.* During a presentation at the All India Ophthalmology Society-Young Ophthalmologists Society of India (AIOS-YOSI) forum in New Delhi, Dr. Vinod Agarwal reiterated that case reports are one of the oldest ways of medical reporting. “Case reports also serve as ‘primers’ leading to new discoveries, such as the development of AIDS, which is a case report of Kaposi Sarcoma in young homosexual males,” said the Mumbai-based surgeon. Another example: The Zika virus outbreak was announced by a case report. Dr. Vinod Agarwal continued: “Case reports of adverse drug reaction form a fundamental part of pharmacovigilance – for example in the Thalidomide tragedy, the link between malformed limbs in babies and a sleeping pill was first suspected by a case report.”

Functions of a case report: 1. Presents unique or rare features of a disease

Is It a Publishable Case?

2. Provides unexpected associations between diseases or symptoms

Dr. Vinod Agarwal noted that it’s difficult to know upon the first interaction whether a case is publishable or not. “You will only know when the progression of the disease is complete. So, by the time you know, it’s often too late as the patient is ‘lost’ and/ or the condition of the disease has changed. Hence, the prerequisite for a case report is good documentation at baseline,” he said. Dr. Vinod Agarwal shared that when he was a resident, he published his first case report by capturing a

3. Describes the mechanisms or pathogenesis of diseases 4. Offers new therapy options 5. Details unexpected outcomes or side effects of drugs or treatment 6. Creates an important platform for medical education

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Most importantly, he emphasized that case reports are a platform for training in scientific writing and critical thinking.

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photo of a patient with dengue fever and bilateral periorbital ecchymosis in the consultation ward with his mobile phone (one of the early Nokia versions). “Today, you can use high-tech devices to photograph things which are otherwise un-photographable, like vitreous base avulsion – which I could not find a single photograph of in the literature. You should also take photos even if it’s a common condition. Whenever you see a good case, you should take a photograph. Even the best of cases cannot be published without good documentation,” he shared. Follow-up is also a must. “Patients should be traceable. So, develop good rapport with the patient,” he said. In addition, Dr. Vinod Agarwal noted that clinicians should look for


Case

Working on It!)

Key Takeaways from Dr. Aniruddha Agarwal: 1. Look for accuracy – Verify your conclusions with colleagues or mentors. Writing a paper is teamwork – you shouldn’t draw conclusions on your own. 2. Look for novelty – You need to verify (with the literature) whether what you are writing has already been published or not. 3. Focus on a single aim in the study. Most journals require easyto-read studies that most readers can follow. 4. Do not be journal-focused – Readers typically focus on the article of their interest rather than the journal. Most seek quality information and would typically browse the internet to find the article that interests them. Some of the best articles are published in small journals which are not indexed. On the other hand, do not submit your paper to multiple journals, and avoid those that are predatory. 5. Summarize your results wisely – Understand the scope and limitations of your investigation. Ensure that whatever observations you are providing solve the hypothesis that you are proposing at the beginning of the paper. 6. Do not format your paper – There isn’t a need to underline or change your fonts, set up margins, etc. It will be a waste of time as each journal will require you to format your paper according to their requirements when it is accepted. 7. Use reference managers – Reference managers like Zotero and EndNote will make the process of writing a scientific paper much easier. 8. Keep plagiarism to less than 12% – Check your manuscript with plagiarism software available in libraries. 9. Get approval from everyone involved – Circulate your manuscript among your colleagues and co-authors and obtain their comments.

what is different in each case: “The inherent vast nature of medicine makes finding differences relatively easy, since no two cases behave similarly in the long run. So, by following up with the patient you could find novelty or an unusual outcome,” he added. Dr. Vinod Agarwal shared a case of a patient with a fungating mass in the eye. Upon closer inspection, maggots were found crawling in the eye – and he subsequently extracted 50 to 60 of them. Later, the patient was found to have developed invasive basal cell carcinoma. The case was published after two years. “A deviation from routine provides an opportunity for publication as well. When you have a relatively rare condition, do something extra – do a literature search and call the patient

back. The literature search is of the utmost importance. What may appear common, can have scarce publication,” continued Dr. Vinod Agarwal. “Last but not least, even if your case is not accepted by one journal, do not let the rejection demotivate you. Keep trying with other journals. Remember that a large number of cases we see are publishable; good documentation and follow-up is a must; good knowledge of the subject is always handy; and try to think out of the box,” he concluded.

A Case of Art & Science “Writing a paper is both an art and a science,” said Dr. Aniruddha Agarwal from Chandigarh, India. He stressed that as an ophthalmologist, writing

papers is equally important as seeing and managing patients. “There are multiple reasons for this – writing a paper is not just for documentation, but has the potential to change the management of several patients,” he noted. The first step, according to Dr. Aniruddha Agarwal, is to organize the data and look for the best representative cases. “With the data from those cases, you’d know exactly what you’re dealing with and would be able to come up with a preliminary conclusion or working hypothesis,” said Dr. Aniruddha Agarwal. “This is the most important stepping stone to begin writing a paper, and opposite to the conventional approach of starting with the introduction.”

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NLIGHTENMENT Case Publication Steps to writing a paper, by Dr. Aniruddha Agarwal: 1. Organize your data, demographics and figures. 2. Draw preliminary conclusions and a working hypothesis; do a preliminary literature review. 3. Work on your methods. 4. Write down your results and choose the best representative cases. 5. Write the discussion, extensive literature review and bibliography. 6. Write the introduction. 7. Finish off with the abstract, title page and keywords.

Next is the methodology. “Describe how you went about analyzing your representative cases, which may be single or multiple cases, or different sets

of data. Define patient recruitment and chronology. You should provide enough information without being too detailed,” he explained. “It’s good to organize your results into headings and subheadings, declutter and give limited information.” “In the discussion, limit yourself and do not come up with new or unnecessary statements that are not part of your study. In the bibliography, avoid excessive self-citation as doing so means that you don’t know what’s going on in literature. This will be taken into account when your paper is under review,” advised Dr. Aniruddha Agarwal. As opposed to traditional writing, in medical reporting, the introduction is the least important part of the paper. “Keep it crisp and concise and limit it to one (or less than one) page preferably. Avoid unnecessary lengthy prologues,” said Dr. Aniruddha Agarwal. “Then finish off with the abstract, title page and keywords,” he continued.

Keywords are very important – your manuscript is only going to come up in the internet search according to the keywords you entered. “The title page is a very sensitive part of the paper as it contains info like authorship,” he said. “As a beginner, you must be absolutely sure that all authors [co-authors and corresponding authors] are on board. Remember to acknowledge all who have directly or indirectly contributed to the case,” he concluded. * Vandenbroucke JP. In defense of case reports and case series. Ann Intern Med. 2001;134(4):330-334.

Editor’s Note: The AIOS-YOSI’s “Young Ophthalmologist – The Way Ahead” Forum was held on 25 November 2018 in New Delhi, India. Reporting for this story also took place at the AIOS-YOSI Forum.

INDUSTRY UPDATE

Making Cataract Surgery Safer and Simpler with Medicel

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ataract is a leading – yet preventable – cause of blindness in India. This can be partly attributed to cost, and therefore a way to lower this barrier is necessary to reduce the disease burden. Fortunately, companies like Medicel are creating high-quality, single-use surgical instruments to make this vital procedure safer, simpler – and more economical. The company offers a complete range of sterile-packed, intraoperative single-use instruments for cataract surgery, made to the same high standard of more expensive, multipleuse ones. Medicel also has both reusable

and multiple-use instruments in its range, and all the products are compatible with most surgical equipment. The company notes that the instruments help facilitate traditional surgery techniques, including the bimanual and coaxial techniques in micro-incision surgery – with the goal of keeping the incision as small as possible. Their product catalog includes IOL injection systems; irrigation/aspiration handpieces; phaco accessories and cassette systems; trocar systems and DMEK (Descemet’s membrane endothelial keratoplasty) injectors. The instruments can be used in both

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cataract and vitrectomy surgeries. In addition, Medicel has set new benchmarks with its lens injections systems: More than four million IOLs are implanted annually with their system. In the future, the company plans to transform the market by continuing to develop innovative products to help surgeons to perform safer and more efficient surgeries. Medicel is a subsidiary of Halma, a public company and leading safety, health and environmental technology group, and has been providing products to Indian customers since 2004. For more information visit, www.medicel.com


April 22 - 26, 2020


NLIGHTENMENT Conference 101

Attending International Conferences

Tips for Young Ophthalmologists

by Tan Sher Lynn s any veteran attendee knows, strategic planning is key to making the most of both the scientific program and networking opportunities offered by international conferences. To help new attendees better plan their time during conferences, Dr. Diva Kant Misra, a vitreoretinal surgery fellow at Sri Sankaradeva Nethralaya in Assam, India, explored this topic at the recent India Ophthalmology SocietyYoung Ophthalmologists Society of India (AIOS-YOSI) forum in New Delhi.

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Why should I attend international conferences?

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There are many reasons to attend international conferences. Among them, according to Dr. Misra, is the opportunity to gain an international perspective. “You can be informed of the latest research and interact with the latest innovators,” he explained. “You get a chance to contribute your research at an international level, and there will be chances for future international collaboration.” March/April 2019

These conferences do not only provide a wealth of information, they also offer an excellent platform for global networking. “Networking isn’t just reserved for business executives. We, as clinicians and academics, should network as well,” said Dr. Misra. “Moreover, conferences offer a great opportunity to meet the masters and learn from them directly. If you are lucky, you can even find a guru among them.” In addition, conferences present an opportunity to grow professionally and personally: “Presenting your


research in international conferences reflects well in your résumé. If you receive awards and grants, they add to your credentials. Finally, the by-product is that you get to travel,” he added.

Which conferences should I attend? With so many conferences happening around the world, it can be difficult to decide which will be the most beneficial. For young residents, or ophthalmologists without a determined subspecialty, Dr. Misra advised to focus on large, general conferences, instead of subspecialty conferences. “A good option would be the AsiaPacific Academy of Ophthalmology (APAO) congress, which has great scientific content and offers travel grants,” he shared. However, Dr. Misra also warned about “predatory” conferences and recommended avoiding them. “These conferences are not organized by scholarly societies, but by revenueseeking companies. They exploit the researchers’ need to build vitas with conference presentations and papers in published proceedings or affiliated journals, with zero peer review process,” he said, noting that a list of predatory journals can be found online by searching for Jeffrey Beall’s website.

How should I prepare for a conference? Careful planning – both on the conference details and travel arrangements – is vital. “Awareness is key,” said Dr. Misra. “Be aware of deadlines for registration and abstract submission.” He recommended having the conference program book as your ‘bible’. “Even though it’s huge, you should read it properly from the very first page to the last. Jot down relevant points and tick the sessions you want to attend,” he emphasized.

It's never too early to plan your congress strategy.

Attendees should also research travel arrangements and plan ahead: “Be a smart traveler – prepare your visa, ticket and currency; learn about the place you are going to through websites like TripAdvisor; learn the local language; and respect local culture and rules,” said Dr. Misra. To maximize your time and effort, Dr. Misra advised not to mix business and leisure: “Separate the days for attending the conference and for personal travel. Do not just attend a session that you want and leave after that.”

How can I fund the trip? Attending conferences can be a financial burden. Therefore, Dr. Misra suggested that young ophthalmologists should go to their institutes for financial support. He shared that his institute, Sri Sankaradeva Nethralaya, helped him considerably in his endeavors. “The university attached to your hospital or institute might also help. Associations like the All India Ophthalmological Society (AIOS) offers travel grants based on your thesis,” he explained. “Conferences like APAO, the Asia-Pacific Vitreo-retina Society (APVRS), and the Association for

Research in Vision and Ophthalmology (ARVO) offer travel grants as well. You should definitely apply for them.” There are a few requirements to apply for travel grants. “Usually, they require a biography of 250 words, where achievements, charities, and public services should be highlighted,” he said, advising to be clear on how the knowledge gained by attending the conference will be applied. “If you are interested in research, a big conference to attend is ARVO – which offers many travel grants. The information is listed in their website with very specific criteria,” he shared. “The Bernadotte Foundation for Children’s Eyecare Inc. (Florida, USA) also gives international travel awards for research and conferences related to retinopathy of prematurity. In India, certain government bodies, like the Science and Engineering Research Board, give out grants as well,” said Dr. Misra. Editor’s Note: The AIOS-YOSI’s “Young Ophthalmologist – The Way Ahead” Forum was held on 25 November 2018 in New Delhi, India. Reporting for this story also took place at the AIOS-YOSI Forum.

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CONFERENCE HIGHLIGHTS AAO 2018 Coverage

In Case You Missed It

Refractive e-Poster Highl by Brooke Herron

The American Academy of Ophthalmology’s (AAO) 2018 annual meeting was held in Chicago, Illinois, U.S.A., from October 27 to 30. Below, we detail some of the intriguing posters in refractive surgery from this prestigious meeting.

Femtosecond-Assisted Crosslinking vs. Conventional Crosslinking

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rosslinking is a hot topic in refractive surgery these days. To prove that deeper cross-linking (CXL) better dampens keratoconus, Dr. Lional Raj D. from Dr. Agarwals Eye Hospital in Tirunelveli, India, compared femtosecond-assisted crosslinking (FC) with the conventional CXL (CC). Twenty-five eyes underwent FC, while 22 underwent CC. Vision, pachymetry, maximum keratometry (K-max), simulated keratometry (SimK), and the anterior segment OCT-derived demarcation line (DL) were analyzed at one year. At follow-up, vision improved 2 lines in the FC group and 1 line in the CC group. Pachymetry was maintained in FC eyes, while it dropped 28 microns in CC eyes. The corneas were flattened in both groups. The FC group’s astigmatism was reduced by 0.31 diopters (D), and in the CC group it increased by 0.27D. Regarding the DL, it was 393 microns deep in FC eyes and 243 in CC eyes. There were no endothelial changes noted. These results led the author to conclude that “femto-laser assists

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Don’t leave your head buried in the sand – check out what you missed at AAO below.

deeper crosslinking than conventional procedures, favoring an effective stabilization as proof of ‘the deeper, the better’ concept”.

Achieving Perfection with Multicomponent IOLs Today, advances in intraocular lens (IOL) technology allow surgeons more flexibility to enhance patient outcomes and visual acuity. For example, multicomponent IOLs (MC-IOLs) allow for refinement after cataract surgery through surgical exchange of its refractive components. To determine the safety and consistency of these lenses, Dr. Harvey Uy, medical director at Peregrine Eye and Laser Institute in Makati, Philippines, presented results of refractive enhancements on eyes that received MC-IOLs after cataract surgery. Three months following the primary surgery, 50 eyes with a manifest refraction spherical equivalent (MRSE) greater than 0.75D underwent enhancement. During the procedure,

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the primary front IOL optic was replaced with a new front optic with the corrected refractive power. The main outcome measures were three-month post-enhancement unaided distance visual acuity (UDVA) in logMAR, MRSE change and adverse events. Following the procedure, the mean (SD) preoperative UDVA of 0.2 (0.15) logMAR improved to 0.0 (0.07), (P= .008). The mean pre-enhancement MRSE decreased from +1.4 (0.9) D to +0.1 (0.4) D, (P= .0002). All eyes had a UDVA of 0.1 or better, and no significant adverse events occurred. This led Dr. Uy to conclude that “MC-IOL enhancement is a safe and consistent method of refractive enhancement that enable cataract surgeons to optimize outcomes”.

Enhancement Options Following SMILE Following any refractive surgery, its possible enhancements might be necessary to optimize visual outcomes. In this poster, Egyptian cornea and


lights from AAO refractive specialists Drs. Moones Fathi Abdalla and co-author Osama Ibrahim evaluated different techniques for enhancement following small incision lenticule extraction surgery (SMILE). Four techniques were used: PRK, flap creation (off-label); circle option, flap creation; capless/cap-preserving re-SMILE (off-label); and sub-SMILE retreatment (SMILE at a deeper level, off-label). This retrospective assessment looked at retreatment cases from more than 10,000 eyes. The authors mandated that time between the primary and retreatment surgeries was at least three months. In all, five eyes underwent PRK, two eyes with new flap creation, three eyes had the circle option, four eyes were capless, and three eyes had the sub-SMILE treatment. Following retreatment, surgical challenges, visual recovery, and visual outcomes were assessed. The authors found that all modalities had minimal surgical complications. And while visual recovery varied widely between the groups, at one-month follow-up all cases showed excellent visual outcomes. This led the authors to conclude that “Retreatment for SMILE visual outcome is very promising if it’s taken into consideration that it is case-specific and that every technique has its indications”.

Managing Complications in SMILE This retrospective review of consecutive case series reported complications associated with the SMILE procedure.

Along with colleagues, Dr. Arturo J. Ramirez-Miranda, assistant professor of ophthalmology in cornea and refractive surgery at Instituto de Oftalmologia Conde de Valenciana in Mexico City, looked at 460 eyes of 231 patients, with a mean follow-up time of 72 months. Including the surgeons’ learning curve cases, they found that 7% had complications. These included: epithelial defect, suction loss, opaque bubble layer, cap rupture, lenticule rupture, interface haze, residual refractive errors, and infectious keratitis. The low complication rate led the authors to conclude that “while SMILE complications can occur, most are related to inexperience and are included in the learning curve of the technique, with favorable resolution, because the majority of them are mild and have no lasting effect on the patient’s final visual acuity”.

Does Bowman’s Layer Influence Corneal Biomechanics? A recent study by Dr. Emilio A. Torres Netto and colleagues at the University of Zurich, Switzerland, tested the biomechanical properties of Bowman’s layer (BL) in healthy ex vivo human corneas using stress-strain extensometry. The investigators obtained 26 corneas following Descemet membrane endothelial keratoplasty, and separated them into two groups. In group 1, the BL was ablated (20µm thick, 10mm optical zone); in the second group the BL was left intact. In both groups, a 110µm thick lamella was cut and elasticviscoelastic properties were analyzed.

During pre-conditioning and destructive testing, no significant differences in the elastic modulus was noted between groups. Additionally, no significant differences were found in relation to stress. Therefore, the authors determined that the presence or absence of the BL did not alter the stiffness of a 110µm cornea lamella. “These results may have implications, not only in refractive laser surgeries, but also for Bowman layer transplantation in keratoconus,” concluded the authors.

Protecting Diabetic Patients Against Macular Edema This prospective, interventional study assessed the efficacy of phacoemulsification combined with intravitreal bevacizumab in diabetic patients without macular edema as a prophylaxis against developing the condition postoperatively. In this study by Drs. Ashraf H. El Habbak and co-author Mohammed Awwad from Benha University in Egpyt, 100 eyes of 65 patients were randomly split into two groups: 50 eyes in Group A underwent phacoemulsification alone; and 50 eyes in Group B received combination phacoemulsification and intravitreal bevacizumab. Patients were followed-up for one year – during these visits, central macular thickness (CMT) was recorded using OCT. The end of the third follow-up month saw significant CMT increases in Group A, from 167.58 ± 7.36mm preoperatively to 208.56 ± 25.99mm (P< .005). No significant changes were found in Group B, from 165.86 ± 6.89mm preoperatively to 160.12 ± 4.48mm (P> .005). This led the authors to conclude that the “use of intravitreal bevacizumab combined with phacoemulsification protects against the development of macular edema in diabetic patients without diabetic maculopathy”.

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CONFERENCE HIGHLIGHTS APAO 2019 Coverage

New Developments in

Cataract Surgery Pharmacology by Khor Hui Min

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eld from March 6 to 9 at the Queen Sirikit National Convention Center in Bangkok, Thailand, the 34th Asia-Pacific Academy of Ophthalmology (APAO) 2019 Congress was all about exciting new developments, diagnostics and treatments in eye care. During the four-day event, interesting symposiums and sessions were held – and among the highlights, as usual, were the cataract symposiums. At the symposium on Cataract Surgery Pharmacology – chaired by Assoc. Prof. Steve Arshinoff, Dr. Tat Keong Chan and Assoc. Prof. Pipat Kongsap – major topics pertaining to pharmacology agents commonly used in cataract surgery were discussed, including preoperative ocular antisepsis, intracameral antibiotic endophthalmitis prophylaxis, intracameral mydriatics, and perioperative use of corticosteroids and their risks and side effects. In addition, the role of nonsteroidal anti-inflammatory drugs (NSAIDs) and the results of the landmark clinical trial on cystoid macular edema (CME) prophylaxis (PREMED) were presented.

New Risk Factors for Steroid Response Prof. David Chang, an internationally recognized cataract sub-specialist and founder of the Peninsula Eye Surgery Center in California, USA, presented a study on risk factors for steroid response among cataract patients. “The take home message from the study was that there are two new risk factors for steroid response: a higher axial length (AL) myopia and a younger age. This was the first study that showed age was a risk factor with topical steroids, as other studies focused on intravitreal steroids.” Prof. Chang

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warned that in the combined group (less than 65 years old, and over 29.0 AL), people can experience a high intraocular pressure (IOP) spike. “Sometimes it’s symptomatic. People would come in and say, ‘when I bend over, suddenly I can’t see’. The pressure can really go up,” said Prof. Chang. “As we move to sustained release or post-op steroids, at least in the US, the theoretical benefits of biodegradable intraocular drug delivery include steady pharmacokinetics, with high, consistent and prolonged delivery, short duration, and avoidance of systemic absorption.” He added that a huge advantage will be patient compliance, because it will be more convenient for people. “There will be less chair time, when traditionally, we had to provide instructions on application of medications,” he shared.

Intracameral Dilation Made Easier The next speaker, Assoc. Prof. Steve Arshinoff from the University of Toronto, spoke on intracameral dilation for cataract surgery. He reported that intracameral Xylocaine-Phenylephrine (IC XYLO-PHE) not only makes surgery easier – it also has a well-documented and tried literature history of safety and efficacy. Also, IC XYLO-PHE is a lower dose, which is safer than 1.5% phenylephrine. “This is one of the few places in medicine where we’ve had a cure before we’ve had a disease, because the use for it didn’t come out until recently. Why does IC XYLO-PHE work so well? It’s because the Xylocaine paralyzes the sphincter, while the Phenylephrine aggressively stimulates the dilator. It maximally enhances iris tone, it’s great for all cataract cases, it’s adequate for 90+% IFIS cases, and it’s safe,” explained Prof. Arshinoff.

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What’s New in Ocular Antisepsis? Assoc. Prof. William Myers from Northwestern University in Chicago, Illinois, US, was up next to talk about the latest in ocular antisepsis. He discussed disinfection rate versus disinfection capacity and the current standard of care. He also touched on testing the worst-case scenario methods and results. He ended his presentation with a consolidated theory – medium dose (0.7-5%) of povidone-iodine (PVI) for initial surface prophylaxis, and low dose (0.25-0.025%) should be applied frequently throughout surgery. “A medium dose of 0.7% would be enough to reduce even a clinically or just barely sub-clinically infected eye to adequate levels. So, what I would propose is that we use medium concentration of between 0.7 and 5%. For practical purposes, I use 1%,” explained Assoc. Prof. Myers.

Which IC Antibiotics to Use? In the subsequent presentation, Assoc. Prof. Steve Arshinoff took to the stage once again, this time to present the different IC antibiotics available. He discussed techniques to prevent postoperative endophthalmitis, which include preoperative betadine, tight wound closure, pre- and postoperative optical antibiotics and intracameral antibiotic injection as the final step of surgery. He also discussed the bactericidal efficacy of intracameral drugs, as well as issues with different antibiotics, such as vancomycin, cefuroxime and moxifloxacin. “Moxifloxacin appears to be the safest and most effective IC antibiotic for POE prophylaxis. Vancomycin and cefuroxime appear less effective


“There is a great need for a preservative-free, pre-mixed, unit dose antibiotic for intracameral injection in the US and other countries. At present, there are no FDA-approved antibiotics for the indication of endophthalmitis prevention. Ongoing clinical trials are planned in the US,” he added.

due to (injected dose/MIC) ratios and time dependence. At least 0.5 mg moxifloxacin should be injected, preferably diluted to exchange aqueous with injection, to get the drug to stay in the eye,” said Assoc. Prof. Arshinoff.

Prevention of Cystoid Macular Edema

Reducing Endophthalmitis Dr. Haripriya Aravind from the Aravind Eye Hospital in Chennai, India, presented on intracameral moxifloxacin for endophthalmitis prophylaxis in cataract surgery. The Aravind Eye Care facilities encompass seven tertiary care centers, six secondary centers, six outpatient clinics, and 57 primary centers. “We started using intracameral moxifloxacin in 2014. At that time, we had concerns about the volume, the different locations and ensuring the right dose in all the patients. That’s when we started making our own intracameral moxifloxacin,” shared Dr. Aravind. “Why moxifloxacin? Because we saw few reports of endophthalmitis prophylaxis – and this was a point of concern. The intracameral moxifloxacin is ready to use, and no mixing or dilution is required. It is available in 1ml vials and each ml contains 5mg of moxifloxacin –0.1ml is injected into the anterior chamber (AC) at the end of the surgery. The dose of 0.5mg/0.1 ml was based on calculations targeting concentration that would exceed the minimum inhibitory concentration (MIC) for bacteria,” she added. Dr. Aravind emphasized careful attention to sterilization and aseptic

Could pre-mixed antibiotics prevent toxicity?

protocols. She found there was a threeto four-fold reduction in endophthalmitis with the use of IC antibiotics, and this was effective in manual smallincision cataract surgery (MSICS) and phacoemulsification (Phaco). This is recommended for higher risk eyes experiencing posterior capsule rupture with vitreous loss.

Intraocular Drug-related Complications Dr. Tat Keong Chan, from the Singapore National Eye Centre (SNEC), spoke on intraocular drug-related complications and learning from past lessons. “Intracameral antibiotics have a long track record and are highly effective in preventing endophthalmitis. However, toxicity can result from improper mixing of these antibiotics for intracameral use,” explained Dr. Chan.

Last but not least, Dr. Marie-Josie Tassignon, from the University Eye Clinic Maastricht, Netherlands, presented on the prevention of cystoid macular edema (CME) after cataract surgery. In the European Society of Cataract and Refractive Surgery (ESCRS) prevention of cystoid macular edema (PREMED) study, she found that a single subconjunctival triamcinolone acetonide injection effectively prevented the development of CME after cataract surgery in diabetic patients. However, the risk of developing CME should be carefully weighed against the risk of developing an increased IOP. It was also observed that intravitreal bevacizumab had no significant effect in preventing CME after cataract surgery. As always, the cataract symposium was a great platform for presenting new research and developments in the industry, as well as promoting lively discussions among the presenters and the audience. Editor’s Note: The APAO 2019 Congress was held in Bangkok, Thailand, on March 6-9, 2019. Reporting for this story also took place at APAO 2019. Media MICE Pte Ltd, CAKE Magazine’s parent company, was the official media partner at APAO 2019.

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Visual Highlights from APAO 2019

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