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

02 The Racing Issue June/July 2019

www.cakemagazine.org

The Race for

Prized Outcomes

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In Pole Position Raj Narayanan discusses the future of an independent Alcon.

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Coming Around the Bend Need for Speed SMILE gains momentum in the U.S.

CataPulse provides rapid visual recovery in cataract surgery.

THE WORLD’S SECOND FUNKY OPHTHALMOLOGY MAGAZINE


This is

Superior Anterior Visualization UP TO UP TO

% INCREASED MAGNIFICATION1,*,†

UP TO

5X 48 42

EXTENDED DEPTH OF FIELD1,*,†

% INCREASED DEPTH RESOLUTION1,*,†

*Compared to analog microscopes. †Specified performance was achieved at maximum system magnification with an aperture setting of 30% open and viewing distance of 1.2 meters.

SEE IT BETTER. DO IT BETTER. IMPORTANT PRODUCT INFORMATION Caution: Federal (USA) law restricts this device to sale by, or on the order of, a physician. Indication: The NGENUITY® 3D Visualization System consists of a 3D stereoscopic, high-definition digital video camera and workstation to provide magnified stereoscopic images of objects during micro-surgery. It acts as an adjunct to the surgical microscope during surgery, displaying real-time images or images from recordings. Warnings: The system is not suitable for use in the presence of flammable anesthetics mixture with air or oxygen. There are no known contraindications for use of this device. Precautions: Do not touch any system component and the patient at the same time during a procedure to prevent electric shock. When operating in 3D, to ensure optimal image quality, use only approved passive-polarized glasses. Use of polarized prescription glasses will cause the 3D effect to be distorted. In case of emergency, keep the microscope oculars and mounting accessories in the cart top drawer. If there are any concerns regarding the continued safe use of the NGENUITY® 3D Visualization System, consider returning to using the microscope oculars. Attention: Refer to the User Manual for a complete list of appropriate uses, warnings and precautions. The CONSTELLATION® Vision System can be connected to the NGENUITY® 3D Digital Visualization System. Please refer to the CONSTELLATION® Vision System user manual for complete instructions, warnings and precautions. Reference: 1. Alcon data on file. Alcon Laboratories, Inc; December 2017. © 2019 Novartis 1/19 US-DAV-18-E-2780


IN THIS ISSUE...

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Cataract 08

IMAGE-GUIDED TECHNOLOGIES: Key to Cataract Surgery Perfection?

Matt Young

CEO & Publisher

Robert Anderson Media Director

Hannah Nguyen

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Anterior Segment 10 NOVEL & TOPICAL: A new approach to the treatment of corneal neovascularization

FLAPLESS APPROACH: A surgical correction of refractive errors that gives patients a reason to SMILE

12 Cover Story

Taming orbital implant migration with 3D printing

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Mastering the art of anterior capsulotomy

The Race for Prized Outcomes

Cover Section

21

Getting into the Driver’s Seat with the New Alcon

Kudos 25

RACE FOR VISION: Against all odds, APAO 2019 Charity Run returns stronger for its fourth year

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Dr. Rupal Shah: A trailblazer in laser refractive surgery

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DOCTORS’ ORDERS: Five best practices to improve ocular surface outcomes

Conference Highlights 36 38

APAO 2019: Seeing the extra mile with keratoprosthesis DOSCON 2019: How is India transitioning from LASIK to SMILE?

Enlightenment 32

THE RIGHT FORMULA: Ode to the movers and shakers in the fight against blindness

40

VEE 2019: New releases from ZEISS foster collaboration and improved care

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CAKE MAGAZINE Letter to Readers THE NEED FOR SPEED

W

hat do ophthalmology and Formula One motorsport have in common? Well... both industries are certainly full of beautiful, rich and successful people (like yourselves). However, it is hard for members of the public to relate to what ophthalmologists do. The instruments and equipment involved in our field are far more advanced than what a ‘civilian’ might use. A diamond knife, for example, is a thousand times more refined than the sharpest kitchen knife; and an excimer or femtosecond laser is light years ahead of a green diode laser pointer. Needless to say, it is easier for a layperson to relate to car racing, as almost everyone enjoys driving swiftly sometimes. Personally speaking, though, the competency gap between driving my old automatic VW Golf and a Formula One car — which won’t brake effectively into a corner unless the tires are warm and the aerodynamics package is set up correctly — is just as big. Still, the comparison is worth exploring. Let’s take cataract surgery as an example. You have a team that has to work — often under great pressure — together, efficiently and effectively, or the race (or here, the case) is lost. There’s also a need for speed. Inefficiencies in the clinic mean fewer patients can be treated, and this means lost turnover. Communication — including accurate transcription of data — is key. While a Formula One team might lose a few places in a race because of a typo in a calculation about lap times, fuel use and optimal pit stop windows, in a clinic, a typo in ocular biometry data leads to a bigger disaster: a refractive surprise. This is why both industries are computerizing (or have computerized as much as possible) to avoid those errors. Communication is as essential in a pit stop as in an operating theater — and is key for a swift and drama-free procedure. Wherever computerized instruments go, big data arrives soon after. For decades now, you’ve listened to drivers talk to reporters about telemetry and how information from sensors throughout the car send data back to the team for inspection and analysis. In some respects, that’s telemedicine today. There’s a growing trend of getting diagnostic instruments out to the tertiary and quaternary centers for screening and diagnostic assessments, with the data generated being sent back to a central resource for analysis. In both cases now, that data is being analyzed (using the buzzword du jour ‘big data’), often automatically, without human intervention, supplying valuable diagnostic advice. Big data is also being used to optimize outcomes. Nomograms can be developed and continually enhanced, thanks to automated data collection and an algorithm that can chomp through the information about before-surgery and after-surgery eyes. Just like Formula One teams, clinics are also expensive to run. For example, the laser(s) in your practice aren’t just expensive to purchase, the servicing that’s absolutely vital to keeping them running smoothly doesn’t come cheaply either. You need staff at all levels to make the practice (or the team) work. These human costs add up, too. But if you have a winning strategy (with good logistics) and a superstar surgeon doing great work, the rewards are great.

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Dysfunctional Formula One teams rarely win, nor do dysfunctional practices. You have to deal with safety issues, too. And both a Formula One race and ophthalmology surgery have a long list of potential risks and dangerous outcomes that need to be either worked around or have effective contingencies planned for. That’s why you pay for those service contracts on your phaco machines and lasers, and why you prescribe post-procedural antibiotics. But I think the greatest parallel of them all is the trickledown nature of both industries. The fuel providers, engine manufacturers, team owners, and even the tire makers justify Formula One as a testbed of (expensive) innovation that eventually filters down to the ordinary cars that mere mortals drive. In 2017, Mercedes announced that they had broken the 50% thermal efficiency barrier for the first time — something that very few internal combustion engine road cars can achieve even under optimal conditions (and they don’t have to participate in races). In ophthalmology, we’re starting to see this first with diagnostic instruments, in the smartphone fundus camera and ophthalmoscope adapters, the Snellen chart iPhone apps, and the portable tonometers for home use. Even therapeutic instruments are going portable. We’re not talking lasers with wheels — we’re talking hand-held devices. For example, you’ll soon be able to perform cross-linking at the slit-lamp with a portable, batterypowered light source, rather than in the operating room under a static lamp. And finally, there are simulators. Formula One teams use them to let drivers explore circuits and test virtual car set-ups, which help the drivers avoid the gravel traps when they get to the circuits. The same can be said about the training eyes used in wet-labs and the eye simulator training set-ups. They make the operator more skilled and make everything safer. Besides the obvious, I would say the biggest difference between both fields is the prize. Formula One drivers race against each other for points, trophies, TV exposure, and sponsorship money; meanwhile, cataract and refractive surgeons typically race against time (and other circumstances) for their patient’s eyesight. Now, let’s find that magnum of champagne and celebrate! Dr. Mark Hillen Director of Communications ELZA Institute, Zurich, Switzerland Editor-At-Large CAKE Magazine


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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ATARACT Imaging IMAGE-GUIDED TECHNOLOGIES

Key to Cataract Surgery Perfection?

t’s not an understatement to say that today’s cataract patients have high expectations. They expect perfection, even the astigmatic ones. Patients expect to maintain their active lifestyles and achieve flawless visual acuity from the end of their nose to the flag on the ninth golf tee, and every distance in between. We know that visual outcomes, associated satisfaction and quality of life are impacted by preoperative astigmatism and postoperative residual astigmatism. Most surgeons will say that surprising refractive outcomes are the result of all the preoperative and intraoperative variables that need to be carefully weighed and balanced. Managing astigmatism with precision during cataract surgery traditionally requires accurate markings to identify a reference position, such as the horizontal axis and the axis of astigmatism. Two major challenges exist: First, an estimated five-degree alignment error of a toric intraocular lens (IOL) against the expected angle can result in a 17% error in anticipated effect.1 Second, the assumed horizontal axis,

ink-marked while the patient is in an upright, seated position, may experience variable degrees of cyclorotation once the patient is supine during surgery. Are we growing tired and frustrated with calculating and recalculating, measuring and remeasuring, and then juggling all the variables? If so, there’s good news: In recent years, imageguided technologies have delivered new and improved ways of looking at cataract surgery, which help to minimize potential sources of error during each step of preoperative and intraoperative process. Dr. Jeewan Singh Titiyal, professor and head of Cornea, Cataract & Refractive Surgery Services and chairman of the National Eye Bank at Dr. Rajendra Prasad Centre for Ophthalmic Sciences, in New Delhi, India, shared his impression of the technology. “Cataract surgery is becoming akin to a refractive procedure with increasing patient expectations. Image-guided technologies have heralded a new era of phacoemulsification wherein cutting-edge technology is integrated with routine cataract surgery to provide a better quality of vision, in addition to precise visual acuity.” He added that novel technological platforms assume even more importance when implanting premium intraocular lenses, such as toric and multifocal IOLs. At present, various platforms are available to optimize results of cataract surgery, including VERION (Alcon, Fort Worth, Texas, USA), CALLISTO (Carl Zeiss Meditec, Jena, Germany), and Optiwave Refractive Analysis (ORA, WaveTec Vision Systems Inc., California, USA). Dr. Titiyal and colleagues recently published their study comparing toric IOL alignment assisted by image-guided surgery or manual marking methods and its impact on visual quality.2 In this prospective comparative study, they enrolled 80 eyes with cataract and astigmatism ≥1.5 D to undergo phacoemulsification with toric IOL

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Repeated calculations getting you down? Good news is on the way...

by April Ingram

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June/July 2019

alignment by manual marking method (bubble marker) or CALLISTO eye and Z align. They found significantly less deviation from the target axis of implantation and significantly better visual quality in the image-guided group. As Dr. Titiyal explained: “CALLISTO and VERION provide step-by-step guidance throughout phacoemulsification, right from the placement of incisions, sizing and centration of capsulorhexis, to the centration of multifocal IOLs and alignment of toric IOLs along the requisite axis. We have observed more precise toric IOL alignment with CALLISTO-guided surgery as compared with conventional manual marking, and the visual quality is definitely superior with CALLISTO.” He further commented: “VERION can be integrated with the LenSx femtosecond laser platform (Alcon) along with ORA, which aids in preoperative planning, provides intraoperative guidance, and enables postoperative assessment and refinement of outcomes. Optiwave Refractive Analysis (ORA) provides a real-time guide to IOL power selection and alignment of toric IOLs.” Dr. Titiyal feels that image-guided surgery allows precise alignment of toric IOL without a need for reference marking. It is associated with superior visual quality which correlates with the precision of IOL alignment. “We have found it to be extremely valuable in post-refractive surgery cases where it is often difficult to calculate an accurate IOL power preoperatively,” he noted. Dr. Stephen Slade of Slade & Baker Vision Center in Houston, Texas, USA, has published a multicenter study with colleagues in Minnesota and South Carolina to assess the clinical utility of the image-guided surgical planning system for eyes with pre-existing astigmatism using toric IOL or corneal incisions. They found that using the image-guided surgical planning system with the LenSx procedure resulted in


a three-month postoperative accuracy of less than 0.50 D residual refractive cylinder in 82% of eyes, compared to 69.6% of eyes not using the procedure.3 Meanwhile, Dr. Bryan Hung Yuan Lin, superintendent of Zhong-Li Universal Eye Center, chief director of Universal Eye Center Alliance Cataract Committee, professor at the Fu-Jian Medical University and Shanghai Raiding Hospital, and director of the Ophthalmological Society of Taiwan Cataract Committee, has tremendous experience with image-guided technology. And in 2017, he published a study of the technology in Clinical Ophthalmology.4 Dr. Lin and colleagues compared the VERION with commonly used keratometers containing monochromatic light-emitting diodes (LEDs) (LenStar LS900, Haag-Streit, Switzerland and AL-Scan Optical Biometer; Nidek, Japan), topographers based on the use of Placido rings (OPD-Scan III; Nidek, Japan), and a rotary prism system (auto keratorefractometer KR-8800; Topcon, Japan). In this retrospective study of the right eyes of 115 patients, they found that none of the VERION parameters were significantly different from those of AL-Scan and Lenstar. “AL-Scan (2.4mm zone) was especially similar to VERION,” shared Dr. Lin. “Wide limits of agreement (confidence intervals) are potential contributors to axis error in patients with toric IOL implants. This study demonstrated moderate to high correlations for all parameters measured using VERION compared to those measured using other devices. No differences were observed between the VERION Reference Unit, AL-Scan and Lenstar devices, which are all automated keratometers that rely on the projection of light onto the corneal surface in order to obtain K-values measurements.” Postoperative visual outcomes are strongly associated with the accuracy of preoperative keratometry measurements. Overcorrection of astigmatism with large degrees of axis misalignment is known to cause the most patient dissatisfaction. Dr. Lin and colleagues reported: “Corneal data

measurements with each device based on different techniques and calculations are thought to result in different K-values measurements. However, no differences in corneal astigmatism axis values were observed.” Dr. Lin shared some key advice: “Understand the utility and performance of available devices. As more severe peripheral corneal shape deformations or irregular astigmatism may affect measurement results, further corneal topography and pachymetry measurements may be required to obtain reference values in such cases.” He added that surgeons can select the most appropriate combination of devices for the evaluation of individual patients and clinical applications.

What are other studies saying? Dr. Eirini-Kanella Panagiotopoulou and colleagues from University Hospital of Alexandroupolis in Dragana, Greece, reviewed 21 studies of current imageguided systems used for cataract surgery or refractive lens exchange.5 They concluded that image-guided systems appear to be accurate and reliable with high degrees of repeatability and reproducibility regarding the keratometry and IOL power calculation. Although superior over the conventional manual inkmarking techniques for toric IOL alignment, they cautioned that these systems were not yet interchangeable with the current established and validated keratometric devices.

References 1

2

3

4

5

Visser N, Berendschot TT, Bauer NJ, Jurich J, Kersting O, Nuijts RM. Accuracy of toric intraocular lens implantation in cataract and refractive surgery. J Cataract Refract Surg. 2011;37:1394-1402. Titiyal JS, Kaur M, Jose CP, Falera R, Kinkar A, Bageshwar LM. Comparative evaluation of toric intraocular lens alignment and visual quality with image-guided surgery and conventional threestep manual marking. Clin Ophthalmol. 2018;24(12):747-753. Slade S, Lane S, Solomon K. Clinical Outcomes Using a Novel Image-Guided Planning System in Patients With Cataract and IOL Implantation. J Refract Surg. 2018:1;34(12):824-831. Lin HY, Chen HY, Fam HB, Chuang YJ, Yeoh R, Lin PJ. Comparison of corneal power obtained from VERION image-guided surgery system and four other devices. Clin Ophthalmol. 2017;11:1291-1299. Panagiotopoulou EK, Ntonti P, Gkika M, Konstantinidis A, Perente I, Dardabounis D, Ioannakis K, Labiris G. Image-guided lens extraction surgery: a systematic review. Int J Ophthalmol. 2019;12(1):135-151.

About the Contributing Doctors Dr. Jeewan Singh Titiyal, M.D., is a professor and head of Cornea, Cataract & Refractive Surgery Services and chairman of the National Eye Bank at Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, in New Delhi, India. Dr. Titiyal is credited with the first live cornea transplant surgery by an Indian doctor. In 2014, he was honored by the Government of India with the Padma Shri, the fourth highest civilian award, for his services to the field of medicine. Dr. Titiyal has published more than 240 peer-reviewed manuscripts and been cited more than 3500 times. He received the Senior Achievement Award (2016) and Achievement Award (2009) from the American Academy of Ophthalmology (AAO). [Email: titiyal@gmail.com] Dr. Bryan Hung Yuan Lin, M.D., is superintendent of Zhong-Li Universal Eye Center and chief director of Universal Eye Center Alliance Cataract Committee. He is a professor at the Fu-Jian Medical University and Shanghai Ruidong Hospital. He is also a lecturer in Optometry at Central Taiwan University of Science and Technology. Dr. Lin is the director of the Ophthalmological Society of Taiwan Cataract Committee and board of director in Taiwanese Cataract and Refractive Surgeon in Laser and Photonic Medicine Society of the R.O.C., as well as a surgical consultant for Bausch & Lomb and Alcon. He has performed more than 30,000 cataract phacoemulsification with M.I.C.S and over 4,000 cases using multifocal and accommodative IOLs. His average surgery time for grade 3 nuclear cataract is between five and six minutes. His interest in teaching young surgeons made substantial contribution to ophthalmic development in Taiwan, especially in training and education for young cataract and refractive surgeons. [Email: hylinmd@ms14hinet.net]

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ATARACT Surgery

anterior caps

Centration is also an important concept in merry-go-round riding.

by Olawale Salami The CAPSULaser provides a “circular, accurately sized and centered capsulotomy, better in all respects compared to a manual continuous curvilinear capsulorhexis (CCC).

– Dr. Richard Packard

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ataract surgery has truly come of age. Now more than ever, we are witnessing an era of remarkable postoperative patient outcomes. And at the heart of the various factors for favorable patient outcomes, lies a successful anterior capsulotomy. Techniques for capsulotomy have progressed from a crude tear to

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the current standard of continuous curvilinear capsulorhexis (CCC). In 2008, a new automated capsulotomy procedure was performed using the femtosecond laser. And for the very first time, surgeons were able to create anterior capsulotomies of accurate size, roundness and centration. A capsulotomy of accurate size, shape and position helps ensure 360-degree overlap of the intraocular lens (IOL) by the capsulotomy. Furthermore, this reduces the risk for posterior capsule opacification and improves IOL centration and effective lens position. This is particularly important when multifocal and toric IOLs are implanted.

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However, femtosecond laserassisted cataract surgery has associated caveats; that is, it requires a considerable investment in capital and operating and maintenance costs. The following study assessed the efficacy and safety of a capsulotomy technique performed using the CAPSULaser selective capsulotomy laser (EXCELLENS, Inc., California, USA). Dr. Richard Packard and collaborators from the GEMINI Eye Clinic, Zlin, Czech Republic, compared the efficacy and safety of anterior capsulotomy creation with a new selective laser device (CAPSULaser) with those of manual capsulotomies. Their findings were published in


psulotomy a recent article in the Journal of Cataract and Refractive Surgery.* In this prospective case series, the authors included patients with clinically documented diagnosis of grade I to IV cataract according to the Lens Opacities Classification System III, clear corneal media with no corneal disease or pathology that might interfere with passage of the laser light, aged 40 to 79 years, and an endothelial cell count of more than 2000 cells/mm. To be included, patients must have read, understood and signed the informed consent and agreed to be randomized to either treatment group. Standard exclusion criteria were used, and included previous eye surgery, ocular comorbidities and poorly dilating pupils. The study protocol stipulated four investigational visits to ensure that the patients fulfilled the eligibility criteria. The patients were subsequently grouped in cohorts, stratified by age and cataract grade, and then randomized to either have laser capsulotomy or manual CCC. The authors stained the anterior capsules with microfiltered trypan blue, and intraoperative video analysis with the use of an intraocular ruler, and postoperative examinations were used to assess safety and efficacy (accuracy of capsulotomy size, circularity, centration). Dr. Packard and colleagues found no intraoperative complications in either the laser group or the manual group, and all capsulotomies in the laser group were free floating with no tags or tears. Following analysis of the study results, the authors concluded that selective laser capsulotomy using a new proprietary trypan blue formulation was

safe and effective in cataract surgery. Furthermore, the sizing, circularity and centration of the laser capsulotomy were more accurate than those of the manual CCC, resulting in consistent 360-degree IOL coverage. Dr. Packard highlighted the major advantages of capsulotomy using CAPSULaser as compared to standard methods. “It provides a circular, accurately sized and centered capsulotomy, better in all respects compared to a manual CCC,” he said. “It is also stronger than both a manual CCC and FLACS capsulotomy. It is simple to perform, and the latest version of the settings can create a capsulotomy in under half a second.” Dr. Packard provided insights into the most important innovations that have changed the landscape of anterior capsulotomy over the last two decades. “Automated capsulotomy has been brought to the forefront by, initially, the femtosecond laser in FLACS,” he shared. “This has been followed by

Zepto with precision pulse capsulotomy. Although the reports of tear out with this have been worrying, it is now available in many countries. CAPSULaser with selective laser capsulotomy achieved a CE mark last year and is currently being evaluated by a number of key opinion leaders (KOLs) across Europe.” In addition, he explained that what all of these devices are trying to do is to achieve a well-centered, accurately sized and circular anterior capsulotomy. “This is important to minimize posterior capsular opacification and to assist in the positioning of premium IOLs where this is most important for best visual outcomes,” he said. Finally, Dr. Packard envisioned the next frontiers in anterior capsulotomy in the coming decades. “The use of the accurately sized, centered and circular anterior capsulotomy to hold the IOL rather than using the oval capsular bag for centration has already been recognized by some lens manufacturers. I believe this trend will continue as these automated devices become more widely used,” he speculated. In addition, he noted that: “IOL companies so far have explored the possibility of using the accurately sized and centered capsulotomy to center and fixate the IOL. This should improve effective lens position prediction and assist in the performance of multifocal IOLs centered on the visual axis.”

* Stodulka P, Packard R, Mordaunt D. Efficacy and safety of a new selective laser device to create anterior capsulotomies in cataract patients.J Cataract Refract Surg. 2019;S0886-3350(18):31009-5.

About the Contributing Doctor Dr. Richard Packard is senior consultant at Arnott Eye Associates in London, UK. He has recently retired as senior surgeon at the internationally known Prince Charles Eye Unit in Windsor. He has been involved in teaching and training cataract surgery for over 39 years in 61 countries. Dr. Packard has a long connection as a consultant to many ophthalmic companies and has been involved in many product launches as a key opinion leader for new machines for phacoemulsification, new intraocular lenses and new microscopes. In 1981, Dr. Packard published the first description in the medical literature of the use of a folded soft lens in cataract surgery. He implanted the world’s first foldable hydrophobic intraocular lens in 1990. In 2010, he designed and jointly has a patent on the Windsor Knife for consistent, accurate cataract surgery wounds. And in 2011, Dr. Packard designed the Packard phaco tip, which is made by MST for microincisional cataract surgery. Currently, he has been advising EXCEL-LENS with their new selective laser for capsulotomy during cataract surgery. [Email: mail@eyequack.vossnet.co.uk ]

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NTERIOR SEGMENT Corneal Surface

NOVEL & TOPICAL A new approach to the treatment of corneal neovascularization In some forms of CNV, the neovascularization mechanism should be the main therapeutic target.

by Konstantin Yakimchuk

D

espite a common belief, excessive blood supply is not always beneficial for the tissue. In fact, it could be damaging for the eye, as in the case with corneal neovascularization (CNV). In a recent issue of the Indian Journal of Ophthalmology, Dr. Sibel Aksoy from the Department of Ophthalmology, Saglik Bilimleri University, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey, reported a successful therapeutic application of aflibercept for the treatment of corneal neovascularization.1 The author presented a clinical case of a seven-year-old patient, who underwent craniotomy surgery for pilocytic astrocytoma and experienced left facial paralysis and significant vision decline, accompanied by redness in the left eye six months after the surgery. He was initially treated with antibiotics and additional topical therapy without significant improvement. Therefore, steroid therapy was applied, albeit without any significant positive effect. Since therapy with loteprednol was ineffective, aflibercept (Eylea, Bayer, Germany), 2mg/0.05ml, was topically delivered by intravitreal injections. The significant regression of CNV symptoms was achieved three days after starting therapy, and complete recovery was observed within seven days. Neither decreased corneal epithelial regeneration nor adverse systemic effects were detected. Moreover, the yearly follow-up detected no signs of neovascularization.

A common assumption about the pathogenesis of CNV implies that macrophages and other immune cells play a critical part in the tissue damage by promoting hemangiogenesis.2 Therefore, glucocorticoids would often be considered as an effective treatment due to their common immunosuppressive properties. Topical application of steroids is considered to be the first-choice treatment option for CNV, since these anti-inflammatory drugs are expected to inhibit eye inflammation. In line with this, previous studies have reported positive effects of glucocorticoids, such as dexamethasone and triamcinolone acetonide.3 Intriguingly, beneficial outcome of steroid therapy has not been observed in the present clinical case. Thus, in the present case, steroids had obviously no significant positive effect on the patient’s condition. It is well-known that vascular growth is mediated via activation of growth factors, such as vascular endothelial growth factors (VEGF). CNV is a common pathological feature in ocular disorders, with VEGF being its main trigger. Earlier research has shown that

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aflibercept inhibits two isoforms of VEGF (VEGF-A and VEGF-B) and placental growth factor, which activates the VEGF receptor (VEGFR) and induces neovascularization. Therefore, instead of focusing on cellular inflammation, Dr. Aksoy aimed to limit vascular growth in the cornea. By suppressing the activation of VEGFR, aflibercept inhibits neovascularization and diminishes vascular permeability. In line with this, the author hypothesized that this drug might enter inflamed cornea and suppress neovascularization. The idea was obviously correct, since complete reduction of CNV was observed. In contrast to glucocorticoids, application of aflibercept has ameliorated the CNV symptoms. In his report, Dr. Aksoy emphasized the novelty of the study, as aflibercept has so far been used mostly in animal experimental studies. One of the studies has used a rabbit model of CNV to test topical application of aflibercept. Significant reduction of CNV symptoms by both 0.1% and 0.01% topical aflibercept and no side effects have been observed.4 The effects of aflibercept have been comparable to anti-VEGF drug bevacizumab.


According to another study, subconjunctival ziv-aflibercept treatment has shown high treatment benefits in decreasing CNV induced by sulfur mustard exposure in rabbits.5 Noticeably, aflibercept has reduced the symptoms of CNV better than bevacizumab. Another support of aflibercept effects has been provided by a study in rats, where experimentally induced CNV was ameliorated by aflibercept. Moreover, that study found the inhibition of stromal inflammation caused by CD68-expressing macrophages, which are known to contribute to the CNV pathogenesis by releasing inflammatory mediators.6 No adverse symptoms were detected. To summarize the observed effects, aflibercept combined the antiinflammatory functions of steroids, such as inhibition of inflammatory corneal hemangiogenesis and anti-angiogenic properties of anti-VEGF antibodies and similar drugs. Furthermore, aflibercept was found to act as an anti-angiogenic and angiosuppressive drug. These combined effects of aflibercept were not accompanied by any side effects common for glucocorticoid therapies. To obtain an expert’s opinion on Dr. Aksoy’s report, Dr. Harvey Uy, the medical director at Peregrine Eye and Laser Institute in Makati, Philippines, commented on the study. “This is a very useful case report, which presents topical aflibercept as an effective, noninterventional method for mitigating the effects of persistent corneal neovascularization from exposure keratopathy,” said Dr. Uy. “Despite prior non-response to topical steroids, the patient still improved with a short course of angiorecessive anti-VEGF drops.” Dr. Uy also agreed that local antiangiogenic treatment may be highly beneficial for patients with CNV. “It should be mentioned that addressing other factors such as lubrication may also be vital for treatment success. This well-written article adds support to the use of topical anti-VEGF drops (aflibercept, bevacizumab, ranibizumab) for non-inflammatory, ocular surface neovascularization.”

In line with this statement, aflibercept has been shown to be highly effective for the treatment of diabetic macular edema, including vision improvement in patients with severe initial visual acuity.7 In addition, Dr. Uy complemented his statement by referring to an earlier study published by his group, where similar regression of CNV by topical bevacizumab drops was observed when bevacizumab treatment was combined with topical steroids.8 Dr. Uy proposed to compare the safety effectiveness of different commercially available ocular anti-VEGF drugs in patients with CNV. Current anti-VEGF therapies include specific neutralizing anti-VEGF antibodies, such as bevacizumab, tocilizumab and ranibizumab, an RNA aptamer pegaptanib and tyrosine kinase inhibitor regorafenib.9 In conclusion, recent studies suggest that in some forms of CNV,

the neovascularization mechanism predominates and should be the main therapeutic target; while in other forms with pronounced inflammatory pathogenesis, corticosteroids might be combined with anti-angiogenic drugs. The present report demonstrated that treatment with aflibercept might be an effective and safe therapeutic approach for CNV. Due to its efficiency and absence of side effects, aflibercept likely has high chances to occupy a strong position within the competitive therapeutic CNV landscape. Future clinical trials are needed to estimate whether aflibercept would be superior over other inhibitors of vasculogenesis and identify its minimal effective dose. Editor’s Note: Dr. Harvey Uy was not part of the studies mentioned, but he was generous enough to contribute his expert opinion to this article.

References Aksoy S. Treatment of corneal neovascularization with topical aflibercept in a case of exposure keratopathy following cerebellar astrocytoma surgery. Indian J Ophthalmol. 2019;67(1):145-147. 2 Abdelfattah NS, Amgad M, Zayed, AA. Host immune cellular reactions in corneal neovascularization. Int J Ophthalmol. 2016;18;9(4):625-633. 3 Liu X, Wang S, Wang X, Liang J, Zhang Y. Recent drug therapies for corneal neovascularization. Chem Biol Drug Des. 2017;90(5):653-664. 4 Park, YR, Chung, SK. Inhibitory effect of topical aflibercept on corneal neovascularization in rabbits. Cornea. 2015;34(10):1303-1307. 5 Gore A, Horwitz V, Cohen M, et al. Successful single treatment with ziv-aflibercept for existing corneal neovascularization following ocular chemical insult in the rabbit model. Exp Eye Res. 2018;171:183-191. 6 Sella R, Gal-Or O, Livny E, et al. Efficacy of topical aflibercept versus topical bevacizumab for the prevention of corneal neovascularization in a rat model. Exp Eye Res. 2016;146:224-232. 7 Al-Debasi T, Al-Bekairy A, Al-Katheri A, Al Harbi S, Mansour M. Topical versus subconjunctival anti-vascular endothelial growth factor therapy (Bevacizumab, Ranibizumab and Aflibercept) for treatment of corneal neovascularization. Saudi J Ophthalmol. 2017;31(2):99-105. 8 Uy HS, Chan PS, Ang RE. Topical bevacizumab and ocular surface neovascularization in patients with stevens-johnson syndrome. Cornea. 2008;27(1):70-73. 9 Voiculescu OB, Voinea LM, Alexandrescu C. Corneal neovascularization and biological therapy. J Med Life. 2015;8(4):444-448. 1

About the Contributing Doctor Dr. Harvey Uy currently serves as a clinical associate professor of ophthalmology at the University of the Philippines and medical director at Peregrine Eye and Laser Institute in Makati, Philippines. He completed fellowships at St. Luke’s Medical Center and the Massachusetts Eye and Ear Infirmary. He has been a pioneer in femtosecond cataract surgery, accommodation restoration by lens softening, modular intraocular lenses, and intravitreal drugs. Dr. Uy has published over 50 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 (APVRS). Dr. Uy received the Jose Rizal Research Award from the Philippine Medical Association, the Xavier School Exemplary Alumni Award, and Achievement Awards from the American and Asia Pacific Academies of Ophthalmology. [Email: harveyuy@yahoo.com]

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NTERIOR SEGMENT Orbital Implant

Taming orbital implant migration

by Joanna Lee

T

with 3D

printing

he practice of enucleation first appeared in the 16th century.1 And in the 500 years since it was first performed, removing an eye and replacing it with an intraorbital implant still poses challenges. However, in an exciting development, a group of researchers in India have found a ‘hack’ to tame the recalcitrant implant. Dr. Tarjani Dave demonstrated a common issue with these implants in a case of a 17-year-old male patient who underwent three sittings of implant exchange, with each attempt resulting in implant migrations. “The implant

migrates when its maximum convexity is not visible in the palpebral fissure,” explained Dr. Dave. The other option, the dermis fat graft2 method, also has limitations. According to Dr. Dave, operating on eye sockets (for the dermis fat graft) that had previous surgery leads to a higher rate of graft necrosis and unsightly scars on the harvest site. This led her to look into other solutions. “What if we blocked the quadrant of migration with another implant, just like a piggy-back IOL? Will that help in centering the migrated implant?”

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wondered Dr. Dave and her team. Based on an idea from their previous study using custom ocular prosthesis, they now focused on using threedimensional (3D) printing technology.3 And the team seemed to have made quite an impression, literally.4 During the Orbital and Oculoplastic Surgery Free Paper Rapid Fire Update Session at the Asia-Pacific Academy of Ophthalmology (APAO) 2019 Congress held in Bangkok, Thailand, Dr. Dave shared insightful tips on how they finally secured the orbital implants.


First, patients’ two-dimensional (2D) scans were taken and imported to a free software program to generate a 3D model of each patient’s orbit. “Then you crop your region of interest (on the customized orbit) to reduce the cost of printing,” said Dr. Dave. The file is then sent to a 3D printer, which prints out a life-sized model of the patient’s orbit. “The orbit is obtained as it is, in vivo and external model. And using that orbit as a template, you can then make any sort of implant that you wish to make,” added Dr. Dave. With this custom-made orbit, they made a second implant that sits in the inferotemporal quadrant. “Placing the implant surgically is very simple. You use the routine transconjunctival inferior orbitotomy approach. Essentially, you’re placing the implant extra-corneally, extra-periosteally, in the quadrant where the spherical implant migrated, so that this blocks the migration,” she shared. In another tip, she shared that the implant could be secured with cyanoacrylate adhesive and any other needed adjunctive procedures could be done in the same sitting. The team decided to put this method to test on more patients. In a study5 published in the Indian Journal of Ophthalmology, the team investigated if centering the migrated implant, with the help of a second patient-specific implant, corrects the migration. It was a single-center prospective consecutive interventional case series of six eyes (of six patients) with inferotemporal spherical implant migration – the inability to retain the prosthesis even after maximal prosthesis modification by the ocularist. Dr. Dave said the study’s main outcome was to measure the centration of the orbital implant clinically and radiologically, while noting any complications of the surgery. The secondary outcome measure was the cosmetic result of the prosthesis, in

[

The study’s main outcome was to measure the centration of the orbital implant clinically and radiologically, while noting any complications of the surgery. The secondary outcome measure was the cosmetic result of the prosthesis, in terms of reduction of the enophthalmos and a decrease in the superior sulcus deformity.

terms of reduction of the enophthalmos and a decrease in the superior sulcus deformity. All six patients had an average of 13 prior orbital surgeries with a mean follow-up duration of just over two years and an average migrated implant diameter of 18 mm. Their average customized implant volume was 2.57 ml3. The result? Success in centration for all six patients with no other complications, although four patients required additional fornix formation sutures (FFS) and mucus membrane graft (MMG) to deepen the fornix. Between the pre- and postoperative periods, the patients had a reduction in the enophthalmos and superior sulcus deformity. “This study is on a novel technique that actually targets the pathology, which is attempting to re-center the migration. It is also a one-step procedure because when you use a 3D printing to craft it, the implant sits

]

exactly where it belongs,” Dr. Dave shared, noting that there will also be a two-year follow-up for these six patients. There are limitations to the study, though. It is a small cohort, thus a larger number would produce more statistically significant results. Also, this method requires 3D printing knowledge and set-up, something which could potentially be outsourced. The good news is that it is cost accessible. “In India, it costs about 2,000 - 3,000 Rupees (28 - 43 US Dollars),” she said, adding that it is necessary to work with ocularists. “With the advancements in technology, we’re definitely at an interesting crossroad in socket surgery,” concluded Dr. Dave.

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.

References Christmas NJ, Gordon CD, Murray TG, et al. Intraorbital implants after enucleation and their complications: A 10-year review. Arch Ophthalmol. 1998;116(9):1199-1203. 2 Nentwich MM, Schebitz-Walter K, Hirneiss C, Hintschich C. Dermis fat grafts as primary and secondary orbital implants. Orbit. 2014;33(1):33-38. 3 Dave TV, Ezeanosike E, Basu S, et al. Effect of optic nerve disinsertion during evisceration on nonporous implant migration: A comparative case series and a review of literature. Ophthalmic Plast Reconstr Surg. 2018;34(4):336-341. 4 Dave TV, Gaur G, Chowdary N, Joshi D. Customized 3D printing: A novel approach to migrated orbital implant. Saudi J Ophthalmol. 2018;32(4):330-333. 5 Dave TV, Tiple S, Vempati S, et al. Low-cost three-dimensional printed orbital template-assisted patient-specific implants for the correction of spherical orbital implant migration. Indian J Ophthalmol. 2018;66(11):1600-1607. 1

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NTERIOR SEGMENT Refractive Surgery

FLAPLESS APPROACH A surgical correction of refractive errors that gives patients a reason to SMILE by Olawale Salami is combining the best of “bothSMILE worlds of PRK and LASIK into one procedure, i.e., performing a PRK without the pain, and having the benefit of a LASIK without a flap.

– Dr. Rupal Shah

S

urgical correction of refractive errors is certainly popular. Twenty years ago, the development of photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) using the excimer laser revolutionized the field of corneal refractive surgery.1 Thereafter, refractive lenticule extraction (ReLEx) of intracorneal tissue became possible using a femtosecond laser. Although the clinical results of LASIK have improved remarkably, there are postoperative complications, among which LASIK-inflicted ectasia is the foremost concern. As most complications are believed to be associated with the corneal flap, recent efforts have focused on the development of new procedures that avoid the flap creation.2 Recently, small incision lenticule extraction (SMILE) has been established as a ‘flapless’ procedure in which an intrastromal lenticule is cut by a femtosecond laser and manually extracted through a peripheral corneal tunnel incision. SMILE is a minimally invasive, laser vision-correction procedure, and excellent visual outcomes with high predictability have been recorded in patients with myopia and astigmatism.3 Several studies have demonstrated a lower reduction and faster recovery of corneal sensitivity and sub-basal nerve

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fiber density after SMILE as compared to LASIK4 – this is because the anterior stroma is disturbed only by the small incision. The potential biomechanical advantages of SMILE have been modeled based on the nonlinearity of tensile strength through the stroma.5 SMILE offers a variety of clinical advantages, and a recent meta-analysis of published studies concluded that the incidence of transient dry eye syndrome following surgery is lower in SMILE, as compared to LASIK.6 As a minimally invasive approach, SMILE offers the potential for more biomechanical stability of the cornea, thereby facilitating rapid wound healing.7 Dr. Rupal Shah, the group medical director for New Vision Laser Centers in India, is one of the global pioneers of SMILE. She shared insights into her decade-long experience as one of the first corneal laser refractive surgeons in the world to use the ZEISS (Carl Zeiss Meditec, Jena, Germany) platform for SMILE procedures. “I’ve been performing laser surgery since 1994, and I have extensive experience in corneal laser refractive surgery. For the past 11 years, I’ve been performing femto-LASIK and SMILE procedures,” shared Dr. Shah. “I am one of the pioneers of SMILE as I got a chance to study the procedure in its infancy.” She recalled the early years of refractive surgery in India: “What we basically do in corneal refractive surgery is to do a corneal reshaping so that the focusing of the rays of light happens exactly on the retina, to match patients’ expectations. Previous procedures involved creating a flap, because the epithelium can regenerate, so you somehow need to go underneath the epithelium to achieve a stable shape. Microkeratome LASIK would offer a much faster visual recovery with less need to take steroids. However, it has the disadvantage of flap-related complications which can be worrying.” Dr. Shah said femto-LASIK came like a breath of fresh air. “It was a huge step ahead of microkeratome LASIK. However, in a country like India, it is

difficult to justify investing in a femtoLASIK, as this significantly increases the cost of the procedure. There is still flap formation, and this takes considerable time to heal. So, SMILE is like a new paradigm because it removes the need to create a flap, while ensuring quick recovery of the LASIK procedure. Therefore, it’s safer and it comes without pain.” While noting its key advantages, Dr. Shah said: “I can describe SMILE as combining the best of both worlds of PRK and LASIK into one procedure, i.e., performing a PRK without the pain, and having the benefit of a LASIK without a flap.” Dr. Shah explained that during SMILE eye surgery, a lenticule is created inside the intact cornea using the VisuMax femtosecond laser (Carl Zeiss Meditec, Jena, Germany) and extracted through a small incision. “The lenticule is removed, thereby achieving

the desired vision correction,” Dr. Shah said. “SMILE will most likely be the future of corneal refractive surgery.” Given its importance in corneal refractive surgery today, Dr. Shah stated that SMILE is an important technique that should be learned by all corneal surgeons. “This procedure is more difficult to learn compared to LASIK, but there is a finite learning curve. In addition, there is only one company that makes these lasers, which is ZEISS, so training is not widely available.” However, she stressed that: “For a surgeon with an established refractive practice, this can be a good addition. And the extra time invested in learning SMILE and the excellent results in patient outcomes will be worth it.” Editor’s Note: In October 2018, the US FDA Premarket Approval (PMA) for ReLEx SMILE expanded myopia treatment to patients with astigmatism.

References Vestergaard AH. Past and present of corneal refractive surgery: a retrospective study of longterm results after photorefractive keratectomy, and a prospective study of refractive lenticule extraction. Acta Ophthalmologica. 2014;92(5):492-493. 2 Chansue E, Tanehsakdi M, Swasdibutra S, McAlinden C. Efficacy, predictability and safety of small incision lenticule extraction (SMILE). Eye Vis (Lond). 2015;2:14. 3 Liu M, Chen Y, Wang D. et al. Clinical Outcomes After SMILE and femtosecond laser-assisted LASIK for myopia and myopic astigmatism: A prospective randomized comparative study. Cornea 2016;35(2):210-216. 4 Denoyer A, Landman E, Trinh L, Faure JF, Auclin F, Baudouin C. Dry eye disease after refractive surgery: Comparative outcomes of small incision lenticule extraction versus LASIK. Ophthalmology 2015;122(4):669-676. 5 Seven I, Vahdati A, Pedersen IB, et al. Contralateral Eye Comparison of SMILE and flap-based corneal refractive surgery: Computational analysis of biomechanical impact. J Refract Surg. 2017;33(7):444-453. 6 Yan H, Gong LY, Huang W, Peng YL. Clinical outcomes of small incision lenticule extraction versus femtosecond laser-assisted LASIK for myopia: A Meta-analysis. Int J Ophthalmol. 2017;10(9):1436-1445. 7 Wang D, Liu M, Chen Y, et al. Differences in the corneal biomechanical changes after SMILE and LASIK. J Refract Surg. 2014;30(10):702-707. 1

About the Contributing Doctor Dr. Rupal Shah is one of the pioneers of laser refractive surgery, being among the first surgeons in India to perform these new procedures since 1994. She is currently the group medical director of New Vision Laser Centers-Center for Sight, a part of Asia’s largest chain of laser refractive surgery clinics. As a pioneer in the LASIK technique, she has performed more than 40,000 procedures, averaging around 2,000 treatments in the last 21 years. She was the third surgeon in the world to perform ReLEx and the first to perform single incision ReLEx smile, the standard way the procedure is performed today. As a consultant for Carl Zeiss Meditec, she has been involved with all kinds of studies on ReLEx smile, including studies for US FDA approval of the procedure. Dr. Shah is a well-known ophthalmic teacher, and over 1,200 eye surgeons globally have performed their first LASIK or ReLEx smile procedures under her mentorship. She has several publications in prestigious peer-reviewed journals, has written chapters in several prestigious international books, and has spoken in around 150 international and regional conferences. [Email: rupalbrd@gmail.com]

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COVER STORY Circuit Gilles-Villeneuve, Montréal RANK TEAM DRIVER

LAP TIME

GAP

LAPS

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TYRE S S S S S S S S S S S S S S S S S

First Formula For Success: Safety Assuming all lasers have the characteristics of precision, speed and accuracy, the main advantage for me is safety and repeatability of the laser. Applying the car racing analogy, this also means I can routinely make the movements – or turns – needed to accurately perform the procedure. -Dr. Francis Mah

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peed. Precision. Accuracy. Fine motor skills. The ability to make tight maneuvers. These characteristics might make some think of surgeons and their high-tech equipment — this is, after all, an ophthalmology magazine. But for the team behind CAKE Magazine, these attributes also make us think of car racing — Formula One, to be exact, with the highest performance cars, the greatest caliber of drivers, and the biggest prizes to be won. Come to think of it, these all sound a lot like ophthalmology — with its complicated surgeries, topnotch eye doctors, and prized patient outcomes. Surgeons, like race car drivers, need the best equipment to provide optimum patient outcomes (the real grand prize). And many of those characteristics required for a race car are also key factors in surgical equipment, devices and lasers. Follow us on this circuitous route — we promise, it comes full circle.

The Race for by Brooke Herron

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Start your Engines Like steering wheels to drivers, lasers are a critical tool for anterior segment surgeons. And if improving a patient’s condition is the race to be won, laser provides advantages like precision, speed and accuracy. Dr. Francis Mah, an advanced corneal, cataract and refractive surgery specialist based in La Jolla, California, frequently uses lasers, including YAG, excimer and femtosecond lasers from J&J Vision Care Inc. (Jacksonville, Florida, USA), Nikon (Tokyo, Japan), and Alcon (Geneva, Switzerland) in his practice. In addition to the above-mentioned advantages in using laser in his practice, Dr. Mah is also looking for one more reward: safety. “Assuming all lasers have the characteristics of precision, speed and accuracy, the main advantage for me is safety and repeatability of the laser,” he explained.

“Applying the car racing analogy, this also means I can routinely make the movements — or turns — needed to accurately perform the procedure. But, hopefully, the main benefit of laser is that I’m going to have a safety advantage.” So, what else fuels Dr. Mah when he’s in the driver’s seat? Ergonomics, for one: “There’s a lot of companies making lasers, and they’re all fabulous. For me, it’s the ergonomics — having everything you need in a sensible place, the user interface making sense the first time you look at it, feeling comfortable as you sit there because you’ll be there case after case. You’re sitting there looking at various different aspects for a length of time, so you must be comfortable lap after lap so you can go the distance.” “Some lasers are more efficient (or inexpensive), and they don’t offer a lot of frills. Some have a smaller footprint, so they don’t occupy as much space. Some

tcomes

The Need for Speed in Cataract

I

n racing, it’s ‘go fast or go home’. And in ophthalmology . . . well, it’s not exactly like that. However, there are times when quicker is better – especially during postoperative recovery when patients expect rapid visual results. Soon, there might be a new device on the market to speed things up: the CataPulse from Med-Logics (Athens, Texas, USA). The device, which is billed as providing “rapid visual recovery for refractive lens exchange”, is currently seeking FDA approval and is available in parts of Asia, including Hong Kong and the Philippines. The CataPulse “phaco-free” lens removal system is a small incision device that dissects and extracts the cataract, using a bimanual technique and without ultrasound technology. This eliminates the risk of thermal damage, and the small incision reduces the corneal astigmatism. Med-Logics CEO Rod Ross underwent bilateral cataract surgery using the device last year. According to Mr. Ross, it’s rare for surgeons to perform phaco bilateral procedures, in part to avoid TASS (toxic anterior segment syndrome). TASS can result from things like issues with sterilization, enzymes and detergents, preservatives, intraocular anesthetics and ointments, among other factors. “It’s best to ultrasonically clean instruments used in cataract surgery, but the phaco handpiece cannot be ultrasonically cleaned because of the piezoelectric crystals inside the handpiece,” explained Mr. Ross. In addition to a more rapid recovery, this is where CataPulse handpiece exhibits another benefit: It is a single-use sterile disposable, so it does not have the re-use issues of a conventional phaco handpiece. With the abundance of cataract cases worldwide – speeding up postoperative recovery is a ‘win’ for both patients and surgeons.

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COVER STORY Circuit Gilles-Villeneuve, Montréal RANK TEAM DRIVER

LAP TIME

GAP

LAPS

TYRE

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

S S S S S S S S S S S S S S S S S

Second Formula For Success: Ergonomics You’re sitting there looking at various different aspects for a length of time, so you must be comfortable lap after lap so you can go the distance. -Dr. Francis Mah

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Glaucoma Pit Crew: The Pressure is On

n tires, as in glaucoma management, maintaining the ‘right’ pressure is key to longevity and performance. In tires, air pressure can be measured with a simple gauge. In eyeballs, detecting intraocular pressure (IOP) can also be done with a simple air – or “air puff” non-contact tonometry – test, but for a full assessment of this glaucoma-related symptom, diagnostic equipment is required. There are several imaging platforms on the market to aid in glaucoma diagnosis and management – one of which is the SPECTRALIS OCT Glaucoma Module Premium Edition (GMPE) from Heidelberg Engineering Inc. (Heidelberg, Germany). Giving them an edge in this lap of the race, is the recent update for the module, the GMPE Hood Glaucoma Report, which highlights essential diagnostic information in an intuitive layout that enables a quick, yet comprehensive assessment.

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Not only is it fast, it’s precise as well. Boosted with GMPE Anatomic Positioning System (APS), the semiautomated technology increases the precision and accuracy of results by ensuring that all glaucoma scans are anatomically aligned with the reference database and account for the individual configuration of axons in each eye. Furthermore, this report allows clinicians to visualize functional and structural measurements along with high-resolution OCT B-scans and relate this information to 10-2 and 24-2 visual field points. Shifting gears to treatment, speed is also the name of the game for glaucoma, especially in the increasingly popular selective laser trabeculoplasty (SLT) procedure, which is carried out with the help of a reflective lens. During the procedure, if the lens only has one reflective surface (which is the current standard), it must be rotated on the patient’s cornea to access all of the trabecular meshwork – this causes discomfort to the patient,

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will be more comprehensive and have all the bells and whistles, and, of course, more expensive. But generally, those are going to be a little more precise, solid and safe,” he said. And, as if describing a race car, he continued: “The ones [lasers] I have, they’re workhorses. They don’t break down, they’re super precise, accurate and safe in general.”

At the Top of the Leaderboard In his line of business, Dr. Mah always has his eye on the laser leaderboard — and in his opinion, there are a few companies who are leading the pack, with regard to cataract. Plus, he said, there’s a relative “rookie” in the arena of refractive surgery that is also gaining traction in the United States: SMILE (small incision lenticule extraction).

it takes additional time, and it’s more difficult for the surgeon. To make SLT more efficient, a new lens – the Rapid SLT (Volk Optical Inc., Mentor, Ohio, USA) – is equipped with four internal reflected surfaces, minimalizing the need for rotation (only once, if needed) . . . and cutting the procedure’s time in half. This firstof-its-kind lens is ultimately a win for both patients and doctors: Rapid SLT means the lens stays on the patient’s eye for less time, which improves the patient’s experience and increases ease of use for the doctor. Of course, like in the name, the Rapid SLT helps ophthalmologists complete the procedure with twice the speed as before – this not only boosts efficiency, it also lowers the odds that the patient’s anesthesia wears off during the procedure, resulting in a second administration and longer procedure time. And faster surgery times are key, as glaucoma is on the rise and more patients are undergoing SLT.


Most popular. Occupying the top spot in Dr. Mah’s list of popularity is Alcon, with its LenSx laser system. “This one has to be one of the most popular lasers out there,” he said, adding that like a modular system, different pieces can be added to extend its capabilities — plus as a larger company, Alcon provides updates frequently. Most unique. According to Dr. Mah, the LENSAR laser system (LENSAR Inc., Orlando, Florida, USA) has the smallest footprint, is the least expensive AND has a unique way of identifying structures of the eye. However, he said it is the smallest company, meaning research and developments might not be as flushed out, though it can maneuver quick and has aligned with some other smaller companies and can be used with some other unique peripherals and machines. Most solid. As he noted above, safety is the critical factor for Dr. Mah and his J&J Vision lasers. “The advantage of J&J is precision, and it seems to have the most solid platform, making it precise and safe.” Most versatile. According to Dr. Mah, the cataract laser from Bausch+Lomb (Bridgewater, New Jersey, USA) is popular and versatile, and it can also do LASIK flaps: “That makes it a little more capable in terms of procedures.” Coming around the bend in refractive laser platforms are both Alcon and Carl Zeiss Meditec (Jena, Germany). Regarding LASIK, he said: “Alcon makes lasers for flaps, as well as reshaping.” But what he’s most excited about – noting it’s their number one advantage – is that Alcon is also advancing topography guided systems. “They’re really speeding up that profile,” he added. Gaining on LASIK is SMILE, which is a relatively new procedure in the US. “ZEISS has a new laser for SMILE — this is a brand-new type of technology for refractive surgery and people are excited about that, especially in Asia. I think it’s starting to pick up momentum, it’s kind of a new, novel type of refractive surgery.”

The Formula for Best-in-Class Dr. D Ramamurthy, chairman of The Eye Foundation in South India, has 27 years of experience in cataract and refractive and refractive surgery. To complement Dr. Mah’s laser nominations for “best-inclass”, Dr. Ramamurthy appointed two of his own: the WaveLight Ex500 (Alcon, Geneva, Switzerland) and VisuMax for SMILE (Carl Zeiss Meditec, Jena, Germany). Let the race begin! Great Overall. Not only does Dr. Ramamurthy own four of Alcon’s Ex500 laser platforms, he’s had one of them for seven years. “I find the Ex500 excimer laser to be great laser to have — it’s truly versatile with wavefront optimized treatment. It works very well, it is extremely fast, it is precise, and it consumes less tissue than some comparable platforms,” he said, adding that the results are predictable, too. Dr. Ramamurthy said the Ex500 is good for a garden variety of refractive errors, but its real advantage is managing difficult situations: “We have this topo-guided treatment where we’re able to regularize an abnormal cornea. For example, if there’s a corneal Circuit Gilles-Villeneuve, Montréal RANK TEAM DRIVER

scar, if there’s decentration from prior laser treatment, or if there’s significant residual astigmatism,” he explained, adding that along with corneal crosslinking (CXL), he is using the platform for treating keratoconus. Surgeons compare to race car drivers in this sense: Both need the highest-grade equipment to perform in difficult situations, whether in making tricky maneuvers or avoiding complications (or crashes!). Most Unique. The VisuMax from ZEISS earns this title from Dr. Ramamurthy for its flapless SMILE procedure. While SMILE is newer in the USA, surgeons in Asia have been performing this procedure for the last 10 years. Dr. Ramamurthy has about five years of experience with the procedure. “The advantage of this laser is that you don’t have to create a flap,” he explained. “We make a very small incision through which we remove the lenticule. And because of that, all the flap-related complications have completely been done away with.” Dr. Ramamurthy said he and his colleagues do SMILE quite often, and they believe it has some significant advantages in the refractive lane, LAP TIME

GAP

LAPS

TYRE

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

S S S S S S S S S S S S S S S S S

Third Formula For Success: Durability The ones [lasers] I have, they’re workhorses. They don’t break down, they’re super precise, accurate and safe in general. -Dr. Francis Mah

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COVER STORY including biomechanics, quality of vision and stability of refractive error. “When we compare it with other platforms, it does equally well, and final outcomes are quite comparable,” he added. With two first-in-class vehicles to choose from, how does Dr. Ramamurthy decide which to ‘drive’ each day? Both are versatile, but he said the Ex500 handles better in challenging conditions. “When I’m faced with a challenging case, I use the Ex500. But when I’m doing a routine case, like a -3.0 or 4.0 D refractive error, and the patient also wants something that is less invasive, I’ll do SMILE,” he said.

have is ‘where is the proof that this is going to improve my outcomes?’ So, outcomes and data are going to be really important.” Number two, he said, is improving safety, which is already at the top of Dr. Mah’s list of necessities. “Third is cost: Can we do it a little cheaper? And number four is making

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

In the Final Lap In the race of laser surgery, new modifications and innovations will continue to propel the technology forward. And whether its highperformance cars or lasers, according to Dr. Mah, there are four essential reasons users will either adopt, or be curious about new products. “One is better outcomes — especially with cataract surgery and femtosecond lasers,” he began. “I think the big question a lot of people

Going the Distance with Multifocal IOLs at the Indian Grand Ophthalmic Prix

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ould the end be in sight for patients needing both near, intermediate and far vision correction? According to a recent study, 99% of patients are spectacle independent following bilateral implantation with the AUROVUE DFINE multifocal IOL (Aurolab, Tamil Nadu, India). The study was conducted at Aravind Eye Hospital in India, with nearly 160 patients enrolled; of those, approximately 140 reported for follow-up. The Aurovue DFINE (standing for Diffractive, Far, Intermediate, Near and Enhanced vision) is a hydrophobic, diffractive, multifocal, aspheric, foldable, preloaded IOL with the near addition of +3 D, uniquely designed to

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it more efficient and faster, everything else being equal,” he said. “In terms of these lasers, if we can do it faster, cheaper and safer with better outcomes — then that’s the winning driver. If we can do something, if we can do all four, that would be winning a Grand Prix for cataract surgery.”

Dr. D. Ramamurthy completed his M.B.B.S from JIPMER, Pondicherry and M.D. Ophthalmology from R.P. Center, AIIMS, New Delhi, India. At present, he is the chairman of The Eye Foundation, a chain of state-of-the art eye hospitals, situated in South India. His areas of interest are in cutting-edge technology in cataract and refractive surgery. He was the chairman of the scientific committee for the All India Ophthalmological Society (AIOS) for a period of six years and the past president of the same organization. He has been awarded 21 named orations both in India and abroad. He has been an invited speaker and has performed live surgeries in most parts of India and in several countries abroad. Has 13 publications in peer reviewed journals. Dr. Ramamurthy has also been conferred the Asia-Pacific Certified Educator (ACE) award by APACRS, the APAO Distinguished Service Award and the American Academy of Ophthalmology Achievement award. [Email: drramamurthy@theeyefoundation.in]

provide maximum energy at near and optimum energy at distance. Mr. Saravanamoorthy V., product manager for Aurolab, says the contrast sensitivity of this IOL is higher than any other multifocal currently available – plus the patient has spectacle-free vision with very good near vision and uncompromised distance vision. With multifocal IOLs, preoperative patient selection, both clinical and psychological, is important for optimal outcomes – and measuring the patient’s angle kappa is a key part of this. “Currently there’s not a lot of equipment to measure angle kappa . . . not all hospitals can measure it, and they don’t have the machines because they’re costly,” explained Mr. Saravanamoorthy, adding that Aurolab has developed a portable machine that can be fitted to any slit lamp for

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measuring angle kappa. “If the angle kappa is more than 5 degrees, the patient will complain of vision disturbances like halos, glare, dysphotopsia and double vision,” he said. “With this device, surgeons can decide whether the patient is clinically a fit for the multifocal IOL.” The IOL is also preloaded which, like a Formula One car, means its fast, and precise. It’s also preloaded for another reason – to protect the multifocal rings from damage. “When the lenses are manually loaded, the surface may get scratched or damaged, which affects the ring’s multifocality,” he explained. Currently, the Aurovue DFINE multifocal IOL is available in Europe; Aurolab is planning to seek US FDA approval as well.


COVER SECTION Industry Update

Getting into the Driver’s Seat with the New Alcon

by Matt Young and Brooke Herron

To win the race, you’ve got to split from the pack. On April 9, 2019, global ophthalmic device leader Alcon announced its separation from Novartis. This independence gives Alcon more ‘steering’ control . . . and more opportunities for growth. Below, we ‘hitch a ride’ with Alcon — in this racing-themed edition of CAKE — to see how it is shifting gears and driving the industry.

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ust as cars and teams in motorsports have sponsors, so did Alcon, which had two ‘sponsors’ through the years: Nestle and the more recent, Novartis — but not anymore. In an interview with Mr. Raj Narayanan, Alcon’s Asia Pacific Regional President, he explained the difference between how medical device companies like Alcon and pharmaceutical companies like Novartis work. Mr. Narayanan, who is now transitioning to the Alcon headquarters in Geneva, sat down with CAKE

Magazine at Alcon’s regional office in Singapore to keep us ‘up to speed’ with the transition. Speaking from both personal and professional experience — Mr. Narayanan is a great person to explain how Alcon’s transition from Novartis will roll out. “Big pharma is all about blockbusters, they have long development timelines, and the pace at which things move is different for all the right reasons,” he explained. “With medical devices, it’s small, incremental innovation . . . it is much more agile and the interactions with the customers are very different.” Mr. Narayanan said the spin-off allows Alcon to operate as a medical device company, without the constraints of being part of a larger parent company. Ultimately, this will translate to better customer support. And now that Alcon has returned to its roots as an independent company, it can steer its own course in investments and decision-making. “Going forward, we can make the right decisions for our business and allocate capital in the most appropriate

way,” added Mr. Narayanan. “We realize that we have a once-in-a-lifetime opportunity to create a truly world-class medical device technology company in ophthalmology.” According to him, this transition is fueled by dedication to the following tenets: agility, simplification, accountability, and empowering the company’s 20,000-plus employees. Now in pole position, Alcon is driving its own resource and capital allocations to fuel opportunities for growth.

Leaderboard Stats Eye care boasts an approximately $23 billion annual market, growing at roughly 4% each year. Last year, Alcon had sales of $7.1 billion, including $4.0 billion in surgical (up 7% from the prior year), and $3.1 billion in vision care (up 3%). Looking ahead, Alcon plans to build on its core strengths to earn lowto mid-single digit net sales growth in 2019 and accelerating to mid-single digit sales growth over the next five

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COVER SECTION Industry Update years. In addition, with more than 100 products in development, Alcon is also focusing on research and development (R&D). Last year, Alcon invested $587 million (8.2% of 2018’s total revenue) into R&D, in areas driven by customer need and patient demand. “We invest more dollars into R&D than any of our competitors, and over the years we’ve seen those investments translate into a strong innovation pipeline. To me, that’s one of the most exciting things about the future,” said Mr. Narayanan. According to him, these efforts all lead into one direction: growth. “As with every company, we want to grow — it’s part of our agenda — and value is created through revenue growth. Growth is good for everyone — the company, our shareholders, our customers and ultimately their patients.”

A Lap Ahead in Asian Education

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Turbo-charging Forward In Formula One racing, the team — from the mechanics, to the driver and sponsors — is dedicated to that championship win. To be a champion in ophthalmic care, Alcon embraces that same dedication, exclusively creating devices for the eye care and vision community. And just like high-performance engines, Alcon’s equipment, whether inhouse or acquired, pushes its products to the extreme for better patient comfort and postoperative outcomes. In March 2019, Alcon acquired a 100% stake in US-based PowerVision, Inc. The privately held medical device company focuses on developing fluid-

Mr. Raj Narayanan courteously put on his new ‘Alcon race uniform’ (thanks to Photoshop) for our CAKE Magazine crew.

based intraocular lenses (IOLs) for cataract surgery patients`— traditionally known as accommodating lenses. These IOLs utilize the eye’s natural accommodative response to provide near and intermediate vision, in addition to distance vision commonly provided by basic IOLs.

lcon also focuses on education, especially in Asian markets. “In Asia, we have a huge opportunity to continue to train doctors,” said Mr. Narayanan. “One of the reasons toric lenses are so underimplemented in this part of the world is because doctors are not confident to implant them.” To help improve quality and standard of care, Alcon runs a program to train doctors in phaco surgeries, in countries including India, China, Bangladesh and Vietnam. This is important because not all degrees include this type of training: “In China, for instance, you graduate from medical school as an ophthalmologist, but you’ve never been trained to use a phaco machine,” explained Mr. Narayanan. The program has been operating for 10 years now and employs 200 associates, each spending up to three months training a single ophthalmologist on phaco machines for cataract surgery. Similar to the phaco program, Alcon also started a vitreoretinal development program in India — and now plans to launch it in China. “It’s not as big as the phaco program, but it’s another area we’re investing in,” noted Mr. Narayanan.

PIE and CAKE Magazines’ CEO & Publisher Matt Young arrives at the Alcon regional headquarters in Singapore, in his CAKE 01 issue attire from APAO Bangkok where the publications were the Official Media Partner, to help usher in the fresh, new Alcon look. Vision Boards, made by Alcon staff, featured some freshly cut out images from PIE (Posterior Segment - Innovation - Enlightenment) Magazine to help usher in a future that is way more than half-baked.

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“This [IOL] is in the very early stages of development, so we’ll have to wait and see what this technology can offer to patients,” shared Mr. Narayanan. “History has been littered with accommodating lenses and products that have not lived up to those promises. We’re acutely aware of that too.” Alcon leads the industry in global IOL share and estimates double-digit growth in this type of advanced technology intraocular lens (AT- IOL), which is largely driven by new innovations. “Our big business is cataract. We’re very excited about PanOptix, our trifocal IOL. Patients are seeing some real benefits [with this IOL] over other trifocal lenses in the market,” noted Mr. Narayanan. The IOL is currently available in the European and Latin American markets, and an Asian launch is planned.

Taking the High-Tech Route In December 2018, Alcon expanded its solutions for patients with dry eye with its acquisition of Tear Film Innovations, Inc., which manufactures iLux, a device that provides customizable treatment for Meibomian Gland Dysfunction, a leading cause of dry eye. It has also expanded its commitment to the posterior segment with the 100% acquisition of Californiabased TrueVision. The company manufactures Alcon’s NGENUITY 3D Visualization System, which provides retinal surgeons with detailed 3D visualization of the back of the eye. Mr. Narayanan said the 3D magnification effect drives better outcomes: “The doctors are able to go much closer with their instruments to the actual wall of the retina when they’re doing their procedures. I think this has enormous potential and benefit to both surgeons and patients.” In addition to treatment solutions, Alcon also has its eye on data. Using the Phillips HealthSuite digital platform (through a partnership with Amsterdambased Royal Phillips), the company is developing the Alcon SMART Suite, which is designed to streamline,

simplify, and improve cataract surgery for surgeons and patients. “[The SMART Suite] starts from preoperative diagnostic measurements, to the operating theater, to postoperative care . . . all the data is collected and readily available in a cloud-based platform,” explained Mr. Narayanan, noting that this could eventually lead to artificial intelligence applications. “In a world of possibilities, once you have all the data in the cloud, you can pool information from different practices and hospitals, and machine learning can analyze that. This can provide surgeons solutions on what lenses they should implant in patients with certain conditions, for example. When you start thinking of how procedures will be done in the future, it becomes more obvious. Clearly it will take a little while to get there, but that’s why we’re doing it now.” Ultimately, he said Alcon is creating a platform that lends itself to further innovation — and an entire suite of solutions. “These are game-changing products and they require us, and the surgeons, to look beyond the immediate benefit of NGENUITY to a future landscape. When we talk about the digital suite, NGENUITY is an essential part of that,” he said. With the company’s global footprint and innovative products, it’s clear that Alcon will continue to deliver a turbocharged performance. Alcon has come a long way from its humble beginnings as a small independent company in Fort Worth, Texas, in 1945. In the years since, it has become the largest eye care device company in the world, with presence in 74 countries and serving patients in more than 140. Today, Alcon is based in Geneva, Switzerland, but still maintains a significant innovation and operations presence in Texas. It is listed on both the SIX Swiss Exchange and New York Stock Exchange (NYSE) under the symbol “ALC.” At the rate things are going, it seems like Alcon is already driving in the fast lane to help patients, as they say, ‘see brilliantly’.

A View from the Stands

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hen a large, global company like Alcon makes a move, it’s big news. We spoke with Indian ophthalmologist Dr. D. Ramamurthy, chairman of The Eye Foundation in South India, for his thoughts on the new, independent Alcon. Noting that Alcon owns a large portion of the global eye care market share, he said it’s extremely important that they become their own entity. “When they were part of Novartis, which is a much larger pharmaceutical company, it was obvious they would have liked to do things differently though they never verbalized it to me,” he shared. “They faced challenges, whether it was conducting a clinical trial or even just organizing a meeting. Now that they’ve come out of the Novartis umbrella as an independent entity, I think they will have much more freedom.” Dr. Ramamurthy credits both the products and people as the hallmarks of the company. He uses several Alcon products in his practice. “The quality of products, like their intraocular lenses, is extremely good.” But what he finds more admirable is the fact that employees at Alcon (at all levels) share a unique vision, ethos and longevity. “Most importantly, many have been there for decades . . . and there’s a certain amount of trust. That’s one of the reasons, not just their products, that I keep going back to them.” As an attendee of several Alcon advisory boards, Dr. Ramamurthy said the company has some excellent and innovative products in all areas of ophthalmology. “To bring these to commercialization, they need to move fast – and being an independent entity will give them more freedom to do that. I believe Alcon will now be able to address the needs of ophthalmologists much better.”

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UDOS Charity Run

RACE FOR VISION

Against all odds, APAO 2019 Charity Run returns stronger for its fourth year by Joanna Lee

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ne Friday morning in March, over 300 runners participated in the 2019 Asia-Pacific Academy of Ophthalmology (APAO) Congress Charity Run at Benchakitti Park in Bangkok, Thailand. At exactly 6:30 a.m., the runners took off on the 5.4km course, circling the park’s beautiful lake. Themed ‘Run for Sight, Run for Life’, the fourth APAO Charity Run aimed to raise funds for two organizations: the Thammasakon Hatyai School for the Blind in south Thailand and the Indonesian Ophthalmologists Association (PERDAMI). Funds raised for the Thammasakon Hatyai School will be used to refurbish their kitchen and upgrade the overall cleanliness of the school, which educates 80 students; while funds for the latter will be directed towards the September 2018 earthquake relief efforts in Central Sulawesi. This year’s organizing committee was led by Dr. Somkiat Asawaphureekorn from Srinagarind Hospital at Khon Kaen, Thailand, about 440 kms from Bangkok. Due to the distance from Bangkok, the glaucoma specialist requested that APAO 2019 Congress president Dr. Paisan Ruamviboonsuk enlist the help of Dr. Rattiya Pornchaisuree, a pediatric

Most supportive group award - Rajvithi Running Club

ophthalmologist at Rajvithi Hospital in Bangkok, as co-organizer. Together, the two became the force behind this year’s Charity Run. “Dr. Rattiya and the Rajvithi Running Club were key behind the success of the Charity Run. This year, we wanted to give runners the best experience, best impressions and the best memories,” said Dr. Asawaphureekorn.

Going the Extra Mile With meticulous planning and thoughtful details, the organizing committee’s effort paid off. This was evident in the specially designed

T-shirts and finisher’s medal. “We wanted to design a unique T-shirt that the runners would not only want to wear, but would also remind them of this run,” shared Dr. Asawaphureekorn. “We also want people to know at a glance that the T-shirt is from Thailand. Made from breathable nano fiber technology, the T-shirt’s special indigo or ‘khram’ hue is one of the 168 Thaitone colors used historically in traditional Thai arts,” he added, noting that it is something not found in the standard printing color system. The ‘eyebrow’ of the ‘iris’ on the T-shirt is derived from a Thai art pattern called ‘kanok’, which can be found in Thai art and temple mural paintings.

Benchakitti Park

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UDOS Charity Run The conference committee then proposed to cancel the run. Dr. Asawaphureekorn and his team felt despair, as it was just two months before the event. But after a long discussion, APAO 2019 Congress president, Dr. Paisan Ruamviboonsuk, agreed to mediate with the Bangkok Metropolitan Administration authority. Two weeks later, the authorities finally agreed to postpone the park’s renovations just for the run.

Overcoming More Obstacles

(From left) Dr. Somkiat Asawaphureekorn, Prof. Clement Tham and Dr. Paisan.

The highlight is perhaps the APAO 2019 Charity Run finisher’s medal made from laser-cut teak wood, which can also be used as a key chain or bag decoration. Dr. Asawaphureekorn shared that as a runner, the medals collected over time usually just end up being unused. “I wanted to design a non-traditional medal with Thai art, which is also practical and functional.” So, for the medal’s design, he chose the flower-like ‘Prachamyam’ traditional Thai pattern, which has four similar shapes originating from the center into four directions. “This represents balanced growth into all directions, symbolizing the sharing of knowledge and wisdom in ophthalmology throughout Asia-Pacific,” he explained.

Two weeks before the run, only 50 people had registered. This got them to quickly create convenient registration forms online, advertising through banners and booths, and even dinosaur mascots – anything to spread the word to APAO delegates about the run. Eventually, 336 people registered, which was well above their target of 300. Dr. Asawaphureekorn credited Rajvithi Hospital Intern Dr. Vorarit Jinaratana for his contributions, especially in producing the run’s promotional video on the APAO website. As days neared, they also found out that their T-shirt suppliers could not produce the zip pocket. After discussions, the T-shirt production company finally worked on the promised zip pocket by hiring extra

Initial Setbacks Amid the challenges of organizing the run, Dr. Asawaphureekorn said they had learned that Benchakitti Park was to be closed in March 2019 for a major renovation. This caused a nervous committee to research three other Bangkok parks, even going as far as to test the traveling time between each park and the conference venue via public transport. It would’ve all taken too long, making the logistics not feasible. Rajvithi running club members

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workers and delivered them only a day before the run. As if those weren’t enough setbacks, on the day of the run, the person in charge had forgotten to bring the air-horn for the VIP to signal the start of the run. Fortunately, he made it back and got it within a five-minute dash to his vehicle, while the emcee quickly led the waiting crowd through a photo-taking session. “I learned that Murphy’s law stands true, so you need to be prepared to solve these surprises,” shared Dr. Asawaphureekorn.

All Smiles at the Finish Line Ultimately, the run went on and ended without incident, complete with a breakfast session after the prize-giving presentations. Among the winners were Prof. Clement Tham, the secretary general and CEO of APAO, who won second runner-up in the Ophthalmologist category with an impressive time of 30:58. “The highlight of the run for me was when I saw all the runners with their happy faces,” he said. “Imagine all from 27 different countries and nationalities gathering to ‘Run for Sight, Run for Life’. They all took selfies and group photos with one another, made new friends, and enjoyed the food. This made me and my team very happy.”


At press time, Dr. Asawaphureekorn said they are still finalizing the total of donations from different sources. “We hope to finish and give the donations to the two charities very soon. Thammasakon Hatyai School for the Blind in Thailand is very thankful and very excited to get the donations,” he shared. Incidentally, the Rajvithi Running Club won the Top Most Supportive Group Award, while the Indonesian Ophthalmologists Association won the Most Participating Group Award. Top contributing individuals and corporate sponsors were also acknowledged. The winner for Top Individual Fundraising Award, Ms. Watcharee Trongmethirat (who raised USD $606), also flew all the way from Khon Kaen to join the run. “My biggest satisfaction in organizing this run came from appreciating how 50 volunteers, about 40 of whom were from the Rajvithi Running Club, came together and worked hard to ensure all runners experienced the very best while running in Bangkok for a good cause,” he said, thanking a long list of individuals and groups for their help.

“I hope the APAO charity run will continue as a tradition and become one of the anticipated events for all delegates,” Dr. Asawaphureekorn said with satisfaction. Editor’s Note: In conjunction with the APAO 2019 Congress, the APAO 2019 Congress Charity Run was held in Bangkok, Thailand, on March 8. 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. For more information on the run’s overall results, visit www.racez. net/result/index/6.

Prof. Clement Tham finished in third place of his category

About the Contributing Doctor Dr. Somkiat Asawaphureekorn is an associate professor in Ophthalmology of the Glaucoma Unit and the vice chairman of the Clinical Epidemiology Unit, Faculty of Medicine, Khon Kaen University, Thailand. He obtained his M.D. with honors from Mahidol University in 1984 and his master’s degree in Clinical Epidemiology from Chulalangkorn University, Thailand, in 2001. He completed his Certificate of Glaucoma Fellowship from the University of California, San Diego, California, USA, in 1995. His subspecialty is in glaucoma with a special interest in angle closure glaucoma, clinical diagnostic and surgical gonioscopy, ocular biometry and imaging in angle closure glaucoma, surgery in angle closure glaucoma and goniosynechialysis in angle closure glaucoma. Dr. Asawaphureekorn is an avid runner who has completed his first full marathon in 2009 and has since then completed three full marathons. [Email: somk_as@kku.ac.th]

INDUSTRY UPDATE

New data shows implant helps control IOP

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ata from recent Phase 3 clinical trials suggests that the intracameral Bimatoprost sustained-release (SR) implant from Allergan (Dublin, Ireland) may control intraocular pressure (IOP) for an extended duration of time. Currently, the implant is being evaluated in various clinical trials for the reduction of IOP in patients with openangle glaucoma or ocular hypertension. And at the recent American Glaucoma Society (AGS) annual meeting in San Francisco, California, USA, new data was presented to address the treatment duration of this first-of-its-kind biodegradable implant. According to Yehia Hashad, M.D., vice president and global head

of Clinical Development and Eye Care for Allergan, this Phase 3 data confirms that Bimatoprost SR could represent a major paradigm shift in the management of glaucoma. “Bimatoprost SR demonstrated an extended duration of effect in many patients, and the potential for most patients to need no additional treatment for one year after three administrations of the implant,” he said, noting that topline Phase 3 efficacy and safety results from ongoing studies will be presented at a congress later this year. “The development of Bimatoprost SR demonstrates our continued commitment to developing innovative

therapies for glaucoma, which is a progressive disease that requires consistent IOP control to preserve vision for patients,” said Dr. Hashad. Allergan plans to submit a New Drug Application (NDA) for Bimatoprost SR to the US Food and Drug Administration (FDA) in the second half of 2019. As a leading global pharmaceutical company, Allergan focuses on developing, manufacturing and commercializing branded pharmaceutical, device, biologic, surgical and regenerative medicine products for patients around the world. For more information, visit www.allergan.com.

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UDOS Women in Ophthalmology

Dr. Rupal Shah

A trailblazer in

laser refractive surgery by Tan Sher Lynn

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enowned eye surgeon Dr. Rupal Shah was born into a large family, but she was the only one who decided to become a doctor. Today, she is now one of the pioneers of laser refractive surgery, and one of the first surgeons in India to perform new procedures. “I was lucky to have chosen ophthalmology,” shared Dr. Shah. “Initially, I decided upon the ophthalmology field, not because of any personal preference, but because I was able to get admission into it for my studies. Nevertheless, I don’t regret my decision at all. What I love about being in this field is that I get to have a lot of interaction with patients, there are no emergencies, and the results of modern cataract and refractive surgeries are really excellent. Most of my patients are really happy with the outcome and I feel glad that I am able to assist in changing their lives for the better,” she added.

A Challenging Beginning After completing her residency, Dr. Shah joined a high-volume cataract hospital, where she would sometimes perform 25 cataract procedures a day. However, due to a difficult pregnancy, she had to go on bed rest and quit her job. “Once my baby was born, my husband suggested that we start a laser refractive surgery clinic. At that time, which was 1994, laser refractive surgery was something that was just beginning in India. We ventured into it and the rest is history,” she said.

A pioneer in LASIK, Dr. Shah has performed more than 40,000 procedures, averaging around 2,000 treatments annually over the last 21 years. In the last eight years, she’s been heavily involved with the development of ReLEx SMILE (often known simply as SMILE, which stands for Small Incision Lenticule Extraction) procedure. She was the third surgeon in the world to

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perform ReLEx and the first to perform single-incision ReLEx SMILE with the VisuMax femtosecond laser (Carl Zeiss Meditec, Jena, Germany) – the standard way the procedure is performed today. She also contributed a lot to the growth of SMILE worldwide. As a consultant for ZEISS, she has been involved with numerous studies on ReLEx SMILE, including those for the


Balancing Career and Family

I think that with strong networking and by encouraging more women to enter the profession, we could make the working environment a fairer and friendlier place for women ophthalmologists. – Dr. Rupal Shah

Even with all her success, Dr. Shah says it wasn’t always easy juggling her career and family, especially when her daughter and son were still young. “In whatever little success I have achieved, there has been both compromise and sacrifice, not only from my side, but also from my husband and my children,” she said. “When my kids were young, I made it a priority to spend time with them whenever I was at home. I used to travel a lot, trying to build our clinic chain. But when I was home, I restricted my social life and engagements to spend more time with my children. I had very little time for myself during those years. However, I am proud of the fact that today, my kids are independent, capable of evaluating their choices critically, and generally citizens of the world,” she said. Her daughter is currently a lawyer practicing in the UK, while her son has just started his bachelor’s degree in the Netherlands. Dr. Shah thinks that in general, women need to work harder than men to move ahead in their career. “Working women need to balance work and family, as society still has expectations for women regarding their role as wife, mother, daughter and daughter-in-law,” she said. “This isn’t always easy to manage. Nevertheless, I think that with strong networking and by encouraging more women to enter the profession, we could make the working environment a fairer and friendlier place for women ophthalmologists.”

She also acknowledges the importance of men giving adequate support to their wives, both with work and family. “My husband and I are a team. We work together. He handles finance, technical stuff and relationships with partners, while I handle the medical aspects of our clinic chain. And of course, he supports me at home as well,” shared Dr. Shah.

Living Her Passion Dr. Shah’s motto in life is to focus on the things that she loves to do, and to pursue them with passion. This is the main reason why she managed to achieve so much in her career. Besides her work, she loves to read, travel and cook. She also enjoys the company of good friends. “I think that ophthalmology is a great profession . . . more women should really consider ophthalmology as their career choice,” she remarked. In the future, she hopes to see more focus on patients and less on technology and expensive gizmos. “Ophthalmology generally involves high investments in diagnostic and surgical tools, which are expensive and absolutely necessary to get good results . . . so, more time is spent on technology acquisition and use.” “Because of this, we sometimes forget that the patient is a real person, who needs empathy, a caring attitude and understanding. I hope ophthalmologists will be more willing to engage with their patients on these grounds,” she concluded.

About the Contributing Doctor US Food and Drug Administration’s (FDA) approval of the procedure. These efforts have led to a sharp improvement in the visual recovery after SMILE. She also contributes to the field of ophthalmology by teaching courses in refractive surgery. With her guidance, more than 1,200 eye surgeons from all over the world have performed their first LASIK or SMILE procedures.

Dr. Rupal Shah is one of the pioneers of laser refractive surgery, being among the first surgeons in India to perform these new procedures since 1994. She is the group medical director of New Vision Laser Centers – Center for Sight, one of Asia’s largest chains of laser refractive surgery clinics. She has been practicing in Vadodara (where she resides) and Mumbai, India, for over two decades. She has several publications in prestigious peer-reviewed medical journals, and has written chapters, prefaces and introductions in several prestigious international books. Besides being a renowned eye surgeon, Dr. Shah is a much sought-after ophthalmic teacher as well as a well-known speaker in various Indian and international ophthalmic meetings. In the last 10 years, she has spoken in about 150 international and national meetings, including the World Ophthalmic Congress in Abu Dhabi and Berlin, several annual meetings of the American Academy of Ophthalmology, the American Society of Cataract and Refractive Surgery, and the European Society of Cataract and Refractive Surgery. [Email: rupalbrd@gmail.com]

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NLIGHTENMENT Ocular Health

DOCTORS’ ORDERS Five best practices to improve

ocular surface outcomes by Tan Sher Lynn

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healthy ocular surface plays a major role in postoperative recovery. Therefore, optimizing ocular surface care before surgery, like in cataract surgery, provides a comfortable ground for intraoperative maneuvers, and allows for the healthy healing of wounds and decreases the chances of postoperative infections. The ocular surface assumes an even more important role in corneal transplant surgery (keratoplasty), where even seemingly mild inflammations can trigger rejection episodes, which can be detrimental to graft survival. In this article, three corneal experts discussed five ways to integrate ocular surface care into patients’ regimens. Ocular surface conditions like dry eye and blepharitis can be a prickly bunch to manage.

1. Note the importance of an accurate diagnosis. According to Dr. Saba Al-Hashimi, assistant professor of ophthalmology in the corneal division of UCLA Stein Eye Institute, Los Angeles, the most important factor in obtaining a positive surgical outcome is making an accurate diagnosis. “There are a number of different factors that impact the ocular surface, from mechanical issues like lagophthalmos, to aqueous deficient or evaporative dry eye disease. Uncontrolled blepharitis is often overlooked as another contributing factor to poor ocular surface health. In our dedicated dry eye clinic, we spend a significant amount of time testing all parts of the ocular surface. Tests that we perform include the matrix metalloproteinase 9 (MMP-9), tear film osmolarity, non-contact tear break-up

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time, meibography and slit lamp exam.” For example, he said, if you have a patient who complains of dry eyes while sleeping and requires waking up in the middle of the night to apply lubricating eye drops, it should heighten your suspicion for nocturnal lagophthalmos. “When the eyes are closed during sleep, the ocular surface should remain protected. A simple intervention like asking the patient to wear a sleeping mask designed to keep the eyes closed and protected during sleep can greatly help.” He added that for those with aqueous deficient dry eye disease, such as Sjögren’s syndrome or ocular graft versus host disease (GVHD), punctal occlusion (sometimes in all four lids), can markedly improve the symptoms. “If there is surface inflammation, it should be addressed first with either a course of topical steroids or steroid-

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sparing agents like cyclosporine or lifitegrast. If punctal plugs are intolerable or fall out frequently, punctal cauterization can be performed,” explained Dr. Al-Hashimi.

2. Identify systemic conditions and medications that may contribute to dry eye. According to Assoc. Prof. Marcus Ang, consultant ophthalmologist at the Cornea and Refractive Service, Singapore National Eye Centre, it is important to identify certain systemic conditions or medications that may also contribute to dry eye. “Autoimmune disorders such as lupus and rheumatoid arthritis, as well as common conditions such as diabetes mellitus, thyroid disorders and Vitamin


A deficiency may cause dry eye,” said Assoc. Prof. Ang. “Seasonal allergies or allergic conjunctivitis can also aggravate dry eye. Therefore, it is sometimes important for physicians to look beyond the eye and identify these conditions.” He added that the use of certain medications such as anti-glaucoma eye drops, antihistamines, antidepressants, hormone replacement therapy and medications for Parkinson’s disease has also been associated with dry eye. Discussion with the primary physician to reduce or change these medications may help.

3. Emphasize the significance of lid hygiene and use of warm compress. Dr. Al-Hashimi noted that the emphasis on lid hygiene can be of significant benefit if the patient can remain compliant. “For those with significant blepharitis, a dedicated lid cleanser has been shown to be well-tolerated, reduce ocular surface MMP-9 levels and improve lipid layer quality. A warm compress used consistently for at least five minutes a day has been demonstrated to improve symptom scores and tear film function.” In addition, according to Assoc. Prof. Ang: “Regular use of lid wipes and lid cleansing solution with clean cotton buds, or wipes every night, is also helpful.”

4. Watch your prescription. According to corneal surgeon Dr. Pooja Shukla, a senior fellow in the Department of Cornea, Sri Sankaradeva Nethralaya, Guwahati, India, eye physicians should avoid prescribing unnecessary or multiple medications to their patients. “It is important to avoid excessive instillation of topical drugs and premedications during examination or surgery,” Dr. Shukla said. “It is also

good to have a protocol for para clinical staff or health workers who prepare your patients. Besides, keeping a meticulous record of adverse events for newly prescribed or launched medication goes a long way in ensuring a happy patient and a safe ocular surface,” she explained.

5. Identify and modify lifestyle or activities that exacerbate dry eye. All three doctors agree that certain lifestyle activities can contribute to dry eye. “In some individuals, prolonged periods of screen time lead to insufficient blinking, which may worsen dry eye disease,” noted Assoc. Prof. Ang.

“For patients who spend a lot of time reading or doing computer work, we need to remind them that the blinking rate is reduced when focusing on such tasks. It is, therefore, helpful to take frequent breaks and use lubricating drops before symptoms become severe,” added Dr. Al-Hashimi. As for Dr. Shukla, she advised patients to limit screen time and take five-minute breaks for every 45 minutes to one hour of work at the computer, and to try to incorporate simple exercises in their daily routine, such as squeezing the eyelids together. “Avoid using too many cosmetics in and around the eyes and never sleep with makeup on. Contact lens wearers should adhere to the proper protocol of wearing contacts and never sleep without removing them,” she said.

About the Contributing Doctors Dr. Saba Al-Hashimi is an assistant professor of ophthalmology in the Corneal Division of UCLA Stein Eye Institute, Los Angeles, California, USA. At the Medical College of Virginia, he was elected into the Alpha Omega Alpha honor society. He pursued additional training at UCLA’s Stein Eye Institute, where he received specialized training in cutting-edge laser refractive surgery, cataract surgery, corneal transplantation and anterior surface ocular disease management. His current activities include laser refractive surgery, femtosecond laser assisted cataract surgery, corneal transplantation and the surgical management of a variety of ocular surface diseases. He also performs corneal crosslinking and helped launch a dry eye clinic. [Email: alhashimi@jsei.ucla.edu] Assoc. Prof. Marcus Ang is a consultant ophthalmologist at the Cornea and Refractive Service, Singapore National Eye Centre. His expertise includes cornea and external eye diseases, cornea transplantation, cataract surgery, femtosecond LASIK with other refractive surgical options. His contributions have been recognized with national awards such as the President’s Award for Volunteerism and Philanthropy in 2017, as well as international awards such as the Excellence in Ophthalmology Vision Award (2013). He has more than 110 scientific publications in peer-reviewed international journals and regularly presents at conferences. His input for this article was adapted from the information provided by the National Eye Institute (NEI)/National Institutes of Health (NIH) website. [Email: Marcus.Ang@singhealth.com.sg] Dr. Pooja Shukla is a senior fellow at the Department of Cornea, Sri Sankardeva Nethralaya, Guwahati, India. She is a cornea surgeon with great interest in ocular surface disorders. Dr. Shukla has attended intensive training in all subspecialties of ophthalmology and is able to perform various procedures in the subspecialty of cornea and ocular surface, such as pterygium excision with autograft, ocular surface reconstruction and limbal stem cell transplant. She has presented various papers, including an award-winning paper in the competitive session in the annual meeting of Andhra Pradesh Ophthalmic society in 2013, entitled “Pediatric ocular trauma, analysis of visual outcomes in a tertiary eye care centre”. [Email: pooja.amc2004@gmail.com]

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NLIGHTENMENT Ophthalmic Leaders

THE RIGHT FORMULA

Ode to the movers and shakers in the fight against blindness Prof. Jod Mehta Head of Corneal and External Eye Disease Service and Senior Consultant for the Refractive Service, Singapore National Eye Centre (SNEC)

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hat makes a Formula One world champion? Knowledge, dedication, driving expertise, superior reflexes and hand-eye coordination, as well as a great engineering team, are just some of the key elements that make a skilled race car driver. As it turns out, these features are also essential in eye surgery – one doesn’t only need the know-how to use the best surgical techniques, dedication and the foresight to innovate in this field, he needs a fantastic team behind them as well. We spoke with three of the many inspirational champions in ophthalmology to learn what puts them in pole position.

s one of the leading cornea specialists, Prof. Mehta is recognized worldwide for his expertise in complicated corneal transplant techniques, penetrating keratoplasty, anterior lamellar keratoplasty, endothelial keratoplasty, combining penetrating keratoplasty and cataract surgery, as well as combining endothelial keratoplasty and cataract surgery. “I like the fact that we can improve not only people’s vision but their quality of life, whether it’s through a corneal transplant or refractive surgery,” shared Prof. Mehta. “I also enjoy the synergy between the academic side of our field and the clinical work, which has really come a long way in the last few decades.” Some of Prof. Mehta’s responsibilities include guiding clinical fellows and postgraduate students in their work. “I try to lead by example for both my clinical and research team,” he said. “There is no better legacy as a clinical teacher or mentor than to train fellows or junior faculty, who can then develop under your guidance and take that knowledge with them.” As a clinician scientist, Prof. Mehta has had the privilege to mentor clinical fellows and PhD and MSc students. “I would like them to think that they can achieve anything they want in our field.” A memorable moment in his career was being one of the youngest trainees appointed as a resident at Moorfields Eye Hospital in London, UK. “That gave me the opportunity to work with many outstanding ophthalmologists, which really taught me important lessons in understanding clinical work and also the importance of research,” he said.

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There is no better legacy as a clinical teacher or mentor than to train fellows or junior faculty, who can then develop under your guidance and take that knowledge with them. – Prof. Jod Mehta

After seven years in Moorfields, moving to Singapore (initially as a fellow) was a real eye-opener for Prof. Mehta. And staying on as faculty taught him a lot – not only about developing as a clinician, but also as a scientist, inventor, educator and speaker. “There have been many highlights along the way and opportunities in Singapore, which led me to where I am today,” he shared. “I could have never imagined this was possible when I first came 11 years ago. Someone told me once, ‘opportunities are about putting yourself in the position to receive them and then taking advantage of them’. It’s so true.” What gets him out of bed every day? “My drive is my hunger to keep doing things better, not only as a clinician and researcher, but also for my patients. Our patients ensure that clinical medicine is never a boring


job, and if you combine this with an academic career, you are constantly challenged throughout your career.” Prof. Mehta, who is also head of the Tissue Engineering and Stem Cells Group at the Singapore Eye Research Institute (SERI), added that he would not be able to do what he does without an amazing support staff. “I am very lucky to work with fantastic nursing and administrative staff in our clinic facility at SNEC and a great research team at SERI,” he concluded. “The support they give me is more than I could ever have wished for.”

Dr. Harvey Uy Medical Director, Peregrine Eye and Laser Institute, Philippines

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r. Uy specializes in treating extreme eye ailment cases and was the first ophthalmologist to conduct laser refractive cataract surgery in Asia. He was also the first Filipino doctor to implant a slow-release steroid

It doesn’t matter where we are from, nor whether we are young or old – as long as we have an inquisitive mind and the desire to work hard and collaborate, we can contribute to the advancement of science and medicine. – Dr. Harvey Uy

device to treat uveitis and pioneered the use of antibodies to treat macular degeneration and retinal diseases in the Philippines. “I am from the Philippines and I hope this will inspire ophthalmologists from developing countries,” shared Dr. Uy. “It doesn’t matter where we are from, nor whether we are young or old – as long as we have an inquisitive mind and the desire to work hard and collaborate, we can contribute to the advancement of science and medicine.” As an ophthalmologist, Dr. Uy is happiest helping patients preserve or restore the gift of sight: “We can treat one eye at a time, but we can also develop new techniques or technologies that will have a multiplying effect and allow our colleagues to better help their patients and communities.” Recounting some of the many remarkable moments in his career, he said: “Our first clinical trial, which was the Retisert study, opened many research doors for us. We were also fortunate to conduct the first femtosecond laser-assisted cataract study in Asia and to work on accommodation restoration by laser lens softening.” Dr. Uy came up with the idea of grading femtosecond laser images and using these to optimize laser patterns and target only the laser nucleus. He also started some first-in-man studies on topics including modular and multicomponent intraocular lenses (IOLs), dual optic IOLs and capsulotomy instrumentation. “We also participated in many pharmaceutical trials such as Ozurdex, anti-VEGF trials and new compounds.” When faced with challenges, this is Dr. Uy’s philosophy: “Research and development is like a roller coaster ride – there are ups and downs. We go through a process where sometimes the best laid plans work, and many times, they don’t. The important thing is to learn from each failure and to keep trying until the plan comes together. And to always ask, ‘why not?’”

Dr. Iqbal “Ike” K. Ahmed Medical Director, Prism Eye Institute, Ontario, Canada Assistant Professor, University of Toronto, Canada

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r. Ahmed is world-renowned for his skills and groundbreaking work in the diagnosis and surgical treatment of highly complex eye diseases, like glaucoma. He performed the first laser cataract surgery in Canada, and he has trained numerous surgeons in innovative surgical techniques. He’s also been at the leading edge of novel treatments for glaucoma and cataract, as well as lens implant surgery.

Every day, it’s inspiring to see patients go through what they go through, their perseverance and strength in challenging cases. They are the reason we do what we do.

– Dr. Ike Ahmed With a keen interest in the development of advanced microsurgical devices and techniques in glaucoma surgery and complicated cataract extraction, Dr. Ahmed has designed innovative glaucoma diamond scalpels for surgery, microsurgical instrumentation and devices, implants, and techniques for the management of the dislocated cataract, iris reconstruction and glaucoma implant devices. He has done pioneering work in innovative glaucoma surgery, developing and coining the term ‘Micro-Invasive Glaucoma Surgery (MIGS)’ as a new genre of surgical approaches and devices.

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NLIGHTENMENT Ophthalmic Leaders “In medical school, I was very interested in surgery. I fell in love with the idea of using my hands to improve sight, and I was really interested in the technical part of it as well,” he shared. When asked what is most important to him as an eye surgeon, he replied, “To do what medical school taught me: To help people feel good about themselves, to be productive and happy, taking care of my patients.” He finds working with trainees, fellows and residents immensely satisfying – to see them improve and develop their skills over the years; meanwhile, patients are a source of motivation. “Every day, it’s inspiring to see patients go through what they go through, their perseverance and strength in challenging cases. They are the reason we do what we do.” And how does he unwind after a day at work? “I like to work out and exercise,” he shared. “I don’t find work heavy and stressful. Work is my hobby. For me, work is a very happy place. But it is important to have a balanced life and to care for your family.”

Non-incisional Glaucoma Treatment

About the Contributing Doctors Prof. Jod S. Mehta graduated from St. Thomas’s Hospital Medical School, University of London, UK, in 1995. He is currently head of Corneal and External Eye Disease Service and senior consultant of Refractive Service at the Singapore National Eye Centre. He is also deputy executive director and head of the Tissues Engineering and Stem Cells Group at the Singapore Eye Research Institute. Prof. Mehta is a member of the Royal College of Ophthalmologists in the UK, the American Academy of Ophthalmology, the Singapore-Malaysian Ophthalmology Society, and the Asian Corneal Society. He is a professor at the Duke-NUS Graduate Medical School, Singapore; adjunct professor at the School of Material Science & Engineering and School of Mechanical and Aerospace Engineering, Nanyang Technological University; as well as adjunct professor at the Yong Loo Lin School of Medicine, Department of Ophthalmology, National University of Singapore. He has won 24 awards in the UK and around the world for his clinical and research work. [Email: jodmehta@gmail.com] Dr. Harvey Uy is a clinical associate professor of ophthalmology at the University of the Philippines and medical director at Peregrine Eye and Laser Institute in Makati, Philippines. He completed his ophthalmology residency in the Philippine General Hospital and Retina fellowship at St. Luke’s Medical Center, and specialized in ocular immunology and uveitis at the Massachusetts Eye and Ear Infirmary. Dr. Uy has served as president of the Philippine Academy of Ophthalmology and board member of the Vitreoretinal Society of the Philippines. He has received the prestigious Jose Rizal Research Award conferred by the Philippine Medical Association, the Xavier School Exemplary Alumni Award, and Achievement Awards from the American and Asia Pacific Academies of Ophthalmology. Dr. Uy also helped organize the Eye Will Survive program that provided eye care to victims of Typhoon Haiyan and restored eye care services in the disaster region. He has published in and serves as reviewer for journals, including the American Journal of Ophthalmology, Cornea, Journal of Cataract and Refractive Surgery and Ophthalmology. [Email: harveyuy@yahoo.com] Dr. Iqbal “Ike” K. Ahmed is a fellowship-trained glaucoma, cataract and anterior segment surgeon with a practice focusing on the surgical management of glaucoma, complex cataract and intraocular lens complications. He is board-certified in ophthalmology in Canada and the United States and is an active member of numerous national and international societies. He is currently an assistant professor at the University of Toronto in Canada and a clinical professor at the University of Utah in the United States. He is the director of the Glaucoma and Advanced Anterior Segment Surgery (GAASS) fellowship at the University of Toronto, and director of Research at the Kensington Eye Institute, University of Toronto. Dr. Ahmed has a tertiary glaucoma and cataract practice at Prism Eye Institute in the Greater Toronto Area, and primarily performs surgery at Trillium Health Partners, Mississauga, Ontario, the Kensington Eye Institute, University of Toronto, Toronto, Ontario, and TLC Mississauga. [Email: ike.ahmed@utoronto.ca]

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April 22 - 26, 2020


CONFERENCE HIGHLIGHTS APAO 2019 Coverage

Seeing the

Extra Mile with

Keratoprosthesis by Gerardo D. Sison III

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hen the cornea becomes severely damaged or diseased, it can often spell out pain, opacification and loss of vision for a patient. Many providers opt to treat with a corneal transplantation from human donors to remedy the situation. While it may work for some people, corneal transplantation sometimes fails for a number of reasons, including graft rejection or endothelial decompensation. Keratoprosthesis, or more specifically, the Boston Keratoprosthesis, has paved the way for alternative treatment in recent years. Clinical experts discussed this ‘artificial cornea’ treatment at a symposium held at the 34th Congress of Asia-Pacific Academy of Ophthalmology (APAO) in Bangkok, Thailand.

Origins and Advantages of the Boston Keratoprosthesis Keratoprosthesis involves the replacement of a damaged cornea with an artificial cornea. But why exactly do we need a permanent keratoprosthesis?

Corneal transplantation has come a long way...

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According to Dr. Kimberly Sippel, from the Weill Cornell Medical College at New York-Presbyterian Hospital, while corneal transplant surgery can produce highly successful outcomes, ophthalmologists can often find themselves in situations where an ophthalmic environment is simply not able to support a clear corneal transplant. Therefore, the need for an artificial cornea is warranted as a permanent keratoprosthesis. There are several different types of keratoprosthesis: the Boston Keratoprosthesis (B-KPro), osteo-odonto keratoprosthesis (OOKP), Moscow Eye Microsurgery Complex in Russia (MICOF) keratoprosthesis, and tibial bone keratoprosthesis. The B-KPro, however, is the most common implant – developed by Claes Dohlman at the Massachusetts Eye and Ear Infirmary, it was approved by the US Food and Drug Administration (FDA) in 1992. To date, there have been 13,000 implantation procedures performed worldwide. The type 1 model (B-KPro) consists of two plates; the front plate and back plate are made up of polymethylmethacrylate (PMMA). Dr. Sippel mentioned the use of titanium for the back plate which may help reduce the incidence of retro-prosthetic membrane formation. “Sandwiched between the two plates is a corneal button to complete the device,” she explained. “The assembled device is then sutured into position in standard penetrating keratoplasty fashion.”

Boston Keratoprosthesis vs. Standard Corneal Transplant “The Boston Keratoprosthesis holds several advantages over a standard corneal transplant,” commented Dr. Sippel. “For example, even if the carrier corneal tissue becomes opacified, the stem remains clear with the B-KPro.” She continued to explain further advantages including a front plate that is not deformable, which translates

Since the KPro procedure is one of exceptional needs and indications, it only makes sense that the post-surgical care would also need to be exceptional. – Dr. Peter Zloty, anterior segment surgeon and recipient of the 2019 APAO Achievement Award to less issues with astigmatism and a quick visual recovery. By the same token, Dr. Sippel remarked that a prompt visual recovery is also aided by immediate clearance of corneal edema. While the B-KPro can be expensive for some people, lower cost alternatives have become available, such as the Lucia keratoprosthesis. Despite the cost, aphakic and pseudophakic powers mean no intraocular lens needs to be present. Requirements for corneal tissue quality is also not as stringent. In other words, the patient’s own cornea may be used in certain instances.

Managing the Boston Keratoprosthesis The B-KPro is not without a risk for complications, which include glaucoma, erosion/extrusion, retro-prosthetic membranes and keratitis. In considering the post-op management of the B-KPro, Dr. Peter Zloty, an accomplished anterior segment surgeon and recipient of the 2019 APAO Achievement Award, contributed to the discussion. According to Dr. Zloty: “Since the KPro procedure is one of exceptional needs and indications, it only makes sense that the post-surgical care would also need to be exceptional.” The three main tenets of B-KPro management are inflammation control, pressure control and the maintenance of ocular surface health in the patient. For the prevention of inflammation and infection, Dr. Zloty recommends a topical antibiotic such as a fluoroquinolone four times daily. While using antibiotics, he said it is best to avoid aminoglycosides. “Unique to KPro is also the use of an anti-collagenolytic antibiotic such as tetracycline,” he said.

“In addition, topical steroids such as prednisolone acetate or dexamethasone can be used post-op to further treat inflammation.” To help prevent post-op pressure spikes, Dr. Zloty advocates the use of a topical glaucoma agent, such as apraclonidine, routinely used after surgery. “If the patient has good lid closure and normal tear film, they will likely do well,” said Dr. Zloty. “The better the ocular surface, the less likely keratolysis or infection will develop.” Additionally, the use of bandage contact lens can also help prevent erosions and melting to maintain the ocular surface. Dr. Zloty recommends changing the lens every three to six months to prevent infection. Overall, diagnosis and management are crucial to the success and full advantages of the B-KPro. Patients need to be observed often when possible to ensure proper restoration of vision. Intraocular pressure needs to be assessed, therapeutic contact lens needs to be replaced, and vision needs to be verified during each follow-up. Although it may be a lifetime commitment for both the patient and the physician, survival studies show greater than 90% retention after five years. Compared to corneal transplantation, the B-KPro is miles ahead in driving 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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CONFERENCE HIGHLIGHTS DOSCON 2019 Coverage

How is India transitioning from by Gloria D. Gamat

Small incision lenticule extraction (SMILE) was heavily discussed at the recently held Annual Conference of Delhi Ophthalmological Society (DOSCON ) 2019 in New Delhi, India. Ophthalmic surgeons in India, who have transitioned from laser-assisted in situ keratomileusis (LASIK) to SMILE, not only discussed the pros and cons of the procedure, but also shared clinical pearls to get the best outcomes in SMILE.

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n transitioning from LASIK to SMILE, each surgeon had issues with SMILE in the beginning,” said Dr. Radhika Tandon, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences (AIIMS), New Delhi. “The mental readjustment to this new procedure is equally important,” noted Dr. Tandon. The surgical learning curve is not that difficult, according to Dr. Tandon, but the step-by step procedure (i.e., from docking to femtosecond laser delivery) should be worked on slowly with patients to get the best outcomes. “More importantly, read, read, read, and listen to what everybody says,” she emphasized. Apart from visual acuity (VA), contrast sensitivity is a more reliable parameter in assessing visual performance following any refractive procedure, reported Dr. Ananth D of Lotus Eye Hospital and Institute, Tamil Nadu and Kerala, India. In LASIK, he said, there have been reports of at least temporary losses of contrast sensitivity, and this loss may persist six to 12 months postoperatively. In a prospective, observational study of myopic patients (100 eyes, 50 patients) who underwent SMILE procedure at the Lotus Eye Hospital and Institute, Dr. Ananth’s team found that most patients (84 out of 100 eyes) achieved the preoperative

contrast sensitivity within three months following the procedure, while the rest of the patients (16 of 100) did so in six months. There was no significant difference found in contrast sensitivity after six months. Also, at six months to one year postoperatively, no significant difference was noted in contrast sensitivity at any spatial frequency. These results, according to Dr. Ananth, showed that correction of myopic refractive error using SMILE provided statistically significant favorable results, not just in terms of visual acuity but also in terms of the time taken to regain quality of vision (contrast sensitivity). “SMILE is LASIK without a flap and photorefractive keratectomy (PRK) without pain,” said Dr. Shilpa Singh, consultant at Visitech Eye Centre, New Delhi, India. That statement, according to Dr. Singh, summarizes the benefits of SMILE: minimally invasive, flapless, uses cutting instead of ablation. “The biggest advantage of the

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procedure is having no flap, and therefore no flap-related complications,” she emphasized. However, the disadvantages, noted Dr. Singh, is that there is a learning curve to be overcome and that SMILE currently cannot treat hyperopia. While the learning curve cannot be truly called a disadvantage, the bigger consideration is the cost of the procedure. While SMILE and FS-LASIK are comparable in efficacy, safety and predictability in correcting myopia, the loss of biochemical effects may occur less frequently after SMILE than after FS-LASIK. On the other hand, reported Dr. Singh, SMILE may have superior aberrations compared to FS-LASIK in some cases. “A small percentage of SMILE patients can have prolonged recovery compared to those who had LASIK. Also, there are some reports of microdistortions in the Bowman’s layer after SMILE, which may account for delayed recovery,” Dr. Singh added.


LASIK to SMILE? “Though we have had multiple studies comparing the dry eye incidence, patient satisfaction, refractive error correction in the two procedures, we are yet to reach a conclusion whether one procedure has a definite edge over the other,” explained Dr. Singh. “The only thing which almost all studies agree with is that SMILE definitely has a better rate of subjective satisfaction among patients in the immediate postoperative period, especially with respect to dry eye compared with LASIK,” she said. “We still need more studies and data analysis to reach a conclusion as to which procedure is better,” Dr. Singh concluded. But is SMILE a game changer? It definitely is, according to Dr. Chitra Ramamurthy from The Eye Foundation, Coimbatore, India. It’s major ‘attractions’ being an all-in-one solution with fewer variables and a small learning curve, she highlighted. “Uncertainties have always been the breeding ground for newer technologies,” said Dr. Ramamurthy. As is the case in SMILE, that the uncertainties of previous technologies have brought this procedure forward. “Although the biomechanics is still a bit of a mystery, but even if SMILE needs more tissue, it still leaves the cornea stronger than LASIK,” said Dr. Ramamurthy. There are still limits of correction to SMILE (i.e., no mixed astigmatism correction yet, not for the treatment of hyperopia yet), and in small refractive errors, SMILE can be a challenge, she added. In refractive outcomes, every parameter is a toss between LASIK and SMILE. LASIK has been around for more than 20 years, while surgeons are still continuously learning about SMILE. “Learning SMILE is an art in itself. It gives us a greater interest in doing refractive surgery. But knowing the rules of the game raises the bar in getting optimum refractive outcomes,” advised Dr. Ramamurthy.

On the other hand, for Dr. Gaurav Luthra of Drishti Eye Institute & Dehradun Wave LASIK Centre, Dehradun, India, to make the best of both worlds, he uses either SMILE or LASIK, depending on the type of patient. He reported that SMILE is more preferred for myopes from 2-10 DS, myopic astigmatism up to 3 D CYL, sportspersons (or professions with higher risk of trauma), borderline dry eye and those seeking faster physical rehabilitation and lesser precautions. While LASIK, he noted, is for hyperopes and pure/mixed astigmatism, high astigmatism, those seeking faster visual recovery, topography guided or wavefront customized treatments, and those who cannot afford SMILE. Guided by such criteria, Dr. Gaurav believes that no one modality is perfect for every situation. “All modalities — PRK, LASIK, SMILE — have a place in the refractive surgeon’s armamentarium. While SMILE is emerging as the preferred option for a significant chunk of cases, PRK and LASIK still have a role in many situations,” he highlighted. However, once hyperopic SMILE becomes available, indications for LASIK may go down. “That, and a larger long-term data on the biomechanical superiority of SMILE, may tilt the table further,” he concluded. Editor’s Note: DOSCON 2019 was held at The Hotel Ashok in New Delhi, India, from April 12 to 14, 2019. Media MICE Pte. Ltd., CAKE Magazine’s parent company, was the official media partner at DOSCON 2019. Reporting for this story also took place at DOSCON 2019.

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Team Media MICE with Prof. Dr. S. Natarajan at DOSCON 2019, New Delhi, India.


CONFERENCE HIGHLIGHTS VEE 2019 Coverage

Working Hand in Hand New releases from ZEISS foster collaboration and improved care

For the eyecare industry – and caterpillars – change can be a good thing.

by Brooke Herron

“The only thing constant is change.”

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his quote from Greek philosopher Heraclitus may be more than 2,500 years old, but it still rings true today, especially when it comes to eye care and vision. For example, in treatment and diagnostics, the landscape is constantly evolving – and that’s a good thing! In some cases, this evolution can create opportunities for collaboration between ophthalmologists, optometrists and opticians, which can provide

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avenues for the M.D.s and the O.D.s to prosper together. At the Vision Expo East (VEE), held from March 22 to 24 in New York City, USA, Carl Zeiss Meditec (Jena, Germany) introduced new equipment designed to enable optometrists and ophthalmologists to work hand-inhand like never before. Each launch is significant and represents the latest technology in diagnostics, helping the O.D. community to deliver the highestlevel in diagnostics and patient care.

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June/July 2019

Updates in Glaucoma Management It is a known fact that there are more people retiring than entering ophthalmology (including the glaucoma subspecialty), and as the population ages, the need for eye care will only increase. According to Mr. Angelo Rago, Global Head of Ophthalmic Diagnostics, Carl Zeiss Meditec, there needs to be a more effective way to manage patients with chronic disease, like glaucoma.


This is especially true for patients who live in rural regions and may lack access to specialist care. The new two releases from ZEISS — for its Humphrey Field Analyzer 3 (HFA3) and CIRRUS platforms — may provide patients seeking care with more options and help fostering co-management between optometrists and ophthalmologists. Mr. Rago said he sees this as an opportunity for the treatment mode or work flow to change, and ZEISS wants to be a partner in that change. “With HFA, the entire patient history can be taken to an ophthalmologist, and they can decide how they want to proceed with treatment,” said Mr. Rago. “The patient can be brought back to the optometrist to be managed over time — a co-management concept.” The newly expanded CIRRUS OCT-HD also includes features valuable to co-management. “The first thing we added in the new version is the angiography OCTA montage, which allows optometrists to manage diabetics more effectively,” said Mr. Rago. If current trends continue, more collaboration might be in the future for American ophthalmologists and optometrists. Recently, private equity firms have been purchasing existing practices, and in some cases consolidating them, in an effort to optimize the flow of patients, while reducing costs and increasing revenues. Opinions on this matter vary greatly within the industry, and, of course, there are pros and cons. Mr. Rago said that a significant shift is happening in the industry. For optometrists, who may already feel the pinch from online, appointment-free access to glasses and contacts, adding value with additional services, like those featured in the ZEISS releases, and co-management of patients with ophthalmologists, might be the way forward. Editor’s Note: Vision Expo East (VEE) 2019 was held in New York City, USA, from March 22 to 24, 2019. Reporting for this story also took place at VEE 2019.

HFA3 SITA Faster v 1.5

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he Humphrey Field Analyzer 3 (HFA3) is a gold standard in managing glaucoma and its progression. And now, the update — HFA3 v 1.5 provides a choice of two new tests: SITA Faster 24-2 tests in as little as 2 minutes or less, and SITA-Faster 24-2C provides more information around the macula in less time than SITAFast test. “Most patients only have visual fields done once per year, which delays the detection of progression,” said Mr. Rago. “The new tests are so short that patients are happier, throughput is increased, facilitating more frequent testing and earlier change detection.” The 24-2C test pattern adds 10 of the most commonly flagged points from the 10-2 pattern to the traditional 24-2 pattern. Therefore, doctors don’t have to choose between a 24-2 or 10-2 test. “Instead of a single flagged point inside 10 degrees, if 2 or 3 contiguous points are flagged that should give doctors confidence that the defect is real,“ said Mr. Rago.

CIRRUS 11.5

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ne new feature to CIRRUS HD-OCT anterior segment premium module is Epithelial Thickness Mapping (ETM) — a one-second, no-contact exam, which allows for confident assessment of corneal response to refractive surgery. This feature, which was recently cleared by the FDA, provides over 200% more measured data in a 9x9 scan than other current technologies. Mr. Rago added that this platform could also be valuable in the comanagement of refractive patients. The update also includes a Wellness Report, which can help manage patients over time. Designed to meet the specific needs of an optometrist performing primary care, the Wellness Report gives clinicians a simple way to add health evaluation services to their practices by providing a single-page report with wide-field OCT assessment of both the macula and optic nerve head. “This fits in the space of chronic eye disease and ensures that these conditions are effectively managed over time,” explained Mr. Rago. “Not only that, but these reports enable communication with the patient, and help with education.” In addition, he said the CIRRUS platform provides access and consistency of data, resulting in a tremendous source of information — to help doctors treat patients. “The original CIRRUS goes back to 2007 — and for glaucoma patients, you can easily have 20 years of data,” said Mr. Rago. “We’re always looking to add more value to collected data.”

CAKE Magazine’s Alex Young with Mr. Angelo Rago (right), Global Head of Ophthalmic Diagnostics, Carl Zeiss Meditec, at the recent VEE 2019 event in New York City, USA

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June/July 2019

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@ DOSCON 2019

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