CAKE Magazine Issue 04: The ebook version ('The Stand-Up Issue', AIOC 2020 Edition)

Page 1



THE STAND-UP ISSUE December/January 2020

Cover Story

No Laughing Matter

The Art of Surgical Improvisation Page 24


06 Matt Young

CEO & Publisher

Robert Anderson

Cataract 08 10 12 15

A Novel Approach to Capsulorhexis Technique in Miotic Pupils

Media Director

Hannah Nguyen

Production & Circulation Manager

Gloria D. Gamat Chief Editor

Brooke Herron Associate Editor

Mark Hillen


Anterior Segment 16 18

SUSTAINED-RELEASE BIMATOPROST: Keeping glaucoma treatment on target, even for non-compliant patients

Intraocular Lens Replacement in a World of Blue Light Comparing Two Novel Approaches to Cure Cataract in Children A Wide-Angle Glimpse of the Latest in Capsulotomy Discoveries CATARACT SURGERY: Enhancing the Patient’s Experience


FIGHTING SMARTER: Optimizing the Current Landscape of Ocular Anti-infectives

WHAT’S UP, DOC? Investigating the effects of ectasia after LASIK and SMILE

Ruchi Mahajan Ranga Project Manager

Samuel McCommon

Digital Content Manager

Andrew Sweeney

Cover Story

Sales & Marketing Representative Graphic Designer


Winson Chua

NO LAUGHING MATTER: The Art of Surgical Improvisation


April Ingram Chow Ee-Tan Gerardo Sison Hazlin Hassan Joanna Lee Konstantin Yakimchuk Tan Sher Lynn

Kudos 30

Dr. Suvira Jain: On Healing Eyes and Touching Lives

Cover Art


Dr. Marcus Ang: The 2019 Artemis Awardee

Prafulla Badgujar Published by

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In the Eye of the Beholder: Eyelid Cosmetic Enhancements and their Associated Ocular Adverse Effects

Conference Highlights 38 41 44 46

Retreatment, Relationships and Regimens at AAO 2019

Enlightenment 36

Making Clear Vision Possible for the Underprivileged


Set your Sights on India for AIOC 2020

Elegance and Innovation Showcased at the APACRS 2019 in Kyoto Managing Corneal Disorders in Cataract and Refractive Patients Latest Technology in Cataract Surgery

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CAKE MAGAZINE Letter to Readers


he hook on which I hang this editorial is the chorus from a song by a long-defunct small Scottish indie band called Amplifico. It goes: “The comedy stops here. It’s time to get serious”. This isn’t a column where I make ‘the cornea, the better’ jokes (for a change). Eye care is a serious business. In fact, comedy is, too. The most successful comedians I’ve seen are the hardest working people in the business. Sure, if you’re funny and you want to coast along, you can get by simply with gigging at comedy clubs and being paid in cash at 3 a.m. But to be truly good, and in control of a room, you have to work hard. It’s the same as, let’s say, cataract surgery: Practice makes perfect. You need to get out there and get hundreds of gigs under your belt before you’re really able to work a room (and the wide spectrum of audiences there) to a successful outcome – laughter and big applause at the end of your set. It’s a bit like eyes with different densities of cataract, zonules and other comorbidities: You need hardwon experience to win over your (one-person) audience. Like laughter (or the lack of it), your feedback is fast. You’ll know very quickly whether it’s a successful procedure or not. Both comedians and ophthalmologists know that failures hurt. After all, this is your reputation you’re building. But to be truly great, you have to do more. Comedians have to tour arenas, star in Netflix specials, play the hilarious sidekick to the Hollywood action movie star. And to unlock all these, they need help. They need a team – a manager to look after their interests and negotiate the best deals for them, a publicist to keep them in the public eye (but also to shield the public from the excesses that only success and a swelling ego can bring), and a roadie – someone to drive them from gig to gig and writers’ room to writers’ room. Think about who you rely on to get your work done. If you’re still writing the practice’s web pages, booking flights and ordering supplies – but you have the hands of a surgical God – have you really joined the ranks of the superstars? Do you need to learn from Adam Sandler, Aziz Ansari or Ken Jeong on how to break through to the next level? It can turn sour for comedians quite quickly. Louis C.K.’s past behavior eventually caught up with him and became too much for even the best professional reputation management team to handle. Despite being one of the best-of-the-best on stage, he’s fallen far, and it’s highly unlikely he’ll reach the top ever again. Annoy the wrong person in your management agency or at a media network, and you can soon become invisible and be booted back down to the ranks of the ‘jobbing comedian’.

But doctors don’t need to be reminded of the duty of being professional in their actions, or the dangers of political faux pas – it’s been like that since medical school. If you want to be on stage and present your work to a room full of your peers – and unless you’re one of the handful of gamechanging mavericks – you’d better play the game. But it’s important to remember why you’re doing what you do. For comedians, it’s validation, camaraderie with their fellow kind, and rising to new heights with shared laughter. To have fun. Again, it’s the same with surgeons. If you look up, take a breath, and notice five years have passed in the blink of a (bloodshot, tired) eye, maybe it’s time to rethink things. Life shouldn’t be a total slog. But pretty much everyone has a mortgage, car lease and a family by the time they get to that point in life. That level of income isn’t something you can easily give up. Here, I defer to an old friend who embraced research early in his career in ophthalmology: It keeps him interested. Where others get disillusioned or bored, and are considering selling up and retiring early, he gets to keep being challenged by the big problems in the field and stays occupied by trying to solve them. And that’s where ophthalmologists and comedians differ. While comedians might experiment with a new joke, story or a different punchline, that’s the daily grind – it’s continual professional development (or CPD). But it doesn’t represent a new and fulfilling avenue, or add a ‘second string to your bow’. So, yes. It’s hard work being a success in either field. Yes, CPD is required. Yes, your public, workplace and political personas are important to keep carefully curated. But you, dear ophthalmologists, made the right choice. By going to medical school, you not only made your mother happy, but you also gave yourself the chance of a more fulfilling career. Your work makes a much greater impact on the lives of the people who see you in your professional capacity, and you’re extremely unlikely to have to tour college theaters to ply your trade and earn your living. Unless you’re Twitter’s own Dr. Glaucomflecken (to my knowledge, ophthalmology’s only stand-up comedian). He’ll at least have a different option when his mid-50’s career blues set in. Best, Mark Hillen Director of Communications ELZA Institute, Zurich, Switzerland Editor-At-Large CAKE Magazine

New F-Sonic Phaco Tips The F-Sonic Phaco Tip allows cataract surgeons to get the best out of every step of phacoemulsification: • Constant aspiration flow • Increased irrigation flow • Chamber stability even under high vacuum conditions • Effective emulsification of the nucleus • Double flared design • Limited tissue damage due to reduction of thermal impact • Effective phaco time reduction also in small incision size (MICS)

With the Medicel F-Sonic Phaco Tip I am able to administer as little phacoemulsification power as possible, even on hard cataracts – which also helps to minimize energy damage in general.

Dr. J. K. Shah, Shah Eye Clinic Andheri West, Mumbai, India

Medicel AG Dornierstrasse 11 9423 Altenrhein / Switzerland T +41 71 727 10 50

Further information: Mr. Dhrubajyoti Mazumdar Sales and Marketing India Mobile +91 94484 78590

The newly developed Medicel F-Sonic Phaco Tip allows a significant modification in my surgical procedure, as I am able to work efficiently quick, using high vacuum levels without having to give up well-established safety aspects. Dr. Christian Scheib, ViDia Kliniken Karlsruhe, Germany

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:]

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:]

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:]

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:]


December/January 2020


ATARACT Surgical Technique

Dense cataract got you down? Now, there may be a technique that can help...

A Novel Approach to Capsulorhexis Technique in Miotic Pupils by April Ingram


patient with a dense cataract and pupillary miosis can not only test the skill and patience of even the most experienced cataract surgeon, it can also shake the confidence of those in training. This is because the obscured visualization of the capsule and nucleus can wreak havoc on the key elements of a successful surgery – seriously limiting the ability to create the desired capsulorhexis, safely removing the lens material, or effectively inserting an intraocular lens (IOL). Complications attributed to inadequate capsulorhexis or poor visualization of the peripheral nucleus during phacoemulsification can include anterior capsule tears, posterior capsular rupture (with or without vitreous loss), zonular dialysis/dehiscence, and nuclear fragment loss.1 These eyes are also at higher risk of iris damage, leaving patient with increased postoperative inflammation and iris defects that can

be cosmetically unappealing or cause visual disturbances. Keeping all these factors in mind, combined with the well-known phacoemulsification learning curve, eyes with dense cataract and pupillary miosis can be an OR nightmare for the novice surgeon.



The Creation of a Capsulorhexis Dr. Stephen LoBue and co-authors from Murrieta, California, USA, have recently published their experience with an approach that they developed and standardized in order to facilitate the creation of a capsulorhexis in patients with pupillary miosis and dense nuclear sclerosis. (Cue the sigh of great relief for cataract surgeons everywhere!) The technique incorporates a pupil expansile ring and capsular staining under both air and dispersive viscoelastic, this stabilizes the iris and December/January 2020

provides consistent dilation throughout the course of the case, thereby minimizing complications. The work of Dr. LoBue was originally presented at the Association for Research in Vision and Ophthalmology (ARVO 2019) in Vancouver, Canada, and more recently published in Clinical Ophthalmology.2 The nine eyes included in the report had 4+ nuclear sclerosis, absent red reflex, white mature or brunescent cataracts, accompanied by impaired preoperative pupillary dilation of 3mm or less. Recall that the minimum threshold for successful capsulorhexis and phacoemulsification has been described as a pupil diameter of 4.5-5.0mm for experienced surgeons and 6mm for novice surgeons. These eyes were at least half of that, and some were smaller.3,4 The mechanism for miosis of patients involved in this study included posterior synechia (3), tamsulosin (2), donepezil (2) and idiopathic (1).

To illustrate how rare the presentation of this combination of dense cataract and small pupils can be, these 9 included eyes were the result of a review of 1,408 phacoemulsification cataract surgeries performed at LoBue Laser and Eye Medical Center Inc. All patients had best corrected visual acuity (BCVA) of 20/70 or poorer. All surgeries were performed by a single experienced surgeon, and phacoemulsification was done using the Alcon Centurion platform.

A Novel Procedure Dr. LoBue described the approach, beginning with the creation of a 1mm corneal paracentesis, superiorly for right eyes and inferiorly for left eyes. They used intracameral methylparaben-free xylocaine to numb the iris and cohesive viscoelastic to fill the anterior chamber. The cohesive viscoelastic temporarily deepens the anterior chamber, widens the pupil and supports the iris. Using a microkeratome blade, a 2.4mm temporal clear corneal incision was made. And if posterior synechiae were present, it was broken with a collar button (a collar button was preferred in order to minimize damage to surrounding structures). Next, to adequately expand the pupil, a 6.25mm malyugin ring was placed through the self-sealing, triplaner cornea wound, docking on the nasal and superior or inferior iris. The cohesive viscoelastic was then carefully removed using an irrigating/aspiration tip, and a small amount of viscoelastic sealed the paracentesis. If necessary, the wound was sealed with a single 10-0 nylon suture before air was injected through a 27-gauge cannula through the paracentesis. Dr. LoBue explained that surgeons shouldn’t worry if multiple bubbles appear in the anterior chamber – they will quickly coalesce into a single bubble after a few seconds. Trypan blue was then injected through the paracentesis, ensuring visualization of the cannula in the air bubble. The air

and dye were subsequently removed by filling the anterior chamber with a dispersive viscoelastic. Special importance was placed on the ability to visualize the cannula within the air bubble so as not to compromise the integrity of the anterior capsule. Finally, a ~5 mm continuous curvilinear capsulorhexis was initiated with a cystotome and was completed using Utrata forceps. [A complete explanation and illustrations of this novel approach can be found in the full article, available in Clinical Ophthalmology.2] The authors outlined the multiple reasons that this approach is advantageous in eyes with dense cataract and small pupils: “First, the anterior segment is well sealed, minimizing air leak and shallowing of the anterior chamber during capsular staining. Rapid changes of the lens-iris plane can lead to unintentional damage of the anterior capsule, compromising capsulorhexis formation. Secondly, staining under air prevents direct contact of the dye with the corneal endothelium and allows for better enhancement of the peripheral anterior capsule rim. As a result of better visualization, the rate of successful capsulorhexis formation significantly improves.”

They added that “the uniform staining of the anterior capsule with trypan may even be helpful for all grades of cataracts, especially in training ophthalmologists”.

Promising Results A novel technique indeed, but more importantly, how were the patient outcomes? As noted, the preoperative distance visual acuity was 20/70 or poorer, but improved from 20/20 to 20/70 in all patients, including the majority of eyes achieving an impressive 20/40 or better. Surgery was uneventful and capsulorhexis formation was successful in all cases with no capsular tear, vitreous loss, or necessary conversion to extracapsular cataract extraction – showing promising results to improve visualization in these difficult eyes. This approach may be beneficial in other circumstances, including highrisk cataract surgery for white mature/ deep brunescent cataracts and miosis associated with intraoperative floppy iris syndrome or for patients with a history of dementia, both associated with a high complication rate.

References Martin KR, Burton RL. The phacoemulsification learning curve: per-operative complications in the first 3000 cases of an experienced surgeon. Eye (Lond). 2000;14(Pt 2):190-195. 2 LoBue SA, Tailor P, LoBue TD. A Simple, Novel Approach to Capsulorhexis Formation in the Setting of A Mature Cataract and Miotic Pupil. Clin Ophthalmol. 2019;(13)2:2361-2367. 3 Kim JY, Ali R, Cremers SL, Yun S-C, Henderson BA. Incidence of intraoperative complications in cataract surgery performed by left-handed residents. J Cataract Refract Surg. 2009;35(6):1019-1025. 4 Malyugin B. Cataract surgery in small pupils. Indian J Ophthalmol. 2017;65(12):1323-1328. 1

About the Contributing Doctor Dr. Thomas LoBue is the medical director and founder of the LoBue Laser & Eye Medical Centers Inc. He has been providing comprehensive ophthalmic care in the Inland Empire since 1989. Dr. LoBue received his undergraduate degree at University of California, Irvine, with a B.S. in Biology. He attended Medical School at University of Health Science/Chicago Medical School in Chicago, IL. He completed both his internship and residency at Rush Presbyterian St. Luke’s Medical Center in Chicago. During his final year of training, he was chosen as chief resident. Dr. LoBue acquired additional training at Estelle Doheny Eye Institute at the University of Southern California (USC). He is a diplomate of the American Board of Ophthalmology, a member of the American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, International Society of Refractive Surgery, and a former faculty member of Rush University and Medical College. [Email:]


December/January 2020


ATARACT IOLs Intraocular Lens Replacement

in a by Gerardo Sison


World of Blue Light

n an aging population, the growing need for cataract surgery and replacement intraocular lenses (IOLs) has become more apparent. However, due to variabilities in macular pigments, crystalline lens changes and light exposure, there may be more at stake. Many patients needing intraocular lens replacement may be at an increased risk of ocular damage due to photo-oxidative effects from short-wave blue light. Intraocular lens solutions for agerelated macular degeneration (AMD) have been used throughout the years and resulted in the development of blue light-filtering intraocular lenses (BLF IOLs). These BLF IOLs may help protect against ocular damage, prevent visual performance issues and improve glare discomfort. Dr. Billy Hammond, PhD, professor and neuroscientist at the University of Georgia, initially studied the effects of dietary compounds such as lutein and zeaxanthin on eye and brain health. In a review conducted earlier in 2019, he reported the effects of BLF IOLs

and their use in AMD patients needing cataract surgery.



Blue Light in Nature “A lot of animals use yellow filters to filter blue light,” said Dr. Hammond. “Some fish have yellow corneas, which is a fairly common way to adapt to ecological niches where visual function could be impaired by bright sunlight and exposure to short-wave light.” The human and animal ocular lenses have become strongly affected by blue light and its influence on visual function and ocular tissue. Not only are humans susceptible to blue light effects, but animal species such as prairie dogs and squirrels have developed filter adaptations to prevent damage from constant exposure. Naturally occurring macular pigments such as zeaxanthin and lutein are found in the macula and absorb short-wave visible light (400-520nm). These macular pigments are found in concentrated proportions in and around the fovea, screening central cones

December/January 2020

and rods of the retina. Research has found that dietary lutein and zeaxanthin supplementation can help improve visual functions in conditions with glare compared to placebo. According to Dr. Hammond, one problem is that over time, humans have become deficient in lutein and zeaxanthin pigments, which has only compounded the problem that blue light elicits. “Blue light is not only deleterious for long-term damage,” he said. “It interferes with visual functions in various ways.”

Combating Photo-Oxidative Damage Ocular damage often contributes to the etiology of several diseases such as pinguecula/pterygium and photokeratitis. Damage caused by continuous exposure to short-wave blue light is also associated with conditions such as age-related cataracts and AMD. In older adults, photosensitizers to specific wavelengths of blue light can be especially damaging to the retina.

Ultra-violet (UV)-filtering IOLs are commonly used for cataracts and were developed to block UV absorbance which can quickly lead to retinal damage. These lenses were also used because they are similar to the human lens, albeit more similar to the infant lens and not the older adult lens. Replacing the opacified natural lens with a non-BLF UV-filtering IOL, however, can alter the natural development of the adult visual system. In older eyes, a non-BLF IOL may increase the risk of photo-oxidative damage from blue light. Blue light transmission is much more damaging in the eyes of an older adult, especially one living with AMD. “Older retinas have more shortwave photosensitizers,” explained Dr. Hammond. “Light is damaging in the presence of photosensitizers. The more damaged it is, the more damaged it becomes.”

The Impact of Blue Light Filtering Lenses In normal healthy eyes, the crystalline lens and macular pigments of the inner retina are able to absorb blue light. As a result of cumulative oxidative damage, the crystalline lens then becomes yellow and absorbs greater amounts of UV and short-wave light. This absorption provides better protection from blue light. “Implanting [an IOL] that mimics the natural lens as closely as we can was the genesis of the blue light-filtering lenses,” said Dr. Hammond. In-vitro studies evaluated BFL IOLs and found that they may aid in reducing retinal pigment epithelial cell death from continuous light exposure. According to the review, BLF IOLs have also been shown to reduce cellular proliferation rates of human uveal melanoma cell lines exposed to blue light more so than UV-filter lenses. For patients with AMD, the use of BLF IOLs has been evaluated for effects on the progression and development of the disease. In one study, fundus autofluorescence was measured to assess the development of AMD after implanting either a BLF

Blue light is not only deleterious for long-term damage. It also interferes with visual functions in various ways.

– Dr. Billy R. Hammond IOL or a UV-filtering IOL. After two years of implantation, AMD incidence was significantly higher (P<0.05) in the UV-filtering IOL group (11%) compared to the BLF IOL group (2%). In another study that examined 66 eyes with geographic atrophy, findings showed slower disease progression with BLF IOLs compared to non-BLF IOLs.

Improved Visual Performance with BFL IOLs In addition to creating a more naturally progressing intraocular lens environment, BLF IOLs may also improve visual function and performance. Glare disability (GD), characterized by the loss of visual function from intraocular scattered light, can be an important factor when choosing an IOL. “Before they put the IOL in, they emulsify the original lens,” said Dr. Hammond regarding cataract surgery practices. “They leave the capsule, but it’s difficult to perfectly remove the old lens. So, any remnants of the old lens can create scattering issues. If you filter out the more energetic part of bright light, you’ll have less glare problems.”

Along with glare disability and discomfort, photostress recovery time, or the time it takes for normal vision to recover after exposure to bright light, may also be improved with BLF IOLs. In a study comparing BLF IOLs and UV-filtering IOLs, both GD and photostress recovery were significantly improved with the BFL IOL (P=0.04 and P=0.02, respectively). This improvement in visual function may be especially practical for improving safety margins while driving. While further studies are needed to determine long-term benefits with BLF IOLs, the potential advantages are hard to ignore. Reduction in degenerative changes in AMD patients is an important factor to consider when assessing IOL options. Research has highlighted the protective effects of BLF IOLs as well as improved visual performance in terms of glare disability. “Correcting refractive errors was at the forefront in the beginning. But now everyone is myopic,” said Dr. Hammond. “There’s more that we can do now with making lenses that adapt your vision with strategic filtering. This is becoming more necessary as people have more issues with their vision.”

Reference Hammond BR, Sreenivasan V, Suryakumar R. The Effects of Blue Light-Filtering Intraocular Lenses on the Protection and Function of the Visual System. Clin Ophthalmol. 2019;13:2427-2438.

About the Contributing Doctor Dr. Billy R. Hammond is a professor in the Behavioral and Brain Sciences program at the University of Georgia, in Athens, Georgia, USA, where he focuses on visual neuroscience and psychophysics. He is also a researcher at the Vision Sciences Laboratory, where he is exploring the role of lifestyle and diet on the progression of degenerative disease and the functions of the central nervous system. Dr. Hammond has published data on the development of age-related eye disease and is currently investigating preventative approaches to dementia. He and his team are also undertaking projects on Sports Vision and overall visual performance. Dr. Hammond received his Ph.D in visual neuroscience at the University of New Hampshire and completed a post-doctoral fellowship at the Schepens Eye Research Institute at Harvard University. [Email:]


December/January 2020


ATARACT Pediatric Cataract

Comparing Two Novel Approaches

to Cure Cataract in Children by Konstantin Yakimchuk


ongenital cataract usually manifests through lens opacification in early childhood. Although the etiology of cataract in many cases is still unknown, mutations in genes regulating lens morphology cause up to 30% of congenital cataracts.1 In infants, surgical treatment is highly recommended for dense cataracts, unilateral cataracts with strabismus, or bilateral cataracts with nystagmus. Currently, both capsulotomy and anterior vitrectomy for treatment of the congenital cataract can be performed either via limbus or pars plana.

A Tale of Two Innovative Approaches Two approaches for cataract surgery – corneal and pars plana/pars plicata – have been compared by Koch et al. in a study published in the recent issue of Clinics.2 The authors compared long-term complications of primary intraocular lens implantation caused by either a corneal or pars plicata or pars plana method. Earlier studies have shown that treatment of infantile congenital cataract with pars plana without intraocular lens (IOL) implantation provides more efficient lensectomy and vitrectomy and reduces local inflammation.3 Koch and co-authors have reported that all patients were operated for cataract using IOL implantation combined with posterior capsulotomy and anterior vitrectomy. The surgery commenced with a corneal incision followed by the injection of an ophthalmic viscosurgical device (OVD) into the anterior chamber, anterior capsulotomy, and lens removal. After this common part of the surgery, two distinct surgical techniques were carried out. According to the study, one group of patients underwent


the surgery via the corneal approach, while the pars plana approach was used in another group.

Are These Surgical Approaches Completely Safe?

How do These Techniques Differ From Each Other?

Despite the recent advancements in cataract surgical cure, surgeons are still facing complications in their pediatric patients, such as visual axis opacification and inflammation. Although surgeons believe that the corneal technique is the easiest surgery to perform, the authors advocate the pars plicata/pars plana method due to both short- and long-term positive outcomes. Moreover, corectopia and visual axis opacification, rather severe complications, were observed only in patients who underwent the corneal type of surgery, while the pars plicata/pars plana technique did not show any side effects. As an explanation, the authors suggested that the corneal technique causes higher vitreous pressure. The present study was in line with a previous observation by Liu et al., who compared the efficiency of the limbal and pars plana approaches.4 Even though both surgical approaches were accompanied by several intraoperative complications in the iris, such as

Briefly, for the corneal approach, surgeons performed capsulotomy using capsulorhesis forceps, and inserted an infusion cannula to sustain electrolyte balance and a vitrectomer to accomplish anterior vitrectomy. Following IOL implantation, 10-0 nylon suture was applied. In contrast to corneal method, the pars plicata/pars plana technique implies an additional corneal incision in order to insert a cannula for balancing salt solution in the anterior chamber. After the aspiration of OVD, the corneal incision was sealed with nylon sutures and vessel coagulation followed. Finally, posterior capsulotomy and anterior vitrectomy were done. Polyglactin suture was applied to close the sclerotomy region. Another advantage of the study was that the authors used the longest follow-up period to compare the two surgical approaches. Notably, no incidence of glaucoma or retinal detachment have been detected. Although ophthalmologists regard the corneal method as the simplest technique, Koch et al. believe that the pars plana method will gain further popularity in the near future. The authors emphasize that the pars plana technique using a 20-gauge vitrector can be considered as a cautious and effective approach to implantation of intraocular lens with capsulotomy and vitrectomy.


December/January 2020

Get excited about pediatric cataract treatments!

aspiration and prolapse, the pars plana technique showed significantly less complications than the limbal approach. In addition to intra- and postoperative observations, Koch and co-authors observed neither glaucoma nor retinal detachment during the followup period. However, they recommend two follow-up visits per year until the patient reaches 18 years of age, since different complications, such as retinal detachment, have been noted up to 10 years after the cataract surgery.5 In addition, apart from visiting their cataract surgeon, the patients are also advised to visit an optometrist and, in complicated cases, a glaucoma or retina specialist.

How Can Surgeons Prevent Complications? The authors of the current study state that intraoperative iris injury can be avoided by proper manipulation of the vitrectomy probe. In addition to surgical techniques, recent studies have achieved notable improvement in vitrectomy probes.6 With regard to the size of the instruments for vitrectomy, the 25-gauge system has been shown to be effective for cataract surgery.7 Smaller-size systems allow more accurate manipulations and prevent the development of postoperative astigmatism. However, a 20-gauge system might be appropriate in some situations. Notably, the current study indicates that the corneal technique was accompanied by higher number of complications. Therefore, if the corneal method is by any reason preferable, Koch et al. strongly suggest smaller size vitrectomy.

Distinct Advantages of the Pars Plicata/Pars Plana Approach To obtain an expert’s opinion, Dr. Shalesh Kaushal, an ophthalmologist in Florida, was invited to comment on the Dr. Koch and co-authors’ article. Dr. Kaushal emphasized that he performs cataract surgery mainly via an anterior approach. Nevertheless,

he shared: “there are certain distinct advantages of a pars plicata/pars plana approach. These include better stability of intraocular pressure, reduced postoperative inflammation, and ease of making posterior capsulotomy”. When asked if the pars method is more cost effective than the other surgical techniques, Dr. Kaushal said, “this really depends on the vitrectomy unit that is used and the cost of disposable packs, including the vitrector and infusion tubing. There can be quite large price differences when comparing companies providing vitrectomy equipment.” Regarding the complications of the pars plana technique, Dr. Kaushal, who himself has performed many cataract and retinal surgeries, added that “the pars plana approach for cataracts affords

greater margin of error, but it takes the eye longer for post-op recovery”. This may be important for a surgeon who is starting these types of surgeries.

Conclusion The present study compares the corneal and pars plana surgical techniques as two common types of cataract surgery. However, the authors favor the pars plana approach due to several advantages of this method. Improved outcomes are seen in patients who were operated via the pars plana approach during the follow-up period. Thus, the study concludes that the pars plana technique is a safe surgical approach, which can be effectively used to treat pediatric cataracts.

References Medsinge A, Nischal KK. Pediatric cataract: challenges and future directions. Clinical Ophthalmol. 2015;9(1):77-90. 2 Koch CR, Kara-Junior N, Santhiago MR, Morales M. Comparison of different surgical approaches for pediatric cataracts: complications and rates of additional surgery during long-term follow-up. Clinics. 2019;74:e966. 3 Liu X, Luo Y, Zhou X, Jiang L, Zhou P, Lu Y. Combined pars plana and limbal approach for removal of congenital cataracts. J Cataract Refract Surg. 2012;389(12):2066-2070. 4 Liu X, Zheng T, Zhou X, et al. Comparison between Limbal and Pars Plana Approaches Using Microincision Vitrectomy for Removal of Congenital Cataracts with Primary Intraocular Lens Implantation. J Ophthalmol. 2016;2016:8951053. doi: 10.1155/2016/8951053. Epub 2016 May 30 5 Agarkar S, Gokhale VV, Raman R, Bhende M, Swaminathan G, Jain M. Incidence, Risk Factors, and Outcomes of Retinal Detachment after Pediatric Cataract Surgery. Ophthalmology. 2018;125(1):36-42. 6 Cacciatori M, Arpa P. Surgical technique for anterior segment surgery in pediatric patients using 25-gauge instruments. J Cataract Refract Surg. 2006;32(4):562-564. 7 Chee KY, Lam GC. Management of congenital cataract in children younger than 1 year using a 25-gauge vitrectomy system. J Cataract Refract Surg. 2009;35(4):720-724. 1

About the Contributing Doctor Dr. Shalesh Kaushal obtained his BS degree at Yale University in Molecular Biophysics and Biochemistry. Subsequently, he completed his MD at Johns Hopkins and PhD at MIT with the Nobel Laureate Dr. Har Gobind Khorana. Following his PhD, he completed his residency at the Doheny Eye Institute/USC Department of Ophthalmology and his surgical retina fellowship at the Washington University St. Louis/Barnes Retina Institute. While at the University of Florida, he was the Richardson II Chair and head of the retina division. Dr. Kaushal established the clinical and surgical retina division, recruited physicians, trained residents and surgical fellows mentored undergraduates, medical students, graduate students, and post-docs in his research lab. In 2009, he was recruited to the University of Massachusetts as the chairman to build a new eye center and the first new academic Department of Ophthalmology in the USA in over 25 years. Besides these academic pursuits, he is the founder of three biotech companies and has been a consultant for most of the leading ophthalmic pharmaceutical companies. In 2013, Dr. Kaushal transitioned back to Florida to pursue private practice. He has currently funded research project studying the incidence of diabetic retinopathy in the general population using a novel telemedicine instrument. In 2015, Dr. Kaushal received the prestigious Seelig Research Award from the ACN. He is recognized in Marquis’s Who’s Who in Medicine and Science and nominated by Castel Connolly as a Top Doctor. He has been invited as a speaker throughout the US and internationally. [Email:]


December/January 2020


ATARACT Surgical Tools

A Wide-Angle Glimpse of the Late A by Joanna Lee

t the 34th Asia-Pacific Academy of Ophthalmology (APAO 2019) Congress, attendees were treated to a wide-angle view of the latest tools and technologies available for better cataract surgeries – from newest developments in intraocular lenses (IOLs), to an insightful debate on the tools currently in the market for capsulotomy. These newly released technologies hold much promise for surgical efficiency and the potential for patients’ comfort and spectacle independence. However, as with every unchartered territory, there remains a need to test the efficacy and reliability of these technologies through trials in order to harness their full potential, especially for patient-specific conditions.

New Lenses on the Block A session, titled “New Technologies for Cataract Surgery”, began with Dr. Tim Schultz from the Department of Ophthalmology, University Eye Hospital Bochum, Germany, presenting a broad overview on IOLs. He reported about the latest clinical trials on enhanced depth of focus (EDOF) IOLs/presbyopia correcting IOLs which are “positioned somewhere between monofocal and multifocal IOLs”. So far, the few studies and cases reported have demonstrated good results for intermediate and near visual acuity with the lenses having advanced diffractive technologies, covering small aperture lens1 technologies, as well as the manipulation of lens aberrations and asphericity. While various EDOF lenses like Lentis Comfort and Lentis Mplus (Oculentis GmbH, Berlin, Germany), Instant Focus (SAV-IOL, Neuchâtel, Switzerland), Precizon (Ophtec B.V., Groningen, The Netherlands), Mini Well Ready (SIFI Medtech, Catania, Italy) and others have been

introduced in the market, Dr. Schultz highlighted the lack of randomized comparative studies in understanding the effectiveness of EDOFs. Out of 11 articles found on Pubmed, only one randomized controlled trial, a French study2, was found. Dr. Schultz’s team’s prospective randomized trial showed the TECNIS Symfony (Johnson & Johnson, Santa Ana, California, USA) and the IC-8 (AcuFocus, Irvine, California, USA) presenting good refractive outcomes for intermediate and near visual acuity with better distance visual acuity for the IC-8 group, especially under mesopic light conditions. Symfony was shown to perform slightly better for near visual acuity, but the issue of halos was reported.



December/January 2020

What about the other lenses on the spectrum? Dr. Gerd Auffarth emphasized on the newer generation of lenses, which promise to reduce the ‘glistening’ effect in patients. The latest enhanced monofocal IOLs, like the TECNIS Eyhance (Johnson & Johnson, Santa Ana, California, USA), are developed from optical technology “based on a continuous asphericity of a higher order”, meaning a continuous power change from the periphery to the middle of the lens. Dr. Auffarth was also involved in one of the trials two years ago. “It’s not an EDOF lens, but it allows for better targeting for on-spot refraction, giving a little bit more refractive tolerability and slight improvements in intermediate vision,” he shared.

test in Capsulotomy Discoveries There’s also a type of hybrid between EDOFs and monofocals, as seen in the Santen lens, a two-ringed hydrophobic lens working under a diffractive principle under trial in Heidelberg, Germany, targeting distance and intermediate acuity. Dr. Auffarth also covered the application of new technologies like reversible trifocality, where supplemental IOL implantations are added on to achieve spectacle independence and reduce dysphotopsia.

Adjustable IOL Technology The latest trends in adjustable IOL technology, according to Dr. Burkhard Dick, includes IOLs requiring a secondary procedure for power adjustment (multicomponent lenses). He gave examples of the PreciSight Lens (InfiniteVision Optics, Strasbourg, France) and Harmoni (ClarVista, Aliso Viejo, California, USA) that allow for customized prescription with a minimized need for touch-ups. Other potential indications were for increased chances of secondary IOL interventions, for instance, where there is anticipated refractive change (midor long-term) for post-keratorefractive surgery, or for multifocals or EDOF optics to allow for neuroadaptation, as well as for pediatric cataract to fix refractive changes over time. Another modality was non-invasive IOL power adjustments, which can be done via a femtosecond laser procedure known as laser-induced refractive index change (LIRIC). Differing widely from the laser-assisted in situ keratomileusis (LASIK), LIRIC is a subthreshold treatment that changes the refractive index caused by multi-photon absorption of ultra-short laser pulses. This can be done either intra-corneal or in silicone or hydrogel or even dyedoped polymers. It can be used to treat sphere or cylinder, higher order aberrations (HOAs) and presbyopia.

LIRIC basically enables writing an optical correction in a design of a thin Fresnel lens. The development of lenses based on refractive index shaping (RIS) principles is gaining traction. Since its first reports in 20113, RIS technology lenses, like those from Perfect Lens (Irvine, California, USA), were able to modify IOLs in live rabbit eyes and add or cancel IOL multifocality in a model eye. Meanwhile, those from Clerio Vision (Rochester, NY, USA) have demonstrated laser-induced refractive index change in a living human cornea. Excitement still remains over light adjustable lenses (LAL). After having performed nearly 500 LAL implants along with trials, Dr. Dick shared his insights, saying these photosensitive silicone materials have shown promise for spherocylindrical errors, postkeratorefractive surgery eyes, long or short eyes, customized near adds, and adjustable monovision. “The LAL technology is ready. It’s coming to the US, and we’ve already had trials in Europe,” shared Dr. Dick. “It has great opportunities to improve refractive outcomes. However, the individually customized treatments for RIS change would be a big competitor for the LAL technology.”

A Look at MiLoop and Intraoperative OCT Dr. Sumitra Khandelwal from Baylor College of Medicine in Texas, USA, shared new tools, particularly the MiLoop, that her team has been working with. The MiLoop fills the gap where femtosecond and chopping methods could not break dense fibrotic plates. It is a technology based on interventional medicine with an ultraelastic, memory-shaped thin filament. It does centripetal (out-in) cutting with minimal stress on the capsule, versus traditional centrifugal (in-out) nuclear

cracking. The MiLoop doesn’t insert like a typical IOL, so Dr. Khandelwal presented a video to show its cutting and cleaning out (of the cortex) capabilities. Dr. Khandelwal said she also utilizes the MiLoop for poor views in her transplants and cornea surgeries. She related how the tool is useful to clean out cortical material and for some patients, it clears the way for a Descemet’s membrane endothelial keratoplasty (DMEK) procedure. “The key is to trust the device and focus with a very steady hand,” Dr. Khandelwal said, explaining how to use the tool effectively. However, she advised caution when considering its use for cases such as posterior subcapsular cataracts, as MiLoop tends to loosen the cortex. Another tool highlighted was the intraoperative OCT (i-OCT). Although it has been around for a few years now, the i-OCT is still a relatively new technology. Dr. Thanapong Somkijrungroj, uveitis and retina specialist from Chulalongkorn University, Bangkok, Thailand, demonstrated its benefits through videos of several case studies, including a double-rhexis surgery. The i-OCT guided a membranorhexis using forceps to avoid anterior capsule damage, following a capsulorhexis. Overall, the i-OCT is useful for both anterior and posterior segment surgery – for surgical planning and decision making during a surgery especially in complex cataract cases – to define pre-existing posterior capsular tears and to help in precise premium IOL implantations, particularly in toric IOL implantations. Dr. Somkijrungroj shared that for his practice, his i-OCT is already conveniently integrated with the microscope used during surgery, so that the patient won’t need to be moved to a separate i-OCT machine for checking during the procedure.


December/January 2020


ATARACT Surgical Tools A Friendly Debate on Capsulotomy Devices The session culminated in a friendly “debate” on capsulotomy devices. Dr. Soon-Phaik Chee argued for femtosecond laser-assisted cataract surgery’s (FLACS) advantages, which included the ability to do precise, round cuts on lenses with shallow anterior chambers depths. Despite its size and cost and a 10-year record, FLACS can be also used for refractive procedures and lens fragmentation. “More studies are needed for ZEPTO (Mynosys Cellular Devices Inc, California, USA) and CAPSUlaser (Excel-Lens, California, USA) to prove their safety and efficiency in the eyes of different sizes. There are many cataracts which femto can handle better than manual, which the ZEPTO cannot and the CAPSUlaser may not,” Dr. Chee said in her summary. For the ZEPTO capsulotomy device, Dr. David Chang demonstrated through 20 cases how the device is suitable for more complex cases, such as anterior capsular fibrosis, brunescent lenses, mature lenses, and traumatic cases. It also allows for a normal sequence with convenience of its small size. “It’s really about having different options,” shared Dr. Chang. “ZEPTO is an instrument you can plug in separately, and I think surgical sequence is important.

Overall, the i-OCT is useful for both anterior and posterior segment surgery – for surgical planning and decision making during a surgery especially in complex cataract cases – to define pre-existing posterior capsular tears and to help in precise premium IOL implantations, particularly in toric IOL implantations. Start with something that preserves a normal surgical efficiency and does not require a huge investment. That’s why we think it’s a wonder,” he added. Finally, the CAPSUlaser’s potentials were examined, as Dr. Richard Packard expounded on its effectiveness while pointing to a few studies.4,5 Small in size, CAPSUlaser is cost-effective compared to the ZEPTO or FLACS. It gives 360-degree IOL coverage and allows for more stretching of the capsulotomy than other techniques without negative effects. It also offers greater accuracy of

sizing, circularity and centration incision. Furthermore, it performs extremely well when comparing published results of femto-laser and manual capsulotomy. Editor’s Note: APAO 2019 was held in Bangkok, Thailand, from March 6 to 9, 2019. Media MICE Pte. Ltd., CAKE Magazine’s parent company, was the official media partner at APAO 2019. This article is based on the “New Technologies for Cataract Surgery” session held as part of APAO 2019. Reporting for this story also took place at APAO 2019.

References Dick HB, Piovella M, Vukich J, et. al. Prospective multicenter trial of a small-aperture intraocular lens in cataract surgery. J Cataract Refract Surg. 2017;43(7):956-968. 2 Cochener B, Boutillier G, Lamard M, Auberger-Zagnoli C. A comparative evaluation of a new generation of diffractive trifocal and extended depth of focus intraocular lenses. J Refract Surg. 2018;34(8):507-514. 3 Xu L, Knox W H, Demagistris M, Wang N, Huxlin KR. Noninvasive intratissue refractive index shaping (IRIS) of the cornea with blue femtosecond laser light. Invest Opthalmol Vis Sci. 2011;52(11):8148-8155. 4 Daya S, Chee S, Ti S, Packard R, Mordaunt DH. Comparison of anterior capsulotomy techniques: Continuous curvilinear capsulorhexis, femtosecond laser-assisted capsulotomy and selective laser capsulotomy. Br J Ophthalmol. 5 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;45(5):601-607. 1


Slit Lamp Microscope

iS7 Digital (WDR), References

1 Dick HB, Piovella M, Vukich J, et. al. Prospective multicenter trial of a small-aperture intraocular 5 Steplens NewinOptics with inbuiltJ Cataract Refract Surg. 2017;43(7):956-968. cataract surgery. Yellow Filter 2 Cochener B, Boutillier G, Lamard M, Auberger-Zagnoli C. A comparative evaluation of a new LED generation of diffractive trifocal and extended depth of focus intraocular lenses. J Refract Surg. Digital System with Infrared function 2018;34(8):507-514. for Meibomian glands examination. 3 Xu L, Knox W H, Demagistris M, Wang N, Huxlin KR. Noninvasive intratissue refractive index Most Effective Tool for Dry Eye shaping (IRIS) of the cornea with blue femtosecond laser light. Invest Opthalmol Vis Sci. 2011;52(11):8148-8155. 4 Daya S, Chee S, Ti S, Packard R, Mordaunt DH. Comparison of anterior capsulotomy techniques: Continuous curvilinear capsulorhexis, femtosecond laser-assisted capsulotomy and selective laser capsulotomy. Br J Ophthalmol. 5 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;45(5):601-607.

| December/January 2020 TARUN ENTERPRISES, 8/8, Strachy Road, Allahabad - 211001, U.P. , INDIA Phone : 91 8176080204 e-mail :


+91 9335154556, URL -

ATARACT Patient Outcomes CATARACT SURGERY | Enhancing the Patient’s Experience by Matt Young


apid innovation in medical devices and medications has resulted in a wider and better range of treatment options in cataract surgery. This allows cataract surgeons to plan and design treatments accordingly to help meet patient expectations, as well as improve vision and quality of life. During the Santen Lunch Symposium on the first day of the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2019) annual meeting in Kyoto, Japan, three experts shared their tips to enhance patient satisfaction following cataract surgery, in a presentation titled The Most Natural Choice in Cataract Surgery.

Novel IOLs Dr. Hiroyuki Arai from the Queen’s Eye Clinic, Japan, discussed selecting appropriate intraocular lenses (IOLs) for individual patients in a paper called Optimize Outcomes with the Choice of IOLs and Innovations. IOL options have expanded with the emergence of multifocal and extended depth of focus (EDoF) lens. In this vein, Dr. Arai introduced a new IOL – the LENTIS Comfort – which was launched in April last year. The IOL has been approved in Japan and is covered by the Japanese national health insurance program. Dr. Arai emphasized that this low-add segmental IOL is designed to minimize light loss and has almost no glare and halos.

Postoperative Dry Eye Management Dry eye disease (DED) after cataract surgery has become a critical concern, and various treatments have been developed to counter this condition. “Most cataract surgery patients have prior ocular surface disease (OSD),” said Adjunct Associate Professor Lim Li from the Singapore National Eye Centre (SNEC). Clinical signs of dry eye are commonly found in cataract patients before surgery. “However, the majority

Dry eye can be a prickly problem for cataract patients.

of patients were asymptomatic or minimally symptomatic,” said Prof. Lim about a recent study. Seventy-seven percent of eyes had abnormal corneal staining and more than 60% of patients had an abnormal tear film break-up time (TBUT). Additionally, a blurred vision was more likely than burning or foreign body sensation. So, why is it important to manage the ocular surface? Preoperative biometry and topography could be affected, as well as postoperative outcomes, like visual and refractive results. According to Prof. Lim, studies have shown that hyperosmolarity of the tear film is associated with significantly more variability in average keratometry readings and anterior corneal astigmatism. This may result in significant differences in IOL power calculations. “Corneal staining is the single most critical sign of OSD that should be normalized before cataract and refractive surgery,” said Prof. Lim. Artificial tear preparations such as Hialid (Santen Pharmaceuticals, Tokyo, Japan), which contain various polymers like cellulose derivatives and hyaluronic acid, are the first-line treatment for dry eye symptoms after cataract and refractive surgery due to their effectiveness in alleviating symptoms of dry eye after cataract surgery. Therapeutic contact lenses may be beneficial for severe OSD including corneal ulcers, persistent epithelial defects, corneal perforation, and chemical burns. Bandage lens may be used in the preoperative setting to allow epithelial healing of punctate keratitis before preoperative biometry measurements. “Visually significant (VS) OSD leads to reduced visual quality and potential

errors in preoperative measurements,” cautioned Prof. Lim. In short, according to Prof. Lim, it is important to identify VS OSD patients, defer preoperative measurements until fully treated and resolved (as they can be affected), postpone surgery, and treat patients before surgery to achieve an optimal outcome. “A study found that the use of an aspirating speculum aggravated dry eye parameters during the early postoperative period after cataract surgery,” said Professor Jong Suk Song from the Korea University College of Medicine in South Korea. Cataract surgery can also worsen ocular surface parameters and aggravate dry eye disease. Therefore, he advised physicians to aggressively treat cataract patients with existing dry eye disease. In addition, increased incision extent, operation time, irrigation and microscopic-light exposure time decreased the TBUT and goblet cell density. And the use of topical eye drops after cataract surgery can worsen the goblet cell density. Conjunctival goblet cell loss in dry eye is associated with ocular surface inflammation. According to Prof. Jong, studies have revealed that preservative-free diquafosol showed better efficacy in treating DED after cataract surgery than preservative-containing diquafosol or preservative-free hyaluronate. “Therefore, preservative-free diquafosol may serve as a reliable option for the management of patients with pre-existing DED after phacoemulsification,” he concluded. These practical tips from renowned surgeons should help to manage patients’ expectations and improve satisfaction – which are valuable pieces of advice for any cataract surgery practice. Editor’s Note: This article was first published in CAKE Today, CAKE Magazine’s electronic daily congress news, Media MICE’s daily at the AsiaPacific Association of Cataract and Refractive Surgeons annual meeting (APACRS 2019) held in Kyoto, Japan, on October 3-5, 2019.


December/January 2020


NTERIOR SEGMENT Glaucoma Treatment


Keeping glaucoma treatment on target, even for non-compliant patients by April Ingram


n managing glaucoma, lowering the intraocular pressure (IOP) and preserving vision are always top priorities. If we can achieve these and, at the same time, support a good quality of life for the patient, then it’s a win-win situation. The go-to, first-line therapy for glaucoma treatment is typically topical prostaglandin analog (PGA) medication. PGAs are the first choice due to their trusted and favorable efficacy and safety profiles, not to mention the added benefit of a oncea-day dosing that patients appreciate and can easily adhere to. However, no matter how easy the medication instructions, compliance can be a challenge for patients. Several studies have shown that patients are not motivated to administer their medication as directed, especially when their glaucoma is still asymptomatic. Some of the reasons given for non-adherence include forgetfulness, difficulty of administration, medication cost and undesirable side effects. Non-compliance and non-adherence can be harmful to the patient and frustrating to the physician.

A Possible Answer to Patient’s Non-Adherence Issues In a perfect world, we could take a page from our vitreoretinal colleagues and deliver a sustained-release product and be assured that even our most noncompliant, no-show patient is taken care of. This perfect world may be on the horizon as sustained-release formulations are already in development – which hold the promise of prolonged drug exposure and specifically targeting intended tissues. This could be the answer to adherence and compliance issues of daily dosing and perhaps even the occurrence of surface and periocular adverse events. Bimatoprost SR is a sustained-release, biodegradable implant currently in clinical development. This tiny, rodshaped implant has a solid reservoir of bimatoprost, held within the biodegradable NOVADUR (Allergan, Dublin, Ireland) drug delivery platform. NOVADUR underwent some modification to ensure a steady-state, non-pulsatile slow release of bimatoprost after it has been placed intracamerally, using a prefilled, single-use applicator.

Backed by Scientific Studies

Sustained release glaucoma treatment is the gift that keeps on giving.



The promise of slow, controlled release of bimatoprost, which quietly and consistently lowers IOP in glaucoma patients for four to six months after administration, sounds pretty perfect. But what do the studies have to say? Lewis and colleagues published their phase 1/2 study results in the American Journal of Ophthalmology in 2017, comparing the IOP-lowering effects of Bimatoprost SR to

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topical bimatoprost 0.03% over six months. They found the IOP-lowering efficacy to be similar1. Jennifer Seal and colleagues recently explored the potential added benefit to intracameral implanted bimatoprost targeted drug delivery. By delivering the drug directly to the irisciliary body (ICB), the key site of PGA drug action, and limiting exposure to the conjunctiva and periocular tissues, they hypothesized a reduced occurrence of adverse effects that are typically associated with topical application. Their 2019 publication in the Journal of Ocular Pharmacology and Therapeutics describes the distribution of bimatoprost in ocular tissues of beagle dogs, quantified using liquid chromatography and tandem mass spectrometry following bilateral administration of either a topical bimatoprost 0.03% ophthalmic solution or Bimatoprost SR 15 mg2. Seal et al., confirmed that administration of Bimatoprost SR provided targeted drug delivery to the ICB compared to topical bimatoprost, and drug distribution to surrounding ocular tissues, typically associated with PGA side effects (i.e., conjunctiva, eyelid margins and periorbital fat) were low or undetectable. The group concluded that by targeting bimatoprost delivery to the ICB, and reducing or eliminating exposure to non-target ocular tissues, that the incidence of adverse events typically associated with topical PGAs would be substantially reduced.

Presentation at the ASCRS 2019 Annual Meeting At the recent American Society of Cataract and Refractive Surgery (ASCRS) 2019 annual meeting, Dr. E Randy Craven presented the 24-month results of the phase 1/2 study of Bimatoprost SR in glaucoma patients, which was previously published by Lewis3. In this presentation, they specifically looked at the relationship between implant degradation and IOP lowering over time. They collected data related to whether patients required additional IOP-lowering treatment, and if so, at

what time point after Bimatoprost SR implantation and what medications were used. “IOP was controlled without rescue/retreatment in 68%, 40% and 28% of Bimatoprost SR-treated eyes up to six, 12 and 24 months, respectively,” explained Dr. Craven. More than 25% of patients did not require any additional treatment two years after Bimatoprost SR administration. Dr. Craven presented a case that had a baseline IOP of 24.5 mmHg and received the 6 µg implant. At 24 months, the implant was no longer visible in the intracameral space, but the IOP was maintained at 15.5 mmHg. The second case received a 15 µg implant and had a baseline IOP of 22.0 mmHg. At 24 months the implant was barely visible and the IOP remained at 11.0 mmHg. These cases demonstrated reductions in IOP of 9.0 and 11.0 mmHg, without any added intervention, two years after Bimatoprost SR. When the researchers looked at the rate of implant degradation, they found that at months 12 and 24, the implants were either totally biodegraded or most commonly ≤25% of their initial size at assessment. They concluded that the Bimatoprost SR implant, as expected, effectively reduced IOP, and slow biodegradation of implants was observed over 24 months.

The Future is Clear “The sustained IOP lowering through month 24, when residual implant was small or no longer visible, was seen in some eyes and potentially may be explained by durable remodeling of aqueous outflow pathways,” shared Dr. Craven. “Drop-free medical therapy is on the horizon,” said Dr. Craven, summing it up perfectly. Data from two phase 3 trials showed a reduction in IOP of 30% over 12 weeks, and more than 80% of glaucoma patients were treatmentfree after receiving three Bimatroprost SR treatments and did not require any additional treatment to control their IOP for at least a year. This data was used to support a recently accepted new drug application (NDA) by the United States Food and Drug Administration (US FDA). Action on the NDA is expected in early 2020 – very exciting news for the industry, and that this promising advancement in open-angle glaucoma or ocular hypertension treatment is one step closer to being available in practice. Editor’s Note: Media Pte Ltd exhibited at and covered the recent American Society of Cataract and Refractive Surgery (ASCRS) 2019 annual meeting held in May 3-7, 2019, in San Diego, California.

References Lewis RA, Christie WC, Day DG, et al. Bimatoprost sustained-release implants for glaucoma therapy: 6-month results from a phase I/II clinical trial. Am J Ophthalmol. 2017;175:137-147. 2 Seal JR, Robinson MR, Burke J, Bejanian M, Coote M, Attar M. Intracameral Sustained-Release Bimatoprost Implant Delivers Bimatoprost to Target Tissues with Reduced Drug Exposure to OffTarget Tissues. J Ocul Pharmacol Ther. 2019;35(1):50-57. 3 Craven ER, Chen M, Zhang J, Robinson MR, Rhee DJ. Biodegradation of Intracameral Bimatoprost Sustained-Release Implant (Bimatoprost SR) in a 24-Month, Phase 1/2 Study in Glaucoma Patients. Presentation, ASCRS 2019. 1

About the Contributing Doctor Dr. E. Randy Craven, MD, FACS is an associate professor at the Wilmer Eye Institute. He is currently the medical director of the Wilmer Eye Institute, Bethesda, and the vice chair of the Practice Network. In the 1990s until 2013, he was the president of Glaucoma Consultants of Colorado in Denver and participated in over 100 clinical trials. He served as the chief of glaucoma at the King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia, from 2013 to 2017. He has extensive experience with all forms of glaucoma and cataract issues. []


December/January 2020


NTERIOR SEGMENT Refractive Surgery


Investigating the effects of ectasia after LASIK and SMILE for SMILE Xtra and LASIK Xtra5. Thus, the team investigated if CXL could help protect the cornea after undergoing these procedures.

Careful Hops to a (Studied) Conclusion

This isn’t exactly what we meant when we said “Rabbit Model”...

by Joanna Lee


aser-assisted in-situ keratomileusis (LASIK) has come a long way since Jose I. Barraquer Moner first tried to reshape the cornea with a stromal sculpting method in 1948. In 1990, the use of a microkeratome opened the doors to make the contemporary LASIK surgery a reality.1 Today, the latest method in refractive surgery is SMILE or small incision lenticule extraction. During the procedure, an intrastromal lenticule is created with a femtosecond laser; and compared to LASIK, SMILE has shown to better preserve the biomechanical structures of the eye postoperatively. That’s because LASIK’s vertical cut (to create the flap) increases the risk of structurally weakening the cornea2 – and it’s this weakening that exposes the cornea to ectasia.

Recently, a team in Singapore investigated the effects of ectasia in the cornea after LASIK and SMILE. The goal was to find out if SMILE would result in less ectasia compared to LASIK, as detailed in their paper “Corneal stability of LASIK and SMILE when combined with collagen cross-linking”, published in Translational Vision Science & Technology3. Another objective of the study was to look at one of the latest techniques – collagen cross-linking (CXL), which has been noted to stop the progression of keratocconus4 when the procedure is done together with SMILE or LASIK, also known as SMILE Xtra and LASIK Xtra. Although there has not been much evidence of concomitant CXL’s benefit on the structure of the cornea, there has been, however, emerging support



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Corresponding researcher of this investigation, Dr. Jod Mehta from Singapore National Eye Centre, shared how they used a rabbit model to induce ectasia. “Corneal ectasia is a weakening or protrusion of the cornea due to biomechanical weaknesses,” said Dr. Mehta. According to him, ectasia is caused primarily by keratoconus, while the secondary type of ectasia sometimes arises after LASIK or refractive surgeries. “Previous studies have shown that it is the vertical incision in the cornea, such as after-flap creation, that weakens the cornea the most – hence causing ectasia. With SMILE, the vertical incision is much smaller than after LASIK, therefore SMILE does not prevent ectasia, but it may reduce it. However, this requires more evidence,” he continued.

What the Rabbits Taught Us “We used a rabbit model to induce ectasia by removing a lot of stroma tissue,” shared Dr. Mehta. Fourteen rabbits were involved in the experiment in accordance to ethical guidelines. The team compared the occurrence of ectasia between LASIK and SMILE treatments and also looked at the effects of concomitant CXL. The rabbits were divided into 4 groups: SMILE, SMILE Xtra, LASIK and LASIK Xtra. Save for one rabbit which had corneal infection, 6 eyes underwent SMILE, while SMILE Xtra was performed

on 5 eyes. Another 6 underwent LASIK, while 5 eyes had LASIK Xtra. The rabbits underwent bilateral surgery as the procedure does not interfere with their daily activities. Under anesthesia, the animals were examined preoperatively, and postoperatively at weeks 2, 4 and 6. “We used a model of intentional ectasia induction to mimic a clinical scenario of performing LASIK/SMILE on someone who then went on to develop ectasia,” continued Dr. Mehta. For CXL treatment, the researchers used Vibex Xtra protocol after LASIK Xtra and SMILE Xtra. “Collagen CXL is a treatment consisting of riboflavin and ultraviolet A (UVA) light. It strengthens the cornea by increasing the cross linking of the collagen fibrils,” explained Dr. Mehta.

CXL – Xtra Strength for the Cornea? Following this, investigations and analysis were carried out on the rabbits’ eyes using slit lamp biomicroscopy photography, anterior segment optical coherence tomography (AS-OCT), corneal topography and in vivo confocal microscopy. “The study showed that there was a significant difference in posterior elevation between LASIK and LASIK Xtra (with CXL),” said Dr. Mehta, adding that overall, LASIK alone induced the highest posterior elevation, that is, the induction of ectasia. Meanwhile, the addition of crosslinking provided a certain strengthening of the cornea that was more apparent in LASIK Xtra than in SMILE Xtra. Trials on humans would be difficult to conduct due to the small percentage available of human eyes with ectasia. Dr. Mehta said: “We used a model of intentional ectasia induction to mimic a clinical scenario of performing LASIK/SMILE in someone who had then went on to develop ectasia. Since this study would be impossible to do clinically due to the small numbers of ectasia cases, and ethically, we don’t treat people to induce ectasia, this model gleans some good information.”

The study showed that there was a significant difference in posterior elevation between LASIK and LASIK Xtra (with CXL). – Dr. Jod S. Mehta

Significant Outcomes Despite the Challenges During the investigation, the researchers were mindful of the particular challenges that presented in rabbit eyes. “There is no ideal model of ectasia in any animal, so this had to be created in a controlled manner in this rabbit model,” said Dr. Mehta. “The other challenge was that the rabbit eye has amazing wound-healing properties, so even if you induce ectasia as we did, and if you leave it long enough, the cornea will self-heal, and the ectasia will flatten.” He added that they had expected the latter to occur at some point during the follow-up stage but were unsure of the exact time. However, on the whole,

they were pleasantly surprised at the outcomes of this research. “The results really showed a clear effect in the LASIK eyes that underwent LASIK and CXL compared to LASIK alone, but not such a profound effect in the SMILE eyes, that underwent SMILE and CXL,” he said. The implications of this research for the risks of ectasia associated with LASIK, LASIK Xtra, SMILE and SMILE Xtra could help shed light in the postoperative management of these procedures. “I think it really adds some evidence to the biomechanical stability in patients who are undergoing LASIK and CXL, which would have been very difficult to show through any clinical study,” concluded Dr. Mehta.

References Reinstein DZ, Archer TJ, Gobbe M. The History of LASIK. J Refract Surg. 2012;28(4):291-298. Knox Carwright NE, Tyrer JR, Jaycock PD, Marshall K. Effects of variation in depth and side cut angulations in LASIK and thin-flap LASIK using a femtosecond laser: A biomechanical study. J Refract Surg. 2012;28(6):419-425 3 Konstantopoulos A, Liu Y, Teo EP, Nyein CL, Yam GH, Mehta JS. Corneal stability of LASIK and SMILE when combined with collagen cross-linking. Transl Vis Sci Technol. 2019;8(3):21. 4 Wittig-Silva C, Chan E, Islam Fm, Wu T, Whiting M, Snibson GR. A randomized, controlled trial of corneal collagen cross-linking in progressive keratocconus: three-year results. Ophthalmology. 2014;121(4):812-821. 5 Seiler TG, Fischinger I, Koller T, Derhartunian V, Seiler T. Superficial corneal crosslinking during laser in situ keratomileusis. J Cataract Refract Surg. 2015;41(10):2165-2170. 1 2

About the Contributing Doctor Professor Jod S. Mehta graduated from St. Thomas’s 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. He 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, an adjunct professor at the School of Material Science & Engineering and School of Mechanical and Aerospace Engineering, Nanyang Technological University, as well as Adj. Prof. 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:]


December/January 2020


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NTERIOR SEGMENT Anti-infectives Update Fighting Smarter

Optimizing the Current Landscape of Ocular Anti-infectives by April Ingram


he landscape of ocular infections is changing as pathogens evolve. In addition, how these patients are managed – which differs among regions, and even between practices – is changing as well. To treat patients, doctors need to take the limited clues (and lack of cultures) observed at presentation and act with the speed and precision of bomb diffusion specialist. So, how can optimizing today’s antiinfectives contribute to the best outcomes for our patients . . . and what does the future hold? Prof. Shigeru Kinoshita of Kyoto Prefectural University of Medicine is a cornea surgeon who, for 40 years, has had a special interest in ocular surface biology and treating corneal infection. Prof. Kinoshita has noticed a shift in the microorganisms they are treating in Japan, similar to other regions. “In Japan, we have many microorganisms and used to target gram-negative bacteria, but nowadays, our patients are mainly gram-positive. We aren’t certain why, but I feel it has much to do with the aging population in developed countries,” he shared. An observation confirmed by Asia Cornea Society Infectious Keratitis Study (ACSIKS), surveyed the demographics, risk factors, microbiology and outcomes for infectious keratitis in Asia. The study reported that the most common microorganism isolated in both Japan and South Korea was Propionibacterium acnes, a gram-positive bacterium. Prof. Kinoshita added: “In countries, such as India, China or the Philippines, there are more fungal infections. Singapore and Taiwan have high contact lens usage, and therefore more contact lensrelated infections.” ACSIKS data agrees that wearing contact lenses is the highest risk factor for infectious keratitis in Singapore, Taiwan and Japan, and even higher for females in these regions. Pseudomonas aeruginosa is on the rise and extremely

‘No to mutants!’: Strategy against microbial resistance. Not an X-men movie slogan.

dangerous as more people are wearing contact lenses, and young people are wearing them for longer periods (Stop sleeping in your contacts!). Prof. Kinoshita’s first choice is always levofloxacin, over moxifloxacin or gatifloxacin, for these patients. “If they are younger patients, use it [levofloxacin]. Contact lens wearers – always be thinking pseudomonas, and definitely use it,” he emphasized. Prof. Kinoshita described how he manages these patients. “Initially, all we have is the clinical manifestation, before getting the results of the culture, to know which pathogenic bacteria is which. You don’t always know, but you have to treat – so we cover with both, that’s why we choose levofloxacin for the first seven days. It works for grampositive and -negative and we feel safe enough to use it for Pseudomonas aeruginosa.” Prof. Kinoshita, and his colleagues at Kyoto Prefectural University of Medicine, check the bacterial flora when they first see a patient, and they also try to culture some of the bacteria from the conjunctival specimen. This way they can determine if they are up against a gram-positive or -negative bacteria, and they also try to have all the data of the MIC.

Refresher: MIC is the minimum inhibitory concentration of an antimicrobial agent – it measures the activity an antimicrobial agent has against an organism and the lowest concentration that it will inhibit growth of the microorganism. MIC has been used extensively to classify bacteria as resistant to an antibiotic. A second metric of resistance is the mutant prevention concentration (MPC), the minimum concentration restricting the growth of the least susceptible, single-step mutant of a bacterial isolate. The inhibitory concentration between MIC and MPC is the window (mutant selection window) where the evolution of resistance can occur. Resisting the antimicrobial resistance is futile. Resistance is a wellrecognized and ongoing problem across all infectious diseases. Once upon a time, only one type of MRSA was known and feared . . . now, there are four. Resistance patterns and mutations of organisms have now seen MRSA leave the hospital (a.k.a. health care-associated MRSA) and venture out into the community (community-associated MRSA). Due to the misuse and overuse of antibiotics, there is an increase of failure in previously efficacious treatments and a rise in antimicrobial resistance worldwide.


December/January 2020


NTERIOR SEGMENT Anti-infectives Update Prof. Kinoshita has also witnessed the evolution of drug resistance: “We used to have several kinds of antimicrobials to treat infection, now we only have one,” he said. “Resistance is a real problem, therefore we try not to use antimicrobial agents on a continuous basis. We extensively treat with levofloxacin, and often will use it for a specific duration of time and then stop, in order to prevent resistance.” It might also be considered if altering how drugs are administered, even on an individual basis, could slow development of resistance. Elderly patients can bring a full range of challenges and need to be considered differently when it comes to anti-infectives. As immune systems gradually diminish and are compromised more easily, older people are especially susceptible to infection – and the bacteria in this population may develop resistance to antibiotics quicker. Prof. Kinoshita shared: “Always

think about the age of the patient and the health of the patient. I profile the patient, it is important to determine if they are compromised, or if they are diabetic. Usually up to 50 or 60 years I feel it is safe enough to use a quinolone. For those over 60, we use quinolone less frequently, because we find we often have to modify treatment to another agent because this population easily develops the mutation for resistance.” How can we apply what we know about MPC? Although mutant prevention sounds like a good tactic for the characters in a sci-fi movie, it may provide a strategy to minimize antimicrobial resistance. Knowing that when drug concentrations are below the MIC, neither the original nor first step resistant bacterial cells are inhibited, and they also do not become selectively resistant. At concentrations between the MIC and the MPC, the mutant selection window (MSW) growth of first

step resistant mutants is blocked, but amplification of resistant subpopulations takes place. Finally, at concentrations higher than the MPC, no selective amplifications take place, because the original and first step resistant cells are annihilated. Then why aren’t we always dosing above the MPC? Optimizing this concept, there are data from in vitro studies and animal models to support using the MSW to improve antimicrobial dosing regimens. Unfortunately, the MSW/MPC ‘sweet spot’ varies for every fluoroquinolone/pathogen combination. There is ongoing study, and much debate about the potential impact of MPC on fluoroquinolone resistance. Prof. Kinoshita is following this discussion closely. “I think it is very important, but still conceptual. In vitro data shows some truth, but there is a lack of data that can be applied in the clinical situation, especially when we have to consider the age and overall health of the patient,” he explained.


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The key to optimizing treatment is selecting an anti-infective depending on relative penetration and concentration. The principal treatment strategy for bacterial infections is to administer antiinfectives at high concentrations. The rationale is that high concentration will kill all microbes quickly, so that there is no chance for resistance to develop, while lower concentration treatments can help with resistance but putting selection pressure on resistant strains. Prof. Kinoshita explains how concentration and penetration factor into his clinical decisions: “We have either 0.5% or 1.5% levofloxacin and 1.5% is our choice for most infections. We’ve found the concentration to be almost the same or better with levofloxacin than moxifloxacin, but the effectiveness has to do with the penetration. When we see corneal infection, high penetration is needed,” he said. “We do also use the 0.5% for

prophylactic treatment, 0.5% is less toxic to the corneal epithelium.” When asked about the next generations of anti-infectives, Prof. Kinoshita said: “I haven’t found much difference in 3rd and 4th generation.

It doesn’t matter if someone says, ‘this is a 3rd or 4th generation agent’. Its effectiveness, that is the most important. Is it a quinolone that treats gram-positive and also pseudomonas aeroginas? That is what matters.”

References 1. Drlica K, Zhao X. Mutant selection window hypothesis updated. Clin Infect Dis. 2007;44(5):681688. 2. Hansen GT, Blondeau JM. Mutant prevention concentration as a strategy to minimize antimicrobial resistance: a timely concept but will its acceptance be too late? Therapy. 2005;2(1):61-66. 3. Khor WB, Prajna VN, Garg P, et al; ACSIKS Group. The Asia Cornea Society Infectious Keratitis Study: A Prospective Multicenter Study of Infectious Keratitis in Asia. Am J Ophthalmol. 2018;195:161-170.

About the Contributing Doctor Prof. Shigeru Kinoshita is a professor and chairman of ophthalmology at Kyoto Prefectural University of Medicine, Kyoto, Japan. Prof. Kinoshita is a cornea and refractive surgeon with a special interest in the close relationship between the cornea and glaucoma. Prof. Kinoshita established, along with Richard Thoft, the concept of centripetal movement of corneal epithelium. This shed new light on the importance of the limbal epithelium and contributed to the development of corneal stem cell theory. Over the last 40 years, his primary interests have been focused on the research and development of new therapeutic modalities for the cornea. To this end, Kinoshita’s group has established systems to transplant cultivated mucosal epithelial stem cells and cultivated corneal endothelium.


No Laughing Ma

The Art of Surgical Improv by Brooke Herron

My earliest childhood memory is going to the eye doctor when I was 8 . . . life before that was a blur. – ophthalmic joke


t first glance, it wouldn’t seem like comedy and ophthalmology could have much in common. In fact, other than the quirky one-liner above, an Internet search reveals a startling lack of eyeball-related humor online. Of course, this makes sense as surgery is serious business. Eliciting laughs and removing cataracts are decidedly different things. However, there is one commonality that surgeons and comedians both share – the ability to improvise. Improvisation (or improv) refers to creating an action without pre-planning. Generally, improv is used in comedy, and requires the ability to think, process and retain information quickly. That same ability is also necessary in the OT, especially when complications occur. As such, in this CAKE cover story, we look at case studies in improvisation, with tips on how to proceed when the unwanted surprise of a complication arises.

Keep Calm and Operate On In comedic improvisation, calming skills like meditation and deep breathing are key. That’s because performers must remain calm, but act fast, with complete awareness of their environment. The same can be said for surgical improvisations. When a complication arises, Dr. David Lubeck, a cornea, cataract and refractive surgery specialist from Chicago, Illinois, USA, says that

before any improvisation can begin, he takes a moment to focus with some deep, meditative breathing. “It’s what I do, and it’s what I was taught a long time ago. When a complication happens, I immediately begin a short breathing mediation,” he explains. “I stop the procedure and mitigate anything that is pressing or urgent. This then allows me a moment



December/January 2020

to stop thinking about the case, to do a very quick (but very effective) mediation, and then come back to it.” Dr. Lubeck says this brief moment of quiet, takes him from initial feelings like anxiety and panic, to being clearheaded and focused – and this opens the door for improvisation to mitigate the complication. “Until you’re clearheaded, you can’t improvise,” he explains. “Once



and differently than their intended design, or that the instrument itself may have multiple applications. “Understanding the flexibility and the potential of your resources is part of the broad base of knowledge that surgeons need to have,” he says. “For all the pre-planning you can do on a case-by-case basis, you really just have to have these improvisation strategies in your head, deep in your mechanistic thinking.” He recommends having a general, internalized strategy for handling different situations and understanding all the resources available, as well as their different uses.

Dress Rehearsal: Unstable Lenses in Cataract Surgery

you have the ability to think laterally. You can assess everything you have at hand to help you, such as are your staff, who’s alongside you and how capable they are; your instrumentation; and the capabilities of the hospital where you’re operating (which varies a lot).” Dr. Lubeck says it’s important to understand that certain pieces of instrumentation can be used creatively

A complication that Dr. Lubeck says happens frequently, but can still catch surgeons off-guard, is an unstable lens. “In these cases, there’s often no indication. But the moment you begin working on the cataract and the capsulotomy, you find the lens is unstable and you know things are not going to go as planned.” When CAKE magazine interviewed Dr. Lubeck, he had experienced this exact complication earlier in the same day. “Invariably, what happens is, the cases you think are going to be difficult often end up being straightforward and simple, and the cases that look like they’re going to be straightforward can completely surprise you – like today. I had no indication that it was going to be a loose lens . . . there was no sign of it whatsoever.” When this complication occurs, his first step (following a brief meditation) is to ask if his assistant is familiar with an unstable lens. Their answer is usually ‘no’, so Dr. Lubeck talks them through it: “A loose lens means that I may have trouble extracting the lens, we may drop the lens, we may have to do a vitrectomy . . .” Then he begins his mental – or improv – checklist, asking questions

Understanding the flexibility and the potential of your resources is part of the broad base of knowledge that surgeons need to have.

– Dr. David Lubeck

like: Are there capsule hooks? A vitrector? More visco-elastics? Once he knows what resources are available, a strategy is devised and the surgery proceeds. All of which occurs in two to three minutes. He says that when complicated cases are approached this way, they largely turn out well, and the sense of accomplishment is far greater. “I have much greater sense of satisfaction and sense of accomplishment as a surgeon when these complicated cases turn out well, as compared to the normal cases.”

Curtain Call: The Case of the Skewered Lens As a pediatric ophthalmologist based in Pittsburgh, Pennsylvania, USA, Dr. Kanwal Nischal has many patients referred to him with Marfan syndrome, a genetic disorder that affects the connective tissue. When this affects the eyes, it can cause the lens to dislocate spontaneously and move out of the central position. “This happens because the zonules are weak, so their lenses move


December/January 2020


COVER STORY upwards and laterally,” explains Dr. Nischal. “Of course, that’s a problem: The lens in no longer central and it’s not focusing light properly.” During these surgeries, he says that he normally removes the entire lens without the assistance of a vitreoretinal surgeon, as it’s something he can do safely. However, in one case, due to the position of the lens, Dr. Nischal was worried that the lens was going to drop into the capsular bag – and without a vitreoretinal surgeon on hand, there could potentially be a problem. Thus, his case in improvisation began. The lens in the left eye was dislocated superiorly and laterally, so Dr. Nischal went in at 9 and 2 o’clock, and used two 30-gauge needles to skewer and fixate the lens. “Then you put the infusion in and with the vitrector, you remove the lens material and little bit of the vitreous, so you’re left with nothing in the eye,” he explains, adding that these cases are rehabilitated with a contact lens, with the option for an implant at age 21. “Here, my improvisation was taking two needles and skewering the lens so it couldn’t fall into the back of the eye while I was removing it. And the patient’s result was good,” he says. Dr. Nischal says this isn’t the only instance when he’s used this improvisation: “I’ve done it before in adult cataract surgery, in patients with a posterior polar cataract,” he says, “It’s not something that someone showed me, it’s an improvisation to stabilize the lens while I remove it.”

Often, we are so taken by the moment, we forget to look at the whole eye. So, I always say to my fellows: ‘Don’t just concentrate at the end of your instrument, obviously you need to know where it is . . . but you have look at the whole picture.

– Dr. Kanwal Nischal

Some complications are so severe that surgeons plan in advance for them. For example, when approaching infant corneal transplants, one complication that Dr. Nischal always takes into consideration is an expulsive hemorrhage. Although they can occur during any intraocular operation, in this case, once the cut is made to remove the diseased tissue and the eye is opened, for example, a change in intraocular

pressure can cause the choroid to suddenly fill with blood. And if this continues, it can result in the extrusion of the all the eye’s contents. In these cases, the surgeons must act rapidly to help save the eye. “It’s the worst thing that can happen to an ophthalmic surgeon. If you were to go into any of the conferences and ask somebody, ‘have you ever had an expulsive hemorrhage?’, they would either say ‘yes’ and it was horrible, or they would touch wood 1,000 times,” says Dr. Nischal, who is most well-known for performing corneal transplants in infants. Dr. Nischal says he had one case of expulsive hemorrhage in an infant’s eye in 2001, and since then he takes many precautions. The first thing was to change the anesthesia. “The carbon dioxide (CO2) level has to be below 30mmHg. The lower the CO2, the less positive pressure in the eye, and when you open the eye, there’s less of a change from high pressure to low pressure,” he explains, noting that this complication occurs from the sudden intraocular pressure (IOP) change. At the moment of his initial cut, he checks the blood pressure and pulse with the anesthesiologist. And if either of them rises, the eye could be at risk, so he



Avoiding Improv in Cases of Expulsive Hemorrhage

December/January 2020

proceeds using the ‘sandwich technique’. Dr. Nischal says he’s employed this technique in worrisome cases just five times throughout his career. “Normally, in a cornea transplant, the diseased cornea is removed and the donor cornea is placed and sown in,” he says. “In this sandwich technique, every time there’s a 90-degree cut, a suture is put in. You cut the host, but you’ve put in four sutures as you’ve done it.” Next, the donor tissue is placed on top the host, but with a filling of viscoelastic to protect the donor’s endothelium. In the quadrants where there are no sutures in the host, you place them, but before the fourth is placed, the previous sutures in the host are cut. This allows the host tissue to be removed from underneath the donor tissue, and then the fourth suture can be applied. “It’s complicated, but what you’ve essentially done is you’ve removed the host tissue without ever exposing the eye completely to an absolutely open globe,” explains Dr. Nischal, adding that this is the most technically detailed plan he undertakes to avoid a complication. “I think what happens is that people don’t talk about expulsive hemorrhage. So in your training, no one tells you what you should do when it happens,” he

says. “If you’re lucky, you come across someone whose had it. Most people, when it happens, they are so stunned that it’s too late to do anything.”

Innovations Reduce Improv in the OT According to Dr. Lubeck, over the last decade, continued innovation in devices, instrumentation and surgical techniques has helped reduce the amount of ‘improv’ in the OT, while making the likelihood of complications lower, and the prevention of complications significantly higher. Specifically, he notes that fluidics in phaco machines, femtosecond lasers and improvements to ultrasonic energy delivery are the top innovations that have contributed to this trend. Another game-changer is intraoperative OCT (iOCT). “Integrated intraoperative OCR has made a huge difference for me,” says Dr. Nischal. “It has reduced my complications in the sense that I can do – for example – an endothelial keratoplasty in a cornea that’s completely opaque, because I can see through it with the OCT.” “I can operate using OCT on what I can’t actually see in the surgical field,” he continues. “It not only allows you to take on more complicated surgeries more safely, but it flattens the learning curve. When I do pediatric cataract surgery with my fellows, I can now show them all the steps and what happens to the tissues. I can see vitreous if it’s in the anterior chamber, I don’t have to stain it. It’s a game changer.” However, there can be downsides, even with technology that helps improve safety and reduce the rate of complications. Dr. Lubeck says that, of course, lowering complications is a good thing. However, if surgeons don’t experience them, especially in training, they don’t develop improvisational strategies – and therefore, can’t access those skills when needed. “I think it’s great that we have fewer complications and that the risk of complications is drastically less than when I was trained,” he explains. “But I think the likelihood that the young

surgeons will have the breadth of improvisational skills is less. Surgeons learning in this current environment, with vastly improved technology, won’t need to develop broad improvisational skills.”

Final Thoughts on Improv So, when it comes to improvisation and complications, what tips do experienced surgeons have for the younger generation? Dr. Nischal notes that one thing he teaches his fellows is to look at the whole eye. “Often, we are so taken by the moment, we forget to look at the whole eye. So, I always say to my fellows: ‘Don’t just concentrate at the end of your instrument, obviously you need to know where it is . . . but you have look at the whole picture,” he explains, adding that he himself had to be trained to do this. “In many ways, it’s very Zen, very Buddhist. If you just concentrate on one point, you miss the bigger picture. And that’s when you miss the complication that’s about to happen,” he says. For example, when performing anterior vitrectomy and posterior capsulorhexis in children, Dr. Nischal says to look at the iris. “Rather than waiting until the end to see if there’s

any vitreous in the wound, while you’re doing your vitrectomy, you should be looking at the iris. If you see the iris quiver or flutter, there’s vitreous hitting it,” he says. “But if you’re so taken by looking at the end of your vitrector – and not looking at the whole eye while you’re operating – you’ll miss that.” A final tip? Take a moment to pause and assess. “When you realize a complication is arising, do a hard stop and do whatever it takes to stop its progression,” says Dr. Lubeck. For example, when a complication occurs during cataract surgery, he says filling the anterior chamber with visco (specifically) usually buys the surgeon some time. “Then, you can take a step back and break the neurologic response of panic and fear, so you can then access the rational and calm parts of your brain.” These tips, along with each surgeon’s intrinsic framework of knowledge, experience, training and support from technology, contribute to the overall success of overcoming complications. And with improvisation, a clear head and quick decision making, unwanted surgical occurrences can be abated and visual outcomes can be saved or maintained. And that’s one big reason to cue the applause!

About the Contributing Doctors Dr. David Lubeck is a cataract, corneal and refractive surgeon who has practiced in Chicago, Illinois, USA, for 30 years. He completed his medical training at Northwestern University and then his ophthalmology residency at the University of Illinois Eye and Ear Infirmary in Chicago. A fellowship in corneal surgery was served at Flinders Medical Center, Adelaide, Australia. He is an assistant clinical professor of ophthalmology at the University of Illinois Eye and Ear Infirmary, Chicago. Dr. Lubeck is compelled by the methodology and psychology of surgical learning and practice development. His primary focus is to make current surgical principles, techniques, and instrumentation accessible to physicians at all levels of experience. Curricula that he has developed have been integrated into surgical teaching programs in several different countries. [Email:] Prof. Kanwal “Ken” Nischal is chief of the Division of Pediatric Ophthalmology and Strabismus at UPMC Children’s Hospital of Pittsburgh, director of Pediatric Program Development at the UPMC Eye Center, medical director for Telemedicine Services at Children’s Hospital of Pittsburgh, associate medical director for UPMC International and professor of ophthalmology at the University of Pittsburgh School of Medicine. His focus is on evidence-based protocol-led clinical care with clinical outcome measures as a source of clinical research. His main areas of clinical research are Anterior Segment Developmental Anomalies Affecting the Cornea, Lens and Trabecular Meshwork. He has published widely in Pediatric Cataract, Glaucoma and Cornea and Craniofacial Anomalies. He has developed an ocular genetic service at Children’s Hospital of Pittsburgh and is co-founder of WSPOS. [Email:]


December/January 2020



My dad was given a selfie stick as a Christmas present . . . it turns out that he can now hold it far enough away to read text messages.


Which kind of humor do ophthalmologists appreciate the most? Eye-rony. Why did the gangster have to see an eye doctor? He had glock-oma.


These jokes are as ‘cornea’ as it gets . . . all sourced from When is a lens the finest online not a lens? eyeball comedians. When it’s A man goes to the aphakic. When is a lens REALLY not a lens?

When it’s ‘a-fake-ic’.

Q A 28

What do you call a blind stag?

eye doctor. He sits down and the receptionist asks him why he is there. The man complains: “I keep seeing spots in front of my eyes." The receptionist asks: “Have you ever seen a doctor?" to which the man replies:

No Eye-Deer

“No, just spots."


HOYA Launches Joint Venture with GeMax in China


hinese physicians and patients will have broader access to HOYA Surgical Optics (HSO) products, thanks to a joint venture with GeMax, a specialty intraocular lens (IOL) service provider. Since 2006, GeMax has been a distributorpartner for HSO and has a strong market position in China, covering 630 hospitals in 32 provinces. The joint venture will be called HOYA GeMax Medical and the deal is expected to close by the end of March 2020. Due to its high population, cataract is a major public health concern in

China. According to HSO CEO John Goltermann Lassen, “this venture will allow us [HSO] to be a stronger partner and meet the growing needs in China, a market of strategic importance to our organizations”. Combining sales and distribution into one unified business will provide Chinese surgeons and patients more access to the entire HSO portfolio of IOLs across the AF-1 and Vivinex platforms. HSO Vice President Global Sales Mads Bjerre Andersen said they are

excited to embark on this journey with GeMax: “We have worked together for more than a decade and this next step will help take our business to new heights in China.” “This is a natural progression given the strong partnership and mutual trust between our organizations and we’re looking forward to strengthening our position in China together,” shared Xia Xintao, general manager of Gemax. The official signing ceremony took place in January 2020.

UDOS Women in Ophthalmology

Dr. Suvira Jain

On Healing Eyes and Touching Lives

In an industry largely dominated by men, rising to the top can be challenging for women ophthalmologists.

by Tan Sher Lynn


renowned clinician, skilled surgeon, respected teacher, sought-after speaker and beloved mother - Dr. Suvira Jain, indeed wears many hats. To learn more, CAKE Magazine sat down with the compassionate doctor to discuss what each role means to her.

Dr. Jain obtained her MBBS from Jawaharlal Nehru Medical College, Belgaum, Karnataka, and her Diploma in Ophthalmic Medicine and Surgery (DOMS) at the College of Physicians and Surgeons Bombay. She then pursued her Fellowship of the Royal Colleges of Surgeons (FRCS) in Edinburgh, United Kingdom, where she gained a different perspective in looking at her subjects. Through this training, she learned to see her patients as a whole person – not only through clinical lenses, but also with compassion. This shaped her practice to ensure that not only her patients’ medical needs were met, but their human needs as well. This

also gave her the opportunity to gain recognition as a compassionate clinician. Steered by a sense of purpose to return to her homeland and serve her people, Dr. Jain decided to return to India after staying in England for about seven years. “Following my heart and instinct, I returned to India and joined the KBH Bachoo Ali Eye Hospital in Parel, Mumbai, which is my parent institute,” she shared. “I’ve been working here for the last 19 years as clinical head of the cornea department. Being in an institute, I can continue learning, as well as sustain my interest in academics, teaching and patient care. I also have the honor to work with the underprivileged people in my society. This has been my greatest sense of accomplishment.” “The reason I chose ophthalmology has always been the people – being able to improve people’s vision and seeing them satisfied after surgery. Truly, being an ophthalmologist has enabled me to touch people’s lives in such an impactful way.”



As an Ophthalmologist

December/January 2020

As a Teacher To Dr. Jain, teaching is as equally important as treating patients. “By equipping students with the necessary skill set to operate well and establish themselves as ophthalmologists, I am able to touch many more lives,” she said. In June 2004, she conceptualized and established the Phaco Training Academy at KBH Bachoo Ali Hospital. Since then, the Academy has successfully trained more than 750 qualified ophthalmologists, including residents, from all over the country. “We accept students at any level, work out a customized program and equip them with the skills required to perform the best phacoemulsification possible, making sure that they understand the principles and become very good at the techniques,” shared Dr. Jain. She added that she always encourages her students to learn new things and improve themselves. “It is intimidating to do something new, but

we need to face our fears and just do it. When students make mistakes, we guide them and lift them out of the storm. In any stage of our lives, we need to remember to stay teachable. Our lives and profession are a learning journey,” she said. The Phaco Training Academy organizes a live surgical program for challenging cases once a year, and a retreat every two years. In her book The Art of Phacoemulsification – The Passion, The Essence, The Quest, Dr. Jain describes her expertise and experiences, with the aim of supporting and inspiring trainee surgeons. She has also operated in many live surgical sessions during conferences, teaching the audience every step of the procedure. “Has all this been easy? Well, it was definitely not easy,” she quipped. “To be able to stand out there and work amongst an entire institute filled mostly with men, it took a lot to be taken (even slightly) seriously. It took a firm and infallible belief in who I am and what I stand for. It took intense commitment to my profession, hard work, and the desire for continuous selfimprovement,” she stated. “But throughout this journey, I have had the privilege to be encouraged by my mentors, respected by my seniors and team of doctors, and treated as equal by my colleagues. I am also blessed with the complete faith of my patients, and the love, respect and trust of my students.”

As a Mother For Dr. Jain, the biggest feather in her cap was finding the time, commitment and love to lead and guide her children, despite her workload. “When I was in studying in England, I was raising two small children at the same time. Having obtained my FRCS after toiling for months was really a huge sense of accomplishment, pride and relief.”

She added that it is important for children today to see their mothers work hard and excel in their profession. “They respect that a lot in you. Through our example, our children will have a clear sense of what they want to be when they become young professionals,” she said. Dr. Jain shared that Isha, her first born, worked toward setting up forums for women to engage in public speaking when she was a student in Bangalore. She also worked with underprivileged kids in the schools there, encouraging them to study law. Meanwhile, Meha, her 22-year-old, wrote at 18 in an interview application that “in emulating my mother, I attempt to make sure that every decision that I make is guided by how its implementation would first affect others, then myself. I push myself to embrace my maximum potential in the hope that one day I would become one tenth the person she is”. “My daughters have watched me grow, struggle and rise above various circumstances,” said Dr. Jain, sharing that she has been a single mom for a decade. “I do not moan about the difficulties of being a single mother. Instead, I take it in stride and get things done. My commitment to my profession has taken much of my time, but somehow I managed to be there for my daughters when they needed me, be it emotionally, socially or financially.” Dr. Jain would often text her daughters to say, “Mom’s got your back.

You have nothing to worry about. It’s all good”. And today, the roles have been reversed. “I have a daughter who tells me: ‘I got your back, Mom.’ So, life eventually comes back full circle. Whatever you give, it comes back to you,” added Dr. Jain.

As a Woman According to Dr. Jain, sometimes it can be a challenge for women working in ophthalmology to be taken seriously. But they can overcome it by being good at what they do, being clear about what they believe in, and staying on top of the industry. “With this, there will be no question of people not taking you seriously. And even if there are still people who don’t, it doesn’t matter. You will be confident, you will be clear, and you will be happy,” she said. Dr. Jain stressed that women ophthalmologists need to realize that firstly, they are ophthalmologists. “They need to focus on getting their clinical and surgical skills right, focus on driving their own potential and giving their best. That’s how I live my life and how I inspire my students. Gender is immaterial. Professionalism is all that matters,” she shared. “Truly, we should all strive to live fully and die empty. As my mother wrote in a poem: ‘Our fingerprints do not fade from the lives that we touched’,” concluded Dr. Jain.

About the Contributing Doctor Dr. Suvira Jain is a thinking ophthalmologist, with a mission to deliver new age, top-of-the-line eye care to her patients with care and compassion. As a person, she is no-nonsense, hard-working, dedicated and compassionate. As an ophthalmologist, she has not only acquired exemplary clinical knowledge and surgical skills, but has also been deeply involved in research and teaching, with a tireless inclination to keep abreast with emerging and meaningful technology. She is also a prominent speaker and has presented numerous scientific papers in both national and international ophthalmic forums. To date, she has performed over 80,000 surgeries, taught more than 750 students and given over 100 presentations. [Email:]


December/January 2020


UDOS AAO Awardee

Dr. Marcus Ang The 2019 Artemis Awardee by Chow Ee-Tan

A young, accomplished ophthalmologist from Singapore who demonstrated care and service to an exemplary degree was the recipient of the 2019 Artemis Award from the American Academy of Ophthalmology (AAO).


r. Marcus Ang, consultant ophthalmologist at Singapore National Eye Centre (SNEC) specializing in cornea and refractive surgery, was recognized for his pioneering years of work in providing free vision care for people across Asia, particularly the elderly in Singapore. Driven by his goal to develop innovative and sustainable eye solutions, Dr. Ang has dedicated much of his time to caring for others in – and outside of his clinic at SNEC. The young doctor is the force behind the non-profit organization Global Clinic Ltd., which ventures beyond local borders to provide free eye care and surgery in developing countries around Asia. Dr. Ang also founded and leads the Mobile Eye Clinic (MEC) Project, which aims to bring free eye care to the elderly who lack mobility in underprivileged communities in Singapore.

In addition to being a skilled hunter, the Greek goddess Artemis was also a protector of the vulnerable.

When contacted by CAKE, the busy doctor, who is also associate professor of Ophthalmology and Visual Sciences at Duke-National University of Singapore, expressed his gratitude for the recognition, saying he was, indeed, very honored to receive the award. “This prestigious award has been conferred to many ophthalmologists in

the past who have done amazing work in their field,” he shared. “So, I’m very lucky to be recognized among some of the greats. To me, personally, it is a recognition of my contributions to the field of ophthalmology, outside of academic and clinical work. Thus, it is a great honor,” said Dr. Ang. He added that career-wise, it’s validation of the importance of global ophthalmology and community work in the field of ophthalmology, which he believes will support his current programs and help them progress to greater heights.



Beyond Caring & Service

December/January 2020

The Artemis Awards The Artemis Award was created to acknowledge the contributions of individual ophthalmologists above and beyond what is required or expected. Since 2014, the Academy has annually honored young ophthalmologists with the Artemis Award in recognition of their tremendous work to help disadvantaged communities obtain vision care. The award is named after the Greek goddess Artemis, who was the protector and nurturer of the vulnerable and suffering.

The selection criteria are tight. The Academy’s Senior Ophthalmologist Committee considers nominations that meet the qualifications and selects the winner based on several criteria, such as nature of the service, the sustainability of service, the length and consistency of service, and the scope of impact.

In the Service of Community & Ophthalmology According to Dr. Ang, both the Global Clinic and the MEC Project were born out of very different circumstances, but with the same goal: To provide eye care in communities where access is difficult, both in his home country and beyond. Going beyond his role as director of vision projects at the Singaporean non-profit organization, Global Clinic, Dr. Ang has undertaken voluntary ophthalmology work in the community, leading volunteer missions all over Asia. He regularly organizes missions and travels to countries such as Indonesia, Thailand, Cambodia, India and Myanmar to provide free cataract surgery. This had helped needy beneficiaries overseas who cannot get medical care due to poverty or inaccessibility. On his mission to Myanmar in 2017 with Global Clinic, Dr. Ang and his team of 20 medical professionals helped almost 3,000 patients and completed more than 270 operations in five days. In his home country, Dr. Ang also initiated the MEC Project in 2013 under the auspices of the Singapore Society of Ophthalmology, to provide free eye care to the elderly in underprivileged communities in Singapore. “We provide primary eye care with optical corrections, such as spectacles if required, as well as accurate diagnosis of conditions in the community so that the beneficiaries don’t have to travel to tertiary hospitals for treatments,” explained Dr. Ang. When he first started the program, Dr. Ang and his small team went doorto-door, surveying and examining the elderly using portable eye equipment.

“Today, we have evolved into a MEC bus that has a more comprehensive clinic, providing access to eye care right at the doorsteps of our beneficiaries,” he shared. Surveys had shown that of the elderly patients who went for a regular eye screening, only 25 to 30% sought further treatment as advised. The MEC program managed to raise this follow-up rate to almost 70%. Indeed, the program has grown significantly. Since its inception, more than 5,000 people have benefited from Dr. Ang’s MEC program. The underprivileged elderly are receiving their regular free eye care, and the program enabled some patients with reversible conditions such as cataracts to receive timely surgery or other basic procedures such as laser treatment.

Achievements that Matter Dr. Ang’s volunteer efforts have not gone unnoticed in the past. He was the recipient of awards such as the Healthcare Humanity Award in 2012 and the Young Eye Care Ambassador Award in 2013. In 2017, Singapore President Halimah Yacob honored Dr. Ang with the country’s Volunteer and Philanthropy Award – the highest recognition for volunteer work in the nation. Still only in his late 30s, the list of achievements and accolades under Dr. Ang’s belt is impressive to say the least. But among all his international and local awards, what means the most to him are the ‘patient appreciation

awards’, which are awarded every year by patients to recognize the doctors for their service and clinical care. “I have achieved this several years in a row now, and I’m glad that my patients appreciate my clinical care on a daily basis,” shared Dr. Ang. In the future, he wants to continue to reach out to more elderly patients with eye disease in certain communities. He disclosed that there are bigger plans for 2020, with the Mobile Eye Clinic programs launching in Myanmar and other regional countries. However, Dr. Ang admits there are plenty of challenges in his charity works. “Perhaps one aspect that people don’t see is that with each mobile eye clinic (which is the ‘face’ of the program), is a project that requires a lot of coordination behind the scenes to make sure that patients receive the care and follow-up that they need. Thus, sustainability in this program is a big effort that requires a lot of commitment,” he said. His passion for humanitarian work has led him to teach young doctors, nurses, optometrists, ophthalmic technicians and medical students who are engaged in building sustainable programs, including education and patient care in developing countries throughout Asia. “What gives me the most satisfaction is interacting with beneficiaries and volunteers, and seeing everyone coming together for a common cause,” he concluded.

About the Contributing Doctor Assoc. Prof. Dr. Marcus Ang, MBBS, MMED, MCI, FRCS, PhD, is consultant ophthalmologist at the Cornea and Refractive Service, Singapore National Eye Centre. He is Secretary of the Asia Pacific Academy of Ophthalmology (APAO) Young Ophthalmologist Committee. He is a graduate of the APAO Leadership Development Program (LDP) as well as the American Academy of Ophthalmology (AAO) LDP Class XX. He currently serves on the APAO YO and LDP Standing Committees and several AAO Committees, such as the International Committee and AAO Myopia Taskforce. Dr. Ang is heavily committed to charity work in the ophthalmology field in Singapore and throughout Asia. As founding director of Global Clinic (, he regularly organizes missions to provide free eye-care and cataract surgery in countries such as Indonesia, Thailand, Cambodia, India and Myanmar. He also serves on the Board of the International Agency for Prevention of Blindness as well as Project ORBIS Singapore. He has been commended with the President’s Award for Philanthropy in Singapore, and Prevention of Blindness Award from APAO. His contributions and achievements as a young ophthalmologist have led to him being awarded recently with the Artemis Award from the AAO 2019. [Email:]


December/January 2020


NLIGHTENMENT Ocular Health vs Aesthetics

In the Eye of the Beholder Eyelid Cosmetic Enhancements and their Associated Ocular Adverse Effects

Is ocular damage worth the price of beauty?

by Gerardo Sison


Many women these days opt for longer lashes to enhance their femininity and overall appearance. And one of

the cosmetic procedures for this is the eyelash extension, which involves attaching fake lashes to the base of natural lashes using an adhesive. These adhesives, however, may contain a cyanoacrylate base and are often mixed with latex and ammonia. According to Dr. Moshirfar, these ingredients can be quite toxic and cause adverse reactions. “I see about five to six patients per year with reactions to eyelash extensions,” shared Dr. Moshirfar. “Formaldehyde-emitting compounds like glue adhesives may cause severe damage to the eye, such as toxic conjunctivitis and conjunctival erosion.” Reports have found that many patients experience itching, inflammation around the ocular area, and watery eyes after receiving eyelash extensions. More severe cases have even reported temporary loss of vision. “Note that many patients do not consult after receiving eyelash extensions even if they have red, itchy eyelids, which may be a symptom of blepharitis,” added Dr. Moshirfar.



hile many cosmetic enhancements are widely and readily available today, the quest for beauty can often come at a price. Procedures such as eyelash extensions, eyelid tattooing, and eyelash dyeing can lead to adverse effects, ranging from temporary irritation to long-term ocular damage. Although ophthalmologists might not experience these cases on a regular basis, it is important to be aware of these cosmetic procedures and their possible risks. Dr. Majid Moshirfar, a cornea specialist and clinical director of Hoopes Durrie Rivera Research Center, Utah, USA, provided some insight on the adverse effects of these procedures so that providers can be better prepared to advise and treat these patients.

Are eyelash extensions safe?

December/January 2020

Complications of Eyelid Tattooing Another trending cosmetic enhancement procedure is eyelid tattooing, otherwise known as blepharopigmentation. It involves injecting pigment granules into the upper layers of the skin to mimic the look of eyeliner or eyeshadow. This procedure may appeal to those who want a permanent makeup solution or those who are physically unable to apply makeup due to conditions, such as arthritis or Parkinson’s disease. Still, this procedure does not come without risks. “Allergic blepharitis, granulomatous reactions and allergic contact dermatitis have all been reported in the literature,” said Dr. Moshirfar. “What is worse is if the chemicals reach the eye itself. Improper application of eyelid tattoos may severely damage the ocular surface and periorbital area leading to corneal erosion and meibomian gland loss, as well as dry eye.”

Because eyelid tattooing involves using a needle to inject a foreign substance in the skin, many patients may experience irritation and inflammation from the needle, as well as the pigment. Most often, the dyes used are also not uniformly approved, which can cause even more concern for possible allergic reactions. Therefore, it is important to advise patients to look for experienced, certified practitioners if they want to undergo this procedure. If done in a healthcare setting, patients are also more likely to receive proper anesthesia and sterilization.

What about eyelash dyeing? Eyelash dyeing, or eyelash tinting, is a beauty treatment that gives the eyelashes a fuller appearance. Although it is not permanent, eyelash dyeing can simulate the lash-darkening appearance of a mascara for a few weeks. However, the dyes can often contain ingredients such as stearic acid and acetyl alcohol, which can act as irritants especially for those who are more prone to allergic reactions. “While allergen testing may be appropriate prior to these procedures, it is not a fail-safe test,” explained Dr. Moshirfar. “Besides allergic reactions, eyelash dyeing can cause ocular surface problems which can increase the possibility of a decline in vision.” Other adverse reactions can include loss of eyelashes and swelling of the eyelids. Patients who have undergone laser-assisted in situ keratomileusis (LASIK) or other refractive corneal procedures may also need to be more careful. “The risk of an adverse reaction leading to worsening of any dry eye condition is higher in these patients than in the general population,” noted Dr. Moshirfar. The procedure involves applying a protectant like Vaseline around the eyes to protect the surrounding skin from getting stained. The dye is then mixed with hydrogen peroxide to help deposit color onto the eyelashes. Using a fine brush, the mixture is applied and allowed to set for 10 minutes.

Eye care specialists should consider toxic and allergic reactions when patients manifest with conjunctivitis, blepharitis or corneal issues after eyelid or eyelash cosmetic enhancement procedures.

– Dr. Majid Moshirfar Some products can be applied at home and are marketed for longterm use. These products may contain silver pigment, which can lead to discoloration of the conjunctiva, cornea and skin with prolonged use. Given that eyelash dyeing products are easily accessible to the public, adverse effects may be more common than previously thought.

Treatment and Prevention of Adverse Effects When patients choose to undergo cosmetic enhancement procedures around the eyelid, they are putting themselves at risk for adverse effects, including ocular damage that can’t be undone. “Eye care specialists should consider toxic and allergic reactions when patients manifest with conjunctivitis, blepharitis or corneal issues after eyelid or eyelash cosmetic enhancement procedures,” said Dr. Moshirfar. “For patients with known allergies, advice should be given to refrain, as much as possible, from exposure to dyes and other chemicals.” In regard to treatment, Dr. Moshirfar said artificial tears may be

used initially for dry eye. “Allergic reactions can be treated with systemic anti-allergies or topical eye drops,” he added. “Whereas granulomatous reactions are more difficult to treat, secondary infections can be treated with local or systemic antibiotics depending on the severity. After an allergic reaction, the patient must be advised not to undergo any other cosmetic procedures because of the high risk of an adverse reaction.” Although these enhancement procedures can be successful for patients, it’s best to ensure that the patient chooses a licensed practitioner who knows what she’s doing. “A person seeking cosmetic enhancement procedures involving areas around the eyes should go to a reputable licensed esthetician, eyelash technician or cosmetic practitioner who is experienced in these procedures,” advised Dr. Moshirfar. “Poor technique can lead to injury to the eyelids, eyelashes and glands.” As with everything else these days, you get what you pay for. And this especially rings true for cosmetic enhancements.

About the Contributing Doctor Dr. Majid Moshirfar is a board-certified ophthalmologist, corneal specialist and refractive surgeon. He earned his medical degree from Georgetown University School of Medicine in Washington D.C. and completed his ophthalmology residency at the University of Illinois College of Medicine in Chicago, where he received the Best Resident Award. He then completed two Fellowships at the John S. Moran Eye Center, University of Utah. Since then, Dr. Moshirfar has established his own cornea fellowship program at the Moran Eye Center, which is currently training a total of 38 fellows. Based in Salt Lake City, Utah, USA, Dr. Moshirfar specializes in cornea transplant, vision correction surgery and intraocular implants at Hoopes Vision. He has been a leader in developing complex procedures and techniques involving the cornea and anterior segment. As an internationally renowned specialist, Dr. Moshirfar has also authored more than 200 peer-reviewed publications and contributes on the editorial board of multiple scientific journals. [Email:]


December/January 2020



Making Clear Vision Possible for the Underprivileged by Tan Sher Lynn

ou and I probably won’t have to think twice about changing our glasses if our optical power changes, or even just for the sake of fashion. But do you know that 2.5 billion people – which is one-third of the world’s population – have no access to glasses? Eyeglasses are a low-cost, highimpact intervention that boost earning potential, learning outcomes, road safety and overall quality of life. Yet, despite the fact that eyeglasses are a 700-year-old technology, many lowincome individuals at the base of the economic pyramid do not have access to them. Therefore, VisionSpring, a social enterprise founded in 2001 by eye doctor Dr. Jordan Kassalow, aims to address this issue by delivering affordable spectacles and vision care where they’re needed the most.


A Business Model that Changes Community



“VisionSpring works to accelerate the diffusion of eyeglasses to those who need them the most. We firmly believe that by democratizing vision and bridging the gap between those who have clear vision and those who don’t, we can change the world,” said Dr. Kassalow. According to Dr. Kassalow, 2.5 billion people need eyeglasses and 624 million are visually impaired, costing the global economy an estimated $227 billion each year. In short, this problem is too big to be solved with just charity and philanthropy. “A problem this big requires market-based solutions. The people we serve are our customers, not beneficiaries. People who earn less than $4 per day will pay 1 to 2 days’ wages for eyeglasses. They have purchasing power and will invest in their ability

December/January 2020

to see clearly, to keep working, care for their families, etc.,” continued Dr. Kassalow. “We work to ensure that firsttime vision screening and eyeglasses reach all those billions who need them, regardless of location or means. Our business model enables us to provide these individuals with vision screenings and glasses at subsidized prices, if they aren’t sponsored entirely.” Since 2001, the company has created over $1 billion in global economic impact through their work to provide glasses to children and those earning less than $4 per day to address uncorrected refractive error. “VisionSpring is not the traditional non-profit organization, but rather a social enterprise which adopts a blended model that enables it to be supported by a combination of revenue-generating business streams (25%) and philanthropic investment (75%),” he explained.

“We do not aim to be a 100% self-sustaining model; we pair philanthropic dollars with earn revenue to most effectively increase access to eyeglasses for low-income customers,” said Dr. Kassalow. “We run like a business, with earned revenue, and we manage to a planned net loss. Instead of seeing correcting refractive error – getting eyeglasses on faces – as a traditional public health program, we see it as investment in livelihoods, education, financial inclusion, and road safety.”

See to Learn, Earn and Be Safe Dr. Kassalow pointed out that VisionSpring’s mission is broken down into three main initiatives: see to learn, see to earn, and see to be safe. “These underscore the ways in which improved vision can yield great economic benefits by empowering individuals to learn more easily, work more efficiently and increase their earnings, and see more clearly when driving. These three themes ladder up to five of the United Nation’s Sustainable Development Goals (SDGs), which are SDG 1: No poverty; SDG 3: Good health and well-being; SDG 4: Quality education; SDG 5: Gender equality; and SDG 8: Decent work and economic growth,” he explained. The enterprise reaches its customers using innovative B2B distribution models, which include: 1. Wholesale Partnerships – selling bulk quantities of eyeglasses, coupled with training and marketing, to a network of hospitals, rural pharmacies in Bangladesh, eye care centers, non-governmental organization (NGOs) and government partners. As of 2018, 385 organizations count on VisionSpring’s quality product, timely delivery, favorable payment terms and sell-through support to expand their vision services to low-income customers.

2. Third-Party Subsidized Vision Access Solutions – bringing eyeglasses to workplaces, schools and rural communities by pairing philanthropic funds with the purchasing power of endconsumers and governments. For example, in Bangladesh, 25,000 BRAC community health workers are conducting presbyopia screenings and have sold 1.4 million pairs of reading glasses in 61 of 64 districts in Bangladesh. “In essence, VisionSpring exists to create access to affordable eyewear for everybody, everywhere. Throughout the years, we are proud of the fact that we are able to facilitate the wonder of clear vision through affordable eyewear for millions across the world,” shared Dr. Kassalow.

Get Involved VisionSping collaborates with hospitals, rural pharmacies, eye care centers, NGOs and government partners, employers and supply chain organizations, and schools and rural communities, pairing philanthropic funds with the purchasing power of end-consumers and governments to provide eyeglasses. Individuals belonging to any of the above institutions, especially in Africa or Asia, who would like to explore partnerships can write to global.partnerships@ The public can also donate through their website www.visionspring. org/donate. Every $5 invested ensures that one person across the world will get the benefit of clear vision – a school-aged child can learn better, a low-income worker’s productivity can improve, or a driver can drive safely.

VisionSpring’s Impact Cumulative Reach: 43 countries in Southeast Asia, Africa and the Americas Key Markets: India: Bihar, Madha Pradesh, Odisha, Rajasthan, Uttar Pradesh (5 of the most impoverished states) Other countries: Bangladesh, Ghana, Kenya, Nigeria, Uganda, Zambia Cumulative Results as of Dec 31, 2018: XX 5.5 million pairs of vision correcting eyeglasses sold XX More than $1 billion increased earning potential generated at the household level XX 52% acquiring their first-ever pair of eyeglasses

About the Contributing Doctor Dr. Jordan Kassalow is an eye doctor, social entrepreneur and author. He is the founder of VisionSpring, the co-founder of EYElliance, and a partner at Drs. Farkas, Kassalow, Resnick, & Associates. He also founded the Global Health Policy Program at the Council on Foreign Relations and co-founded Scojo New York. Prior to his position at the Council, he served as director of the River Blindness Division at Helen Keller International. Kassalow is a fellow of Draper Richards Kaplan, Skoll, Ashoka, and is a Henry Crown Fellow at the Aspen Institute. He was named one of Schwab Foundation’s 2012 Social Entrepreneurs, was the inaugural winner of the John P. McNulty Prize, and was recognized in Forbes Impact 30. Additionally, he coauthored Dare to Matter: Your Path to Making a Difference Now. VisionSpring has been internationally recognized by the Skoll Foundation, the Aspen Institute and the World Bank. It is a three-time winner of Fast-Company’s Social Capitalist Award, and a winner of Duke University’s Enterprising Social Innovation Award. [Email:]


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Hot Topics

Retreatment, Relationships and Regimens at AAO 2019 by Brooke Herron


he Refractive, Glaucoma and Cornea Subspecialty Days at the recent American Academy of Ophthalmology (AAO 2019) annual meeting were chock full of new research, including updates on treatment and ongoing studies. Below, we’re presenting some of the anterior segment highlights from the meeting’s exciting scientific program.

CIRCLE Enhancement After Myopic SMILE It’s clear that small incision lenticule extraction (SMILE) is gaining popularity in the refractive sphere. However, enhancement using re-SMILE is neither approved nor commercially available on the VisuMax platform from Carl Zeiss Meditec (Jena, Germany), and very little data exists on its safety and efficacy. As a result, alternative enhancements like surface ablation, cap-to-flap conversion (using the CIRCLE program) and thinflap laser-assisted in situ keratomileusis (LASIK) have been proposed and established as retreatment options. Looking further into one of these methods, Dr. Jakob Siedlecki discussed the advantages and disadvantages of CIRCLE retreatment after SMILE, which converts the SMILE cap into a femtosecond LASIK flap. (Note: While the CIRCLE software is integrated into the VisuMax platform, it is not currently available in the United States.) There are four CIRCLE patterns with different sequential laser cuts available, although Riau et al., found that pattern D was the easiest to lift. And this step-by-step surgical technique was described by Dr. Siedlecki. Results from a study comparing CIRCLE with other retreatments were


Relationships ain't easy: Glaucoma (and its medications) can exacerbate problems in the cornea.

presented. It was found that CIRCLE after SMILE provides outcomes noninferior to surface ablation. And CIRCLE was also non-inferior in terms of safety and efficacy when compared to LASIK retreatments. Another study by Siedlecki et al., found comparable results for both CIRCLE and surface ablation at three months, while CIRCLE retreated eyes showed a markedly quicker visual recovery. CIRCLE is also easy to use and requires less preoperative planning than thin-flap LASIK above the SMILE interface. Additionally, the painless nature of the procedure may also appeal to patients, especially in conjunction with a quicker visual recovery. However, a disadvantage of the CIRCLE approach is that it sacrifices the


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idea of the flap-free approach, which is often touted as a primary benefit of SMILE. In fact, when the anterior stroma is separated above the flap from the posterior corneal structures, more biomechanical weakening is induced than in surface ablation or in thin-cap LASIK. Dr. Siedlecki said this will be especially pronounced in deep caps: “In these cases, thin-flap LASIK anteriorly to the SMILE interface might provide better outcomes.” This led Dr. Siedlecki to conclude that “CIRCLE offers an easy to use, safe and efficient option for refractive enhancement after SMILE. And from a surgical prospective, cap thickness of the primary SMILE procedure might be the most prominent guiding factor”.

Medication and Laser Therapy in Glaucoma Patients with Corneal Disease At times, relationships can be complicated. And the interaction between glaucoma and the cornea is especially complex. Dr. Keith Barton explained the ties between the two, and how their relationship can affect both treatment and visual outcomes. Firstly, glaucoma medication thins the cornea, which can cause a slight underestimation of intraocular pressure (IOP). He said there is some evidence that glaucoma medication (especially prostaglandin agonists or PGAs) results in a small amount of corneal thinning. One study reported a 6.9µm reduction

in central corneal thickness after six weeks on travoprost. And another reported that the rate of central corneal thickness thinning was greater in patients who took PGA monotherapy. However, in either study, the change was not sufficient enough to impact clinical decision making. Ocular surface disease is another consideration. Ocular surface disease is common in the age group that develops glaucoma, with 14.4% of patients experiencing dry eye symptoms. Moreover, the drugs and preservatives in glaucoma medication exacerbate ocular surface disease. Not only that, glaucoma medication can actually cause cornea and ocular surface disease. For example, allergies to topical carbonic inhibitors may develop after years of treatment, while toxicity to medication could result in dystrophic corneal epithelium and conjunctival fibrosis. Dr. Barton continued that elevated IOP reduces the endothelial cell count – with glaucoma being the single biggest risk factor for corneal transplant failure (according to the Australian graft registry). Not only that, glaucoma may also exacerbate corneal endothelial cell loss. However, he added that early laser may protect the ocular surface and endothelium against the long-term affects of medical therapy. According to the recent Laser in Glaucoma and Ocular Hypertension (LIGHT) Trial, clear benefits of selective laser trabeculoplasty over medical therapy in newly diagnosed, medication-naïve ocular hypertension and glaucoma patients were demonstrated. Finally, Dr. Barton explained that in recalcitrant cases, laser may be an alternative to incisional surgery. “Cyclophotocoagulation (CPC) is not new, but there are now many options, either under development or approved, than have been previously available,” he concluded.

Crosslinking for Infectious Keratitis Introduced in 2003, corneal collagen crosslinking (CXL) is used to stabilize the progression of keratoconus. Although it’s also been performed in cases of bullous keratopathy, corneal melting, and infectious keratitis. According to Dr. José Gomes: “The increasing number of publications on CXL treatments for infectious keratitis led cornea specialists to adopt the term ‘PACK-CXL’ (or photo-activated chromophore for keratitis-CXL)”. He said the first clinical descriptions of PACK-CXL in treating bacterial infectious keratitis were promising, with a reduction in central stromal infiltrates and melting. While similarly, other publications demonstrated good outcomes of adjunct CXL and antimicrobial topical medication in nonresponsive corneal infectious ulcers. Various other studies reported on additional advantages, including a lower rate of perforation or recurrence of infection, and corneal epithelial defect and infiltrate resolution occurring faster after CXL. Dr. Gomes concluded that “PACK-CXL seems promising in the management of infectious keratitis, notably bacterial keratitis, and is not indicated in herpetic corneal disease”. Overall, the AAO 2019 anterior segment subspecialty days offered delegates the latest information on the most promising treatments for conditions affecting vision in the front of the eye – all in the name of preserving and maintaining eyesight for hundreds of thousands of patients around the world. Editor’s Note: The American Academy of Ophthalmology’s (AAO 2019) annual meeting was held from October 12 to 15, 2019, in San Francisco, California, USA. Reporting for this article also took place at AAO 2019.


December/January 2020



Set your Sights on India for AIOC 2020

Pack your bags for AIOC 2020!

by Brooke Herron


he 78th Annual Conference of the All India Ophthalmological Society (AIOS) – AIOC 2020 – will take place in Gurugram, Haryana, India, from February 13 to 16, 2020. More than 8,000 delegates are expected to attend from India and around the world. Dr. Rajesh Sinha, who serves as the AIOS honorary treasurer, says: “The annual AIOS conference is one of the leading scientific events in the field of ophthalmology, and we are continuously striving to deliver a better conference experience to delegates each year”. Evidence of this is shown in the exuberant scientific program, with many world-renowned guest speakers on-hand to share the latest updates in all things ophthalmology. For example, some not-to-be-missed instructional courses include complicated cataract surgery cases, a tutorial in oculoplasty, diagnosis and management of chorioretinal inflammatory diseases,

maximizing outcomes in phakic IOLs, customizing keratoplasty, clinical pearls in uveitis, plus many, many more. Meanwhile, master instruction classes offer methods to manage subluxated lenses and phacoemulsification complications. AIOS Honorary General Secretary Dr. Namrata Sharma says attendees can expect the best in terms of scientific content. “The conference will include discussions on a wide array of topics in ophthalmology, as well as its newer aspects... truly living the theme of ‘Global Ophthalmology Beyond 2020’”. Several ‘Special Sessions’ will also take place at AIOC 2020, such as the President’s Guest Lectures, and National Symposiums on topics including small incision cataract surgery (SICS), kerato-refractive surgeries, pediatric ophthalmology, ocular trauma and practice management. International symposiums about anterior



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segment imaging, surgical innovation in glaucoma, genetics in ophthalmology and post-surgical endophthalmitis are additional conference highlights that should not be missed. Of course, AIOC would not be complete without its prestigious awards, including the P. Siva Reddy International Award (jointly awarded to Dr. Suven Bhattacharjee and Haripriya Aravind for the B-HEX Pupil Expander and for endophthalmitis reduction with intracameral moxifloxacin, respectively), and the CN Shroff Award (awarded to Dr. Rajiv Raman for work in vitreoretinal diseases). Numerous awards will also be presented to the best free papers, poster, podium presentations and more. This year will also welcome new AIOS President, Dr. Mahipal Sachdev. “Often described as a living legend in ophthalmology, Dr. Sachdev is sure to take AIOS to new heights with his passion and commitment, his knowledge and sheer brilliance, his zeal and enthusiasm and his leadership and team spirit qualities.” Held in Gurugram, known as the Millennium City of Haryana, at the A Dot Convention Center GNH, AIOC 2020 will be just a 5km drive from the Delhi airport, making transport simple for national and international delegates. Gurugram is known as a financial and technology hub and features various attractions, such as national parks, museums, theaters, temples and more. With such a robust scientific program, with leading experts from around India and the world, AIOC 2020 promises to be the biggest yet. And with continued innovation, research and collaboration at conferences such as this, the understanding, management and treatment of ophthalmic conditions are updated and advanced, ultimately resulting in better visual outcomes for all.

Editor’s Note: Media MICE Pte Ltd, CAKE magazine’s parent company, is the Official Media Partner of AIOC 2020.


Elegance and Innovation Showcased at the APACRS 2019 in

by Matt Young


ight after the Paris runway at the 37th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2019), CAKE magazine next landed in the beautiful city of Kyoto, the former capital of Japan, to discover innovations in the fields of cataract and refractive surgery at the Annual Meeting of the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2019). Aptly themed Elegance and Innovation, the APACRS 2019 presented the latest cutting-edge products and techniques in this ever-evolving field, shared by renowned ophthalmologists from around the world. Located in a venue rich in history and tradition, the titles of the APACRS symposia reflected the Japanese culture. Among them include the ‘Sumo’ session on the challenges in refractive surgery and the ‘Umami’ session, which tackled astigmatism correction in cataract surgery and other non-phaco and intraocular lens (IOL)related issues. Below are some insights from the intriguingly titled session: ‘Katana’ on ‘The Cutting Edge in Phaco and IOLs’. So, what exactly is a katana? In days of yore, the heroic samurai of ancient and feudal Japan relied on the katana, a Japanese sword with a curved, single-edged blade. According to Western historians, the katana was among the finest cutting weapons in world military history. Eye surgeons, on the other hand, can count on their trusty surgical instruments.

The cutting-edge katanas of cataract surgery According to Dr. Oliver Findl from the Vienna Institute for Research in Ocular Surgery, and Hanusch Hospital,

Vienna, Austria, one can also rely on measurements to enhance toric outcomes. He said that different corneal measurements cannot be used interchangeably. He also advised to use a combination of different measurement methods for toric IOL calculation. Swept-source optical coherence tomography (SS-OCT) appears to be more accurate compared to Scheimpflug imaging. Dr. Findl noted that the main source of error in toric-IOL calculation is the corneal measurement. His advice? “Use three different devices and at least two different measurement techniques.” “Doubt your corneal measurements and repeat them, if necessary,” he urged, especially for patients with conditions such as dry eye, and irregular cornea. Meanwhile, Professor Soon-Phaik Chee, from the Singapore National Eye Centre (SNEC), talked about the CAPSULaser, a selective non-contact non-pulsatile laser that creates a capsulotomy in less than a second. She said that problems with femtosecond laser-assisted cataract surgery (FLACS) included the cost. It also requires additional room and an additional set of staff, while also affecting patient flow. Meanwhile, ZEPTO, the precision pulse capsulotomy device from Mynosys (Fremont, CA, USA), requires un-scrubbed staff to assist, one of its limitations. She concluded that the CAPSULaser has its advantages including its selective thermal laser capsulotomy and it does not disrupt the patient flow. Some biomaterials are purer than others, said Professor Gerd Auffarth from the International Vision Correction Research Centre, Germany, during the session.


He noted that a purity study on hydrophobic acrylic IOL material comparing Hoya’s Vivinex, Alcon’s SN60WF and J&J Vision’s Tecnis showed that hydrophobic-acrylic IOL models differ in their resistance to develop glistenings and glistening patterns. Glistenings do not reduce visual acuity but increase ‘straylight’, which can cause patients to be blinded by oncoming car headlights and hazy vision. In the study, an accelerated aging protocol was used to induce glistenings, or microvacuoles, in hydrophobic acrylic IOLs. The IOLs were warmed to 45°C and then cooled to 37°C. “Although less severe, the glistening problem needs to be addressed by the IOL manufacturer through either the introduction of new materials or by continuous improvement of the manufacturing process,” concluded Prof. Auffarth.

Of rapid innovations and wider treatment options Rapid innovation in medical devices and medications has resulted in a wider and better range of treatment options in cataract surgery. This allows cataract surgeons to plan and design treatments accordingly to help to meet patient expectations, as well as improve vision and quality of life. Dr. Hiroyuki Arai from the Queen’s Eye Clinic, Japan, discussed selecting appropriate intraocular lenses (IOLs) for individual patients in a paper called Optimize Outcomes with the Choice of IOLs and Innovations. IOL options have expanded with the emergence of multifocal and extended depth of focus (EDoF) lens. In this vein, Dr. Arai introduced a new IOL – the LENTIS Comfort – which


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CONFERENCE HIGHLIGHTS APACRS 2019 Coverage was launched in April last year. The IOL has been approved in Japan and is covered by the Japanese national health insurance program. Dr. Arai emphasized that this low-add segmental IOL is designed to minimize light loss and has almost no glare and halos.

Postoperative dry eye management Dry eye disease (DED) after cataract surgery has become a critical concern, and various treatments have been developed to counter this condition. “Most cataract surgery patients have prior ocular surface disease (OSD),” said Adjunct Associate Professor Lim Li from the Singapore National Eye Centre (SNEC). Clinical signs of dry eye are commonly found in cataract patients before surgery. “However, the majority of patients were asymptomatic or minimally symptomatic,” said Prof. Lim about a recent study. Seventy-seven percent of eyes had abnormal corneal staining and more than 60% of patients had an abnormal tear film break-up time (TBUT). Additionally, a blurred vision was more likely than burning or foreign body sensation. So, why is it important to manage the ocular surface?

Preoperative biometry and topography could be affected, as well as postoperative outcomes, like visual and refractive results. According to Prof. Lim, studies have shown that hyperosmolarity of the tear film is associated with significantly more variability in average keratometry readings and anterior corneal astigmatism. This may result in significant differences in IOL power calculations. “Corneal staining is the single most critical sign of OSD that should be normalized before cataract and refractive surgery,” said Prof. Lim. Artificial tear preparations, such as Hialid (Santen Pharmaceutical, Tokyo, Japan), which contain various polymers like cellulose derivatives and hyaluronic acid, are the first-line treatments for dry eye symptoms after cataract and refractive surgery due to their effectiveness in alleviating symptoms of dry eye after cataract surgery. Therapeutic contact lenses may be beneficial for severe OSD, including corneal ulcers, persistent epithelial defects, corneal perforation, and chemical burns. Bandage lens may be used in the preoperative setting to allow epithelial healing of punctate keratitis before preoperative biometry measurements.

Rapid innovation in medical devices and medications has resulted in a wider and better range of treatment options in cataract surgery. This allows cataract surgeons to plan and design treatments accordingly to help to meet patient expectations, as well as improve vision and quality of life.

“Visually significant (VS) OSD leads to reduced visual quality and potential errors in preoperative measurements,” cautioned Prof. Lim. In short, according to him, it is important to identify VS OSD patients, defer preoperative measurements until fully treated and resolved (as they can be affected), postpone surgery, and treat patients before surgery to achieve an optimal outcome. “A study found that the use of an aspirating speculum aggravated dry eye parameters during the early postoperative period after cataract surgery,” said Professor Jong Suk Song from the Korea University College of Medicine in South Korea. Cataract surgery can also worsen ocular surface parameters and aggravate dry eye disease. Therefore, he advised physicians to aggressively treat cataract patients with existing dry eye disease. In addition, increased incision extent, operation time, irrigation and microscopic-light exposure time decreased the TBUT and goblet cell density. And the use of topical eye drops after cataract surgery can worsen the goblet cell density. Conjunctival goblet cell loss in dry eye is associated with ocular surface inflammation. According to Prof. Jong, studies have revealed that preservative-free diquafosol showed better efficacy in treating DED after cataract surgery than preservative-containing diquafosol or preservativefree hyaluronate. “Therefore, preservative-free diquafosol may serve as a reliable option for the management of patients with preexisting DED after phacoemulsification,” he concluded. These practical tips from renowned surgeons should help to manage patients’ expectations and improve satisfaction – which is valuable advice for any cataract surgery practice.

The heroic samurai of ancient and feudal Japan relied on the katana, a Japanese sword with a curved, single-edged blade, deemed among the finest cutting weapons in world military history. Today in the modern world, eye surgeons rely on their trusty surgical blades!



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Can you take the heat… in the OT? In the popular Japanese cooking show ‘Iron Chef’, contestants battle each other to win the title. Sometimes exotic ingredients are thrown into the mix to flummox participants. Similarly, while most cataract surgeries are routine, surgeons are occasionally faced with challenging cases. During the ‘Iron Chef’ session at APACRS 2019, which tackled ‘Challenging Cataract Surgery’, several experts shared their experiences and insights on various problematic scenarios. “There are many complications when it comes to cataract surgery for the elderly,” said Dr. Hisaharu Suzuki from Zengyo Suzuki Eye Clinic and Nippon Medical School, Japan. These include a hard nucleus, weak zonular fibers, corneal endothelial cell loss, myosis, and glaucoma. Therefore, considerable preparation is required for cataract surgery in the elderly. “Congenital cataracts are complicated,” added Dr. Zhao Yun-E, from the Eye Hospital of Wenzhou Medical University, China. They are always idiopathic, involve complicated and difficult operations, often entail numerous complications, and have uncertain clinical outcomes in the long-term. She advised diagnosing before surgery, avoiding cortex shrinking for cases of posterior capsule defect (PCD), preventing hemorrhage for those with persistent fetal vasculature (PFV), and suturing the incisions.

Wrestling with challenges in refractive surgery Meanwhile, in the ‘Sumo’ session, the audience heard from various refractive surgery experts on the latest innovations. Professor Kimiya Shimizu, M.D., from the Sanno Eye Center, Japan, presented the latest developments and clinical results on the ICL KSAquaPORT, which he developed. (Note: The KS stands for his initials.)

He said that the visual performance of Implantable Collamer Lens (ICL) is better than laser-assisted in situ keratomileusis (LASIK), and is also reversible. In summary, he said that the ICL KS-AP is safe, efficient, provides high predictability, offers stable refraction, and is shown to have no complications in his patients since 2007. “The most commonly performed corneal refractive surgery procedures in the past decade changed from LASIK to surface ablation (SA),” said Dr. Cordelia Chan, from Eye Surgeons@Novena & Napier, Singapore. In 2005, 81% of surveyed patients in Korea had LASIK and only 15% had SA. But 10 years later, in 2015, 40% had SA, while 35% had LASIK. The main reasons for this shift were due to a fear of flap-related complications and because Koreans have a relatively thin central cornea. However, LASIK has its strengths, namely that it offers excellent and stable vision, quick recovery and short downtime, with minimal or no haze and minimal pain. In a study comparing femto-LASIK versus photorefractive keratectomy (PRK), Dr. Chan said both groups saw excellent safety profiles, but LASIK saw a faster visual recovery at 1 month. But LASIK did have potential problems, such as more dry eye, tears, buttonholes, diffuse lamellar keratitis, epithelial ingrowth, flap dislodgement, rainbow glare, and ectasia risk. Small incision lenticule extraction (SMILE), on the other hand, according to Dr. Chan, had good outcomes but saw some variability. Plus, dissection can be tricky for an inexperienced surgeon due to the thin lenticule. Visual recovery was slower compared to LASIK, but faster than PRK, and with less pain. Moreover, Dr. Chan noted that she no longer performs Epi-LASIK due to cases of stromal incursions among patients at her center. Her preference for low to moderate myopia is femto-LASIK for the fastest visual recovery, comfortable postoperative recovery, and excellent safety, efficacy and predictability profiles.

To LASIK or to SMILE, that is the question “A study comparing wavefront-guided LASIK versus SMILE showed that both provided excellent clinical outcomes and predictability,” said Dr. Edward Manche, professor of ophthalmology at Byers Eye Institute, Stanford University School of Medicine. He said there was no difference in the induction of higher-order aberrations, but added there was a faster visual recovery in the WFGLASIK group. There was also better uncorrected and corrected distance visual acuity (UDVA) at 20/16 or better in the WFG-LASIK group. On the other hand, Associate Professor Marcus Ang from the Singapore National Eye Centre (SNEC) said that a study on intraoperative patient experience and postoperative visual quality after SMILE and LASIK found that SMILE achieved good refractive predictability at 3 months. “Secondary outcomes such as safety, efficacy and stability for SMILE at 3 and 12 months were similar to LASIK,” he said. Dr. Ang noted that intra-operative experience was similar between SMILE and LASIK except for surgical manipulation, which was more uncomfortable during SMILE compared to LASIK. He added that at 1 month after surgery, patients had similar symptom scores between eyes, except more occasional blurring with SMILE compared to LASIK. Other fascinating sessions at APACRS included the ‘Wisdom of the Samurai’, in which experts presented subtle surgical tips and maneuvers that other surgeons can bring home and use the next time they are in the OT. Editor’s Note: A version of this article was first published in CAKE Today, CAKE Magazine’s electronic daily congress news, Media MICE’s Daily at the Asia-Pacific Association of Cataract and Refractive Surgeons annual meeting (APACRS 2019) held in Kyoto, Japan, on October 3-5, 2019.


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CONFERENCE HIGHLIGHTS ESCRS 2019 Highlights Managing Corneal Disorders in

Cataract and Refractive Patients

by Hazlin Hassan

For refractive surgery patients, new technologies are available for the detection of corneal disorders, thereby potentially improving outcomes.

and posterior corneal surface, lens thickness and opacification, as well as higher order aberrations. High order aberrations of the anterior and posterior corneal surfaces are good indicators for diagnosing keratoconus and for classifying the stage of the disease, with sensitivity and specificity of 98 and 99%, respectively. “The diagnosis of irregular corneas is complex and depends on many factors. One device by itself is not a good predictor of the condition. Predictive models can be obtained in combination with other indicators,” concluded Prof. Kymionis.


his is among the good news that delegates heard at the 37th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS Paris 2019) during the EuCornea Symposium called ‘Approaches to the Diagnosis and Management of Important Corneal Disorders in the Cataract and Refractive Patient’.

Diagnostic Imaging of the Irregular-Keratoconic Cornea

Diagnostic imaging is the 'cherry on top' for evaluating keratoconus.

Prof. Georgios D. Kymionis of JulesGonin Eye Hospital and University of Lausanne, Switzerland, explained that keratoconus – a disorder where the cornea thins into a cone-shape and distorts vision – occurs in one of 2,000 people, with 7% having family history of the disease. The incidence of keratoconus differs according to geographical location and environmental factors may also contribute to the wide variation in prevalence. Areas with sunshine and hot weather like India and the Middle East have a higher prevalence (2.3%), compared with places with less sunshine such as Finland, Denmark and Russia (0.0003%). “Thus, ultraviolet light-induced oxidative stress may have a role to play,” said Prof. Kymionis. Keratoconus impacts the patient’s quality of life. “Vision-related quality of life was worse in keratoconic patients due to low visual acuity,” he explained, adding that using contact lenses to maintain visual acuity (VA) may improve vision-related quality of life. Keratoconic patients also had significantly lower values in social functioning, mental

health, role difficulties and overall composite scores. Diagnostic imaging technology is essential for corneal analysis, especially in the early stages of disease. It’s used for screening subclinical keratoconus and evaluating the disease’s progression, preoperative screening of refractive (excluding patients with subclinical keratoconus) and cataract patients – especially in those where a premium intraocular lens (IOL) is used. It’s also important in the evaluation of corneal irregularities in postrefractive surgery patients and in the determination of possible retreatment. Diagnostic imaging technology for corneal analysis includes topography, tomography, corneal thickness maps, epithelial thickness maps, aberrometers and artificial intelligence (AI). Comparing corneal topography to tomography, Prof. Kymionis said that corneal topography is limited to evaluating the anterior surface of the cornea and has decreased sensitivity and specificity for patients with subclinical keratoconus. On the other hand, corneal tomography measures the elevation maps of both the anterior



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New Technologies for the Detection of Corneal Disorders in Refractive Surgery Patients According to Prof. Burkhard Dick from the University Eye Hospital Bochum, Germany, new technologies are now available for the early detection of corneal disorders in refractive surgery patients. “Early detection of keratoconus is a serious need. The lack of affordable tools is holding us back,” he explained. Millions of patients are at risk for keratoconus based on corneal curvature alone, revealed Prof. Dick. There are 309 million patients with >46D corneal curvature or >2D cylinder. Some 90% of these patients live in Asia-Pacific countries, while 60 percent live in India and China. A total of 1.7 million patients are between the ages of 15 and 30-years-old. And while there are 4,000 cornea specialists, around 75% of physicians worldwide do not have topography capability in their offices. This is where the Delphi EyeTopo System – a small, fast and cost-effective smartphone-based topography system at around $1,800 per unit – can help fill the gap. It’s equipped with AI-enhanced, cloud-based analytics and backed by

the entire Nidek Magellan topography library, available to the smartphone and cloud environment. Genetic testing can also be done to identify patients at risk. Genomic deoxyribonucleic acid (DNA) is extracted from a buccal swab sample, and next generation sequencing (NGS) analysis is carried out using a custom panel, primarily targeting the coding regions of 75 genes identified to be involved in the eye structure and function. The test screens for over 70 mutations that lead to transforming growth factor beta-induced (TGFBI) corneal dystrophies. This allows for the analysis of a larger number of collected positives and control samples, greater detailed information on individual variant contribution to keratoconus progression, and therapeutic use. There is a need for technology that is easy to adopt, and AI will further improve diagnosis of the disease. Genetic testing is a new addition to the clinician’s toolbox. Add this to

existing optical and scanning methods, and at-risk patients can be identified earlier, perhaps before any changes are detected on current devices. With improved monitoring, doctors can implement preventative treatments. Preoperative evaluation in refractive surgery can help determine the individual’s potential to progress to keratoconus, which can be a deciding factor in procedure selection or against a corneal procedure.

Preventing the Onset and Progression of Keratoconus Dr. Mario Nubile, MD, PhD, from the University of Chieti Pescara, Chieti, Italy, provided tips on how to prevent the onset or progression of keratoconus. “Avoid eye rubbing and use topical steroids or cyclosporine eye drops,” he advised, noting that hybrid lenses offer higher satisfaction and visionrelated quality of life, as compared to rigid lenses. Larger diameter contact

lenses are associated with decreased lens awareness and enhanced on-eye stability. On corneal transplants, he said that deep anterior lamellar keratoplasty (DALK), a safe procedure for all levels of keratoconus, is preferred in phakic eyes or in patients with mental disability. It spares the recipient’s endothelium, there is a lower risk of rejection and a higher graft lifespan, and it’s less prone to increases in intraocular pressure (IOP). “Penetrating keratoplasty (PK) to treat advanced keratoconus with endothelial failure has a higher risk of rejection and deep central corneal scarring,” added Dr. Nubile. Editor’s Note: The 37th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS) took place from September 14 to 18 at Pavilion 7, Paris Expo, Porte de Versailles, Paris, France. Reporting for this story also took place at the ESCRS 2019.


New Intraocular Lens Injector Announced by Medicel


witzerland-based med-tech company Medicel, a leading producer of lens injection systems, has announced a new intraocular lens (IOL) injector: Ergojet. The new multi-purpose tool is an evolution of ACCUJECT PRO and promises increased safety and efficiency in ophthalmic surgery. Medicel is the exclusive manufacturer of this patented technology. Designed with vital input from surgeons, Ergojet was created for an easier, more ergonomic procedure, and comes with bespoke adaptation, readyto-use documentation, and packaging solutions. Additionally, it enables IOL manufacturers to go to market with a reliable, high-end system in the shortest time frame. Two IOL manufacturers

launched the preloaded IOL Ergojet at ESCRS Paris 2019. The pioneering instrument is the first disposable screw injector and is made for single-handed operation of a push injector. This allows for smooth and controlled injection of almost any one-piece IOL, and it can be used in various ophthalmic surgeries, including implanting IOL pressure sensors, capsular tension rings, IOLs and artificial irises. Ergojet can also aid in corneal transplants. The new instrument retains the benefits and is compatible with ACCUJECT PRO, a platform for preloaded hydrophobic and hydrophilic preloaded systems. It’s designed to lie stable, without unintended rotation between the thumb and index finger, and the gear driven plunger allows

surgeons to screw or push with one hand for complete control and easier operation. Ergojet is available as backor top-loaded, with incisions ranging from 1.6 to 3.0mm, depending on the lens and diopter used. Designed with Switzerland’s famous watch technology in mind, Medicel focused on precision gears – resulting in an almost powerless transmission. This means it doesn’t matter how fast or slow surgeons inject: It follows their direction and turns the operation wheel accordingly. The power felt is only one-quarter of that invested, which makes surgery less risky for patients and surgeons alike. Worldwide, Medicel injection systems are used in 20% of foldable IOL procedures.


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Latest Technology Trends in Cataract Surgery by Hazlin Hassan

All the latest cutting-edge technologies in cataract surgery – from imaging, measuring and lenses – were revealed at a symposium called “Mastering Your Cataract Surgery Workflow with Next Level Technology” during the 37th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2019).

Automated Measurements & Centralized Data Storage Dr. Peter Stalmans, MD, PhD, from the Department of Ophthalmology Uzleuven, Belgium, shared how high-tech tools have helped the University Hospitals Uzleuven in managing its 500,000 patients a year. The hospital has over 1,900 beds and 9,000 employees. Its Department of Ophthalmology alone has 10 full-time staff members, 26 consultants, 25 residents and 300 personnel. It handles 10,000 procedures annually, including 1,000 vitreoretinal surgeries. Some 40% of these are combined with lens surgery using intraocular lenses (IOLs), whether spheric, toric, trifocal or extended depth of focus (EDOF). “Clearly, there is a need for perfection in patient data management,” said Dr. Stalmans. This includes taking accurate measurements, which is the first step in ensuring accurate IOL calculations. He pointed out that automated measurements can avoid operator-

induced errors, while centralized data storage means that all data is accessible within the same software. “The system is hassle-free as it involves as few steps as possible to do tasks such as order IOLs,” he said. A centralized data overview allows all the data to be available on the same screen, and an integrated visualization during surgery provides an augmented reality to guide the surgeon. Within the Zeiss ‘ecosystem’, the IOLMaster 700, which uses swept-source optical coherence tomography (SS-OCT) technology, provides a full-length OCT image for fewer refractive surprises. Meanwhile, the Cirrus OCT, with its spectral domain-OCT based imaging, allows clinicians to scan patients fast, with increased efficiency and improved imaging detail. The Artevo 800 digital microscope provides depth of field, reduced light intensity requirements and real color impression for increased certainty, as well as access to patient data remotely on the cloud through the Zeiss Cataract Suite.

Don't be late to the party: Digital surgery has arrived.



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“The IOLMaster 700 takes accurate SS-OCT based measurements, even in cases of detached retina,” shared Dr. Stalmans. In short, with a centralized data storage and online calculator, surgeons can look forward to a mistake-free and hassle-free experience. The advanced Zeiss technologies provide integrated visualization during surgery, and integrated intraoperative OCT for corneal and retinal surgeries.

Digital Surgery: Higher Accuracy and Reduced Staff Time According to Professor Wolfgang J. Mayer, MD, PhD, head of University Eye Laser Center, University Eye Hospital Munich, Germany, “digital surgery allows surgeons to build a secure data trail from biometry to surgery”. From the IOLMaster, the gold standard in optical biometry, to the OPMI LUMERA with the innovative CALLISTO eye OR management system, these technologies enable surgeons to perform complex procedures with greater confidence to achieve optimal patient outcomes. The Callisto eye, with its high level of precision, assists cataract surgeons in the precise alignment of IOLs and is an integral part of the Zeiss Cataract Suite. Prof. Mayer shared that the Zeiss FORUM software has been implemented at University Eye Hospital Munich, Germany since 2011. The FORUM Eye Care Data Management system allows doctors access to diagnostic patient data which is available through central storage. The system boosts workflow efficiency and supports doctors in clinical assessments. To sum up, there is improved networking of diagnostics with the OR unit. OCT-based biometry and individual lens calculation are done using one platform. The surgical assistance system

helps in axis control, rhexis guidance, incision marking and IOL centering. Surgeons are also able to streamline the refractive cataract workflow using the EQ workplace, from biometry and calculation, selection and ordering of IOLS, to surgery preparation and postsurgery data collection. This can help save time and prevent possible human error. The EQ Workplace connects the IOLMaster and other DICOMcompatible devices remotely, as well as to Callisto eye. After surgery, the pre- and postoperative refraction can be reviewed and personalized. “Using the latest technology for higher accuracy and reduced staff time is not a contradiction in terms,” concluded Prof. Mayer.

State-of-the-Art Microscope: The Future Is Now The Zeiss Artevo 800 – the first and only digital microscope – provides better ergonomics, enables greater visualization of the surgical field, and allows access to data on the digital display . . . all of which can help the surgeon perform a better and more reliable eye surgery. Dr. Brandon D. Ayres, MD, from the Wills Eye Hospital, US, told

delegates about some of the key features of the state-of-the-art tool. The Zeiss Artevo 800 comes with two 3-chip 4K cameras and can be used with oculars. Built with 3D surgery in mind, it uses a 56-inch medical grade 3D LCD display. With the change to digital, the microscope is able to link the patient, surgeon, and data with a feature that allows data to be seen on the digital display. Auto adjust allows the microscope to change lighting parameters during cataract surgery. Orthopedic concerns are important for surgeons. “Neck and back pain are a major concern for ophthalmologists,” said Dr. Ayres, noting that up to 70 percent of ophthalmologists complain of neck and back pain. “Sometimes this leads to the need for surgical intervention,” he cautioned. In some cases, the back pain was enough to cause retirement from the operating room. With the Artevo 800, there is improved surgeon ergonomics. Not only that, there is also improved visualization of the surgical field. “Visualization of all structures are critical with a minimum of adjustments on the microscope,” stressed Dr. Ayres. “Improved depth of focus means easier transition from one

structure to another. In some cases, no refocusing is needed during a case. The ability to incorporate real-time intraoperative OCT (iOCT) saves time and enhances surgical success.” Although some may hesitate in getting started, he noted that “it in my experience, the idea of operating with no oculars is much worse than actually doing”. Optimizing the screen placement in the OR and having technical staff help with the initial set up is critical. He advised that it is best to start with straightforward cases, as the comfort level will improve with experience. “The ability to work in a digital format allows the microscope to be the ‘smart hub’ of the operating room, connecting the patient, surgeon and operative data without interruption in workflow. The improved cameras, video processors and displays make 3D heads up surgery a reality today,” concluded Dr. Ayres. Editor’s Note: The 37th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS) took place from September 14 to 18 at Pavilion 7, Paris Expo, Porte de Versailles, Paris, France. Reporting for this story also took place at ESCRS 2019.


Santen Receives Reimbursement Recommendation for Verkazia Eye Drops in Canada


anadian patients are one step closer to reimbursement, and therefore access to Verkazia TM (cyclosporine 0.1%) eye drops from Santen Pharmaceutical. A subsidiary of the global ophthalmic company, Santen Canada Inc., made the announcement as the Canadian Agency for Drugs and Technologies in Health (CADTH) and the Canadian Drug Expert Committee (CDEC) released their recommendation. According to the company, “this reimbursement marks an important

step toward providing patients access to this new formulation of cyclosporine eye drops in Canada”, adding that “provincial jurisdictions are the final decision makers on public reimbursement”. Verkazia is a topical emulsion indicated for treatment of severe vernal keratoconjunctivitis, a rare and potentially debilitating ocular allergic disease characterized by inflammation of the ocular surface. Clinical manifestations include

tarsal (palpebral) and/or bulbar conjunctiva, which could be seasonal or chronic. The eye drops are indicated for children, from age 4 through adolescence. Health Canada recommends using the eye drops four times daily. As the market leader for prescription ophthalmic pharmaceuticals in Japan, Santen’s products now reach patients in more than 60 countries. For more information about the company or its products, visit


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