CAKE & PIE POST (ESCRS & ASRS 2021 Edition) - Issue 3

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HIGHLIGHTS Tactics — Check 04 Promising out the latest in imaging techniques in anterior segment these anterior 09 Spot segment surgery issues before they happen!


Care Heroes — Who 15 Eye are the winners of the 2021 ASRS Awards?


the lowdown on 19 Get the latest in eye floaters treatment

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ESCRS 2021 Reports Digital ophthalmology promises better patient care, cautions against privacy breach by Hazlin Hassan

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Andrew Sweeney Elisa DeMartino Hazlin Hassan Olawale Salami Nick Eustice Sam McCommon Tan Sher Lynn Maricel Salvador


ith the use of artificial intelligence (AI) promising better patient care, the future of digital technology is here! However, does the use of personal data breach privacy laws?


These hot topics were discussed during the Main Symposium on Practical Digital Ophthalmology at the 39th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2021) yesterday.

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The European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) was set up to improve treatment and standards of care for cataract and refractive surgery Cont. on Page 3 >>

Team Media MICE rocked it in global physical conference formats all weekend long, at ESCRS Amsterdam and ASRS San Antonio. We covered their digital events, too. Next up: AAO!


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CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

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and make a significant impact on the exchange of best practices concerning patient safety, as well as develop evidence-based guidelines for cataract and refractive surgeries across Europe.

A benchmark for clinical improvement Today, EUREQUO is also a reference database for ESCRS members for comparison and benchmarking, aiming for clinical improvement. More than 3 million cataract surgeries have been recorded in the system to date, with 25 countries contributing to the cataract database, said Prof. Mats Lundstrom, clinical director of EUREQUO. “Such a big registry is suitable for studies of rare events, in terms of rare complications or preoperative conditions. So, we have studied cataract surgery in eyes with previous corneal refractive surgery, risk factors for dropped nucleus and cataract surgery and eyes with previous vitrectomy,” continued Prof. Lundstrom. “We have met a number of challenges during the year. With this registry, of course, the most important one maybe is the double-entry of data. No one wants to enter data twice, so we have been working with different kinds of techniques to enter that data more automatically,” he added. Plans are afoot for the future, with an expansion in the works. An international consortium of national cataract registries is also being planned.

Tech companies helping healthcare innovation Over the last few years, there has been an explosion of papers that have been published, and exponential growth of papers in the field of machine learning and healthcare. There have been tons of products in the consumer space nowadays. “For example, Google Photos or any kind of photos or email that use AI today as real products,” said Sunny Virmani, product manager, Google Health. However, when it comes to

taking machine-learning techniques and applying them to products, that hasn’t happened yet. There remain challenges, such as technical, clinical, and deployment issues, that have to be resolved before machine-learning techniques can be clinically adapted. There is an expectation and a reality, and there’s a huge gap between the two. This is where tech companies can play a role in bridging the gap. “One question that needed to be answered was, does your algorithm work only on the train and test set that you have, or does it actually work when you take it to a completely different variable,” said Mr. Virmani. “So we went to India and Thailand where we decided to do some retrospective study back in 2016 and 2018, where we looked at the fact that our algorithms worked to train on a variety of data,” he said. “They actually generalized well on at least retrospective images from India and Thailand, which is a very different population from the US.”

“Does your algorithm work only on the train and test set that you have, or does it actually work when you take it to a completely different variable?” — Sunny Virmani, product manager, Google Health To make sure to get high compliance from the patient, the technology needs to be deployed to where the patient is, closer to vision centers and clinics where they may not have ophthalmologists. The upshot? “It’s not just about the quantity of data,” explained Mr. Virmani. “The quality of the ground truth and the quality of the images are really important. It’s not just about an accurate algorithm to make a useful product. You have to take a human-centered approach, you have to understand what the clinicians and nurses need. And it’s not just about a good product. You have to make sure to do implementation research and

health economic research, which are very critical to success.”

Machine learning pros and pitfalls However, machine learning has its possibilities as well as limitations, said Prof. Pearse Keane, consultant ophthalmologist, Moorfields Eye Hospital, and professor of Artificial Medical Intelligence, UCL Institute of Ophthalmology. “Deep learning works very well on high dimensional data,” Prof. Keane shared. “And so, it works well if you’ve got photographs or videos, voice recognition tasks and things like that — which are data that typically have more than 1,000 dimensions to them.” On the other hand, with data that is low dimensional such as a blood pressure measurement or an axial length, deep learning may not provide any advantage over conventional statistical techniques. “I think there is an emerging ecosystem for clinical artificial intelligence, and in that ecosystem, there will be an increasing role for domain experts, people like us clinicians,” he explained.

Ensuring legal compliance with the use of personal data “When it comes to personal data, the situation has changed to become more strict in terms of data processing activities and checks and balances that need to be put in place in order to lawfully process personal data,” said Prof. Paolo Balboni, professor of privacy and cyber security, European Centre of Privacy and Cyber Security, Italy. “Whatever you do with data processing activities, you need to do a risk assessment beforehand on the rights and freedoms of individuals,” he continued. If the risk is high, a full data protection impact assessment needs to be carried out. Data protection and security need to be put in place to make sure that the processing operation abides by the law.



11 October 2021 | Issue #3

Promising Tactics New imaging techniques in the anterior segment and beyond by Tan Sher Lynn


hile the demand for anterior segment photography is considerably less compared to retinal imaging, anterior segment imaging is an important modality for the documentation of corneal and ocular surface disease. Consequently, on Day 3 of the 39th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2021), experts shared new and promising imaging techniques that can elevate the diagnosis and treatment of ocular diseases. Here are a few of them…

OCT elastography Optical coherence elastography (OCT elastography) is a promising imaging technique for high-resolution strain imaging in ocular tissues.

“I think OCT elastography has a high potential as a biomechanical diagnostic tool. It measures the local changes in corneal biomechanics using a tool that we all have in the clinic — OCT technology.” — Dr. Farhad Hafezi, Dietikon, Switzerland “OCT elastography reveals elastic material properties,” shared Dr. Farhad Hafezi from Dietikon, Switzerland. “In the cornea, several steps are involved with this imaging technique. First, you need to mechanically deform the cornea, then take an image through OCT, and, finally, analyze the deformation.” Ways to deform the cornea include micro

air-puff simulation, compression, and the use of sound or ambient pressure. “I think OCT elastography has a high potential as a biomechanical diagnostic tool. It measures the local changes in corneal biomechanics using a tool that we all have in the clinic — OCT technology,” continued Dr. Hafezi, adding that he and his colleagues will start a trial on measuring the first patients at the end of 2021 using Dr. Kling’s prototype at the ELZA Institute in Switzerland.

OCTA for the anterior segment Corneal vascularization accompanies the most common causes of corneal infectious blindness in the world, including herpetic keratitis and glaucoma. Apart from causing visual impairment, it is also a major risk factor for corneal graft failure. Thus, imaging corneal vascularization and monitoring its

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

development and treatment response are an important part of clinical evaluation, said Dr. Marcus Ang from Singapore. As optical coherence tomography angiography (OCTA) is emerging as an imaging tool for the retina and posterior segment, Dr. Ang and his colleagues were the first to describe the adaptation of such a system for the anterior segment. They found that even though OCTA is not designed for the anterior segment, it successfully images normal, corneal, and limbal vessels with good repeatability in a non-invasive manner. “The OCTA has potential clinical applications in the delineation of corneal vascularization, guiding fine-needle diathermy treatment, monitoring of response to anti-angiogenic therapy, ocular surface evaluation (e.g., limbal stem cell deficiency [LSCD] or ocular surface squamous neoplasia [OSSN]), and monitoring infections or inflammation (e.g., peripheral ulcerative keratitis [PUK]),” Dr. Ang explained. According to him, there is also a wide range of other anterior segment applications, such as detecting abnormal vessels, or the degree of inflammation and vascular changes associated with scleritis. “We have also found that the anterior segment OCTA may be useful in objectively quantifying bleb vascularity, and correlate with bleb scarring and filtration,” he continued. The anterior segment OCTA may also be used to diagnose and monitor lesions or tumors on the ocular surface. “It has been used to image abnormal iris vessels as well as monitor iris tumors and other inflammatory conditions,” Dr. Ang added. Despite the potentials of OCTA, Dr. Ang noted that it has several limitations that clinicians should recognize. “First, image acquisition with good image quality requires technical skills and experience in order to strike a good balance between image resolution and field of view. Images can be affected by corneal opacity or projection artifacts from neighboring vessels. Eye motion is also an issue. Structure within the eye can affect image processing and interpretation,” he explained. “While recognizing these limitations, the emergence of the anterior segment OCTA still provides a rapid, non-contact imaging technique that has been shown

to be comparable to indocyanine green angiography (ICGA) in terms of vessel delineation and vessel measurement,” he concluded.

Imaging the posterior segment “When we speak about imaging of the posterior pole, we refer to the 50° area of the retina within the temporal arcade,” said Dr. Josef Huemer from London, UK, during his talk on posterior segment imaging. “Widefield imaging should be focused on the fovea, and includes four quadrants plus the vortex vein ampullae.” According to Dr. Huemer, ultra-widefield imaging and OCTA are the cornerstones of retinal imaging, and the two most popular ultra-widefield imaging devices are the Optos (pseudocolor) device and the ZEISS CLARUS (true color). Dr. Huemer also noted that OCT can facilitate the diagnosis of polypoidal choroidal vasculopathy (PCV) and help with treatment planning without ICGA.

OCTA in vascular retinopathy Speaking on the use of OCTA in diabetic vascular diseases, Dr. Leonardo Mastropasqua from Italy said that OCTA is a safe and fast dye-less method to study ocular microcirculation, providing both structural and functional information. “OCTA allows the visualization of retinal capillary and choroidal circulation, including superficial capillary plexus (SCP), deep capillary plexus (DCP), intermediate capillary plexus (ICP), and choriocapillaris (CC),” shared Dr. Mastropasqua.

“It is very useful in all retinal vascular diseases, particularly diabetic retinopathy (DR), retinal vein occlusion (RVO), and retinal artery occlusion (RAO),” he continued. “Thanks to OCTA, we can detect all DR anomalies and early vascular changes in diabetic patients and all DR stages in a three-dimensional modality. It is also possible to assess DR severity based on vessel density, predict responsiveness to treatment, and assess retinal vascular recovery after treatment.” Widefield OCTA (WF OCTA) has comparable diagnostic efficacy in DR versus color fundus photography and ultra-widefield fluorescein angiography (FA). WF OCTA can be used to identify peripheral ischemia and neovascularization (NV) as well. RVO is the second cause of visual loss worldwide among retinal vascular diseases after diabetic retinopathy. “Thanks to OCTA, it is possible to study retinal microvasculature alterations, particularly foveal avascular zone (FAZ) enlargement and capillary drop-out of sup plexus, vein anastomosis between sup and deep capillary plexa, and dilation of deep plexus,” enthused Dr. Mastropasqua. Meanwhile, RAO is an ophthalmic emergency associated with high cerebrovascular and cardiovascular morbidity and mortality. OCTA allows for a detailed assessment of retinal vasculature alterations than FA in RAO, as well as assessment of vascular recovery after treatment. “Widefield OCTA allows for evaluation of non-perfusion and neovascularization in the peripheral retina. However, the evaluation of the far peripheral retina is still not possible,” he concluded.

New anterior segment imaging techniques have limitations that clinicians should recognize.



11 October 2021 | Issue #3

Hard Pill to Swallow When eye surgeons have to count dollars and cents by Hazlin Hassan


s people enjoy longer life spans, the cost of medical care is rising. However, this comes in tandem with the costs of aging and its consequences on national healthcare budgets. Consequently, the emergence of new types of medications — thanks to cutting-edge technologies, sophisticated drugs, and regenerative surgery — has accelerated the process. “All this puts into perspective the need to optimize the use of our resources to better utilize these new procedures and treatments, selecting those that balance the cost with the outcomes obtained,” said session chair Jorge L. Alio, University of Alicante, Spain. During a Clinical Research Symposia at the 39th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2021) yesterday, several eye surgeons debated the need to consider cost-effectiveness and valuebased healthcare when treating patients.

Is the fee for service incentivizing failures? Dr. Gregory Katz, professor at the

University of Paris School of Medicine, pointed out that there are substantial variations in hospital outcomes across countries. “Complication rates in Sweden vary by 3,100%, depending on which surgeon and which clinic is treating you,” shared Dr. Katz. “It is shocking because it means we are currently living in the pre-industrial era of medicine because the industrial era is when you can replicate a procedure from one place to another, with minimal variation.” He continued: “It is shocking because the underperformers with complications will have to re-operate patients and generate more revenues than those who will outperform without complications. So the fee for service is, in essence, incentivizing failures.”

Making patients’ outcomes visible In Wales, UK, the National Health Service found that 20% of cataract surgeries do not improve patient visual function in daily activities. A total of 20% of cataract patients who underwent surgery had deteriorated visual function after surgery.

The French Ministry of Health incentivizes transparency on patient outcomes following cataract surgery, by measuring patient health gains and paying a 30 euro fee per case for practitioners to share health gains with patients, peers, and payers. “So the purpose here is not only to make patients’ outcomes visible, but also to encourage practitioners to change their practices. Transparency is about reputation; financial incentive is about remuneration.”

Choosing the cost-effective option Dr. Alexander Day, a cataract surgeon from Moorfields Eye Hospital, United Kingdom, talked about whether femtosecond laser-assisted cataract surgery (FLACS) is cost-effective. Cataract surgery is one of the most commonly performed operations in the United Kingdom and Europe. The current technique, phacoemulsification (PCS), is over 50 years old, and it’s almost 10 years since the first femtosecond laser cataract surgery platforms were introduced. Three large European randomized control trials show that essentially there is no difference or there is very little difference in outcomes between the two techniques of FLACS and PCS, said Dr. Day. To compare, the cost of cystotome or rhexis forceps or insulin needle is 10 pounds, while a FLACS platform is 250,000 pounds, he noted. “So if the outcomes are similar, and we know that theater productivity is no better… therefore, it’s pretty obvious that FLACS is not going to be cost-effective,” Dr. Day said. “So to conclude, we know that both FLACS and phacoemulsification cataract surgery are as good in terms of vision, complications, and outcomes. PCS is very cost-effective, while FLACS is more expensive, not faster, and not costeffective,” he concluded.

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

Refractive Issues Managing patient expectations pre-surgery and making enhancements post-surgery by Olawale Salami


anaging expectations before lens surgery and refractive lens exchange are of utmost importance. This issue was a major topic discussed yesterday during one of the main symposiums at the 39th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2021). “We have to be realistic,” shared Dr. Nic Reus, Rotterdam, Netherlands. “Getting the correct effective lens position remains difficult. In most cases, we do achieve excellent results, but some situations are not predictable.” In addition, Dr. Reus said: “We have to be aware that in a certain percentage of patients, we will not be within one dioptre of the target, which will lead to a decreased vision. Even more, for toric intraocular lenses (IOLs), we cannot achieve a perfect reduction in astigmatism. Therefore, residual astigmatism has to be considered during preoperative consulting.”

Stay calm amid refractive surprises However, refractive surprises are the primary reasons for patient dissatisfaction after premium lens surgery, and this includes all postoperative refractive errors not anticipated by the ophthalmologist or the patient. The frequency of refractive surprises is dependent upon how the preoperative expectations were discussed with the patients.

Dr. Reus shared suggestions on how to handle situations where refractive surprises occur. “The first thing is to analyze the cause of the refractive surprise. Next, you formulate possible treatments. And, finally, discuss the pros and cons of possible treatments,” he said. Dr. Reues further explained: “Analyzing the cause of a refractive surprise entails the performance of manifest refraction which is especially important in the new generation lenses, like the monofocal and trifocal lenses. Next, a repeat slitlamp examination may reveal missed pathologies like anterior basement

membrane dystrophies, dry eye, corneal edema, capsular fibrosis, epiretinal membrane, or cystoid macular edema.”

“Corneal cross-linking has become the mainstay prevention progression of corneal ectasias, such as keratoconus.” — Dr. Theo Seiler, University Hospital Dusseldorf, Germany



11 October 2021 | Issue #3

Furthermore, he added that it is also important to recheck the implanted versus intended IOL power, as well as to re-evaluate the biometry used for the calculation. “Errors in initial biometry could be related to patient errors, reliability of measurements, prior lenticular astigmatism, history of laser vision correction, or the formula used in IOL power calculations,” he cautioned. As a general rule of thumb, Dr. Reus said: “In the presence of a refractive surprise, it is important to retake all measurements which were done preoperatively, including biometry, corneal topography, and keratometry.”

What are the options for treating refractive surprises? According to Dr. Reus, correction with spectacles or contact lenses is always a possibility, and this remains a viable option. In addition, it is possible to rotate a toric lens to reduce astigmatism. Laser vision correction is an option for aspherical errors below 1D. “In the presence of larger refractive and hyperopic errors, IOL exchange can be performed,” shared Dr. Reus. “However, this carries the risks of posterior capsular rupture, surgically induced astigmatism, and corneal edema. An add-on lens could also be implanted.” Overall, it is essential to communicate openly with the patient and wait until at least six weeks to establish the refractive error. Furthermore, you may explain various options and the pros and cons of treating the refractive surprise.

transepithelial route, and increasing to a high oxygen atmosphere can optimize the efficacy,” he shared. “However, oxygen remains the bottleneck of corneal crosslinking, and increasing oxygen availability can optimize efficiency.” But not for long.

Say hello to a 100% oxygen environment “We know that in transepithelial crosslinking, the bottleneck is always oxygen as there is never enough in the deep layers to support efficient cross-linking,” discussed Dr. Seiler. He and his collaborators aimed to solve this problem. “Using the standard protocol, we showed insufficient oxygen in the deeper layers to allow for sufficient cross-linking,” Dr. Seller shared. “However, when we apply energy of around nine milliwatts, we get a deep cross-linking of 300 microns. These data are congruent with optical coherence tomography (OCT) findings, which show deep demarcation lines,” he added. Dr. Seiler presented a case of customized cross-linking in a 100% oxygen environment using more energy in the center of the ectasia, tapering off towards the non-ectatic region. “We observed that four months postoperatively, there was a substantial flattening in the range of six to eight diopters, consecutive steepening, and

a deep demarcation line down to 370 microns.” He continued: ”On average, we get flattening rates of around three to five diopters, so our results are at least three times more efficient than conventional cross-linking,” shared Dr. Seiler. A second scenario is when they perform refractive surgery after the cross-linking procedure. He then presented a case of a patient who complained of poor vision after cross-linking. “The options here include primary deep anterior lamellar keratoplasty, penetrating keratoplasty, or refractive treatment,” Dr. Seilier explained. “If the photorefractive keratectomy (PRK) option is chosen, the goal remains to select the best spectaclecorrected visual acuity by treating higherorder aberrations and removing very minimal tissue during surgery, given the weakened cornea in keratoconus.” When wavefront-guided treatment was compared with topography-guided therapy in patients with keratoconus, there was a lower level of tissue ablation in the ocular wavefront-guided group compared to the topography-guided treatment. “If a refractive approach is chosen for the treatment of keratoconus, then a wavefront-guided penetrating keratoplasty is a powerful option for contact lens intolerant patients,” concluded Dr. Seiler.

Corneal cross-linking 2.0 takes off In summary, corneal cross-linking involves the application of energy in the form of UV-A light to the photosensitive molecule riboflavin, which induces the formation of reactive oxygen species (ROS). The ROS then forms new covalent bonds within the collagen molecule, increasing the cornea’s stiffness. According to Dr. Theo Seiler from the University Hospital Dusseldorf, “Customization of UV- irradiation patterns is improving the outcomes of corneal cross-linking. This approach may require supplemental oxygen delivered via a

Manage patient expectations and fix the problem pre- and post-refractive surgery.

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

Keep an Eye Out Spot these anterior segment surgery complications before they happen by Elisa DeMartino


ike a swig of fresh coffee on a Sunday morning, the third day of the American Society of Retina Specialists (ASRS 2021) Scientific Meeting opened with a robust and lively symposium moderated by Dr. Keith A. Warren and Dr. Rahul N. Kurana on the topic of complications in anterior segment surgery — including studies and observations of different challenges experienced by participating surgeons.

Glare or distortion after retinal detachment surgery Dr. Bryon McKay started the day strong with his presentation on “Evaluation of Subretinal Fluid Drainage Techniques in Pars Plana Vitrectomy for Primary Rhegmatogenous Retinal Detachment Repair”. In their study, Dr. McKay and his co-authors addressed the differences between pars plana vitrectomy with subretinal fluid drainage from the original retinal breaks vs. posterior retinotomy vs. perfluorocarbon liquid (PFCL) for rhegmatogenous retinal detachment. “Many patients still have some issues,” said Dr. McKay. “They may have some glare or some distortion, so they may be less happy. It led us to think: what’s going on with retina detachment repair and how can we improve our techniques?”

The group found that drainage technique could impact long-term visual acuity results and photoreceptor integrity, with PFCL leading to worse results compared with drainage from the original breaks.

Prevalence of endophthalmitis after MIGS procedure The second speaker, Dr. Yoshihiro Yonekawa, covered one of the latest hot specialties: minimally invasive glaucoma surgery (MIGS). “Despite its increase in popularity, we’re not too sure yet about complications such as endophthalmitis,” shared Dr. Yonekawa. “We’re not too sure how these patients present, or whether some procedures have more risks than others. There was really not much out there except single case reports.” Dr. Yonekawa and his colleagues looked at the prevalence of endophthalmitis after both implantable and non-implantable MIGS procedures over a five-year study of 1,000 patients. They concluded that while the occurrence of post-MIGS endophthalmitis was not too prevalent in the study (0.13%), there were still enough unique cases that post-operative risk should be considered a possibility by clinicians.

Scleral-sutured IOL dislocations Finally, Dr. Nimesh A. Patel presented a study highlighting the scleral-sutured IOL dislocations secondary to eyelet fractures, focusing specifically on the enVista MX60 lens. Dr. Patel noted: “We had a fracture and a dislocation in one of our first few cases, and we were wondering, could this be happening to other people?” It wasn’t a suture problem, he and his colleagues concluded, but a lens one, and the fracture could happen as late as three months post-op. “Maybe the reason for the delayed fracture is that the hydrophobic acrylic material becomes more flexible over time in the body at a higher temperature,” he continued. The rate of breakage for the lens isn’t yet known, but they estimate it at 15.4%.

More lively discussions via our show dailies With that last brief note by Dr. Patel, as quick as it started, the discussion came to a close. Luckily that was just the beginning of a long and interactive day at ASRS 2021 — the rest of which our readers can experience vicariously through our show dailies!



11 October 2021 | Issue #3

Inclusivity in the Industry From women vitreoretinal specialists to board-certified practitioners by Tan Sher Lynn


hat is the extent of women’s involvement as speakers in vitreoretinal meetings? Are intravitreal injections safer when done by a board-certified practitioner? These and other important issues were tackled by experts at yesterday’s session of the American Society of Retina Specialists (ASRS 2021) Scientific Meeting.

Achieving diversity in the industry Over the last two decades, the US has seen a steady increase of women entering the medical field. Women are now representing the majority of matriculants in US medical schools. And ophthalmology has experienced a similar increase, with 41% of 2019 residency applicants being female, according to Dr. Jayanth Sridhar from Miami, Florida. Dr. Sridhar and his colleagues did an analysis, looking at the representation of women in vitreoretinal meeting faculty roles from 2015 through 2019. They found that overall, female presenters in vitreoretinal meetings in the US had a significant increase over a five-year period, which is from 19.6% (2015) to 25.5% (2019), primarily driven by abstract submissions.

“Women were more likely to be included as abstract presenters than invited speakers,” shared Dr. Sridhar. “Interestingly, programs with at least one female committee member were more likely to invite female speakers and female panelists or moderators.” Dr. Sridhar suggested possible paths for continued improvement, which include achieving diversity in planning committees/leadership, increasing the proportion of double-masked submitted abstract driven content, reexamining the structure of retina meetings by providing alternatives that may encourage greater female participation — such as more virtual presenting options, onsite childcare services, and designated nursing areas.

Intravitreal injections by board-certified practitioners Meanwhile, according to Dr. Geoffrey Emerson from Minneapolis, Minnesota, in the US, relaxation of the scope of practice boundaries in ophthalmology is being suggested to meet the increasing need for intravitreal injections. However, there are safety concerns. During the presentation, Dr. Emerson aimed to show if credentials of the

intravitreal injection proceduralist impact the safety of the procedure. “The hypothesis is that proceduralist board certification and subspecialty training provide a safety benefit regarding postinjection endophthalmitis,” he said. He and his colleagues looked into the 2013-2017 dataset of de-identified Medicare beneficiaries and identified intravitreal injections that were followed by a new diagnosis of endophthalmitis within two weeks. For each proceduralist, a web search was done to determine if he/she has board certification by ABO and retina subspecialty fellowship training. The number of patients involved in the study is 219,640, where 60% is female and the average age is 78. From 2,907,324 injections for the treatment of AMD (77%), diabetic retinopathy (12%), retinal vein occlusion (10%), and others (1%), there were 1,088 (0.037%) endophthalmitis outcomes. Among the 1,088 endophthalmitis outcomes after the injection, 1,024 (0.037%) cases are performed by ABO-certified practitioners and 64 cases (0.050%) by non-ABO-certified practitioners. “This is statistically significant, as there is a 28% reduced odds of endophthalmitis if the injectionist is ABO-certified,” Dr. Emerson shared. The study concluded that post-injection endophthalmitis is reduced when ABO-certified physicians perform the intravitreal injection. “To the prior suggestion of relaxing the scope of intravitreal injections, caution is recommended as there may be a safety issue by doing so,” he concluded.

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

Fire up that Laser! Treat non-compliant DR patients straight away

by Brooke Herron


iabetic retinopathy (DR) has been a hot topic during American Society of Retina Specialists (ASRS 2021) Scientific Meeting — and with good reason. So, it was fitting to have a Hot Topics in Diabetic Retinopathy panel discussion following one of the main DR symposiums. During this brief session, Dr. Charles Wykoff presented panelists with patient cases and asked for their opinions on diagnosis management and treatment. And while we always look forward to a good debate, these experts were mostly in agreement — and it’s always interesting to learn how each ophthalmologist approaches confounding retinal cases. Below, we cover just one of the fascinating discussions presented by the panel — but it’s an important one: patient compliance.

Understanding your DR patients We all know the difficulties

poor patient compliance can present to outcomes. This is especially crucial in diabetic patients who often have additional health issues to contend with. Thus, Dr. Wykoff asked the following: Do you ever treat patients differently based on their past show rate to your clinic? Do you change treatment patterns? Or when they’re treatmentnaive, do you ever try to get a feeling for their compliance? How do you incorporate this risk into your management strategy?

Treating non-compliant patients right away is crucial First up was Dr. Sophie Bakri, who shared that it’s important to speak with the patient to get a sense of whether they might return to the clinic. “When I get the sense that somebody is not going

to come back, or they’re not compliant, or if there are any other issues going on (health or social), I do my best to do injections and PRP (panretinal photocoagulation) on the same day before they leave the office,” she shared. “I think we just have to make it happen, because the thought of that person leaving the office and then thinking ‘will the injection or laser hurt, etc.,’ and then they may never come back… I think whatever we can do to make it happen is important for these patients.”

“When I get the sense that somebody is not going to come back, or they’re not compliant, or if there are any other issues going on (health or social), I do my best to do injections and PRP (panretinal photocoagulation) on the same day before they leave the office.” — Dr. Sophie Bakri Dr. Rishi Singh was next to chime in and shared that they had just published some data on delayed PRP. He said the Academy recommends that these patients are lasered within one month of conversion to proliferative disease. “You can see major detriments in their visual acuity if you go beyond that month,” said Dr. Singh. “At month two and beyond, their level of achieving 20/25 or better vision is very, very poor. So, I think Sophie’s aggressive nature is actually very good in these patients — you’re preventing severe visual loss or impending — albeit you have to do it within a very short period of time, 3 to 4 weeks maximum,” he added. As Dr. Wykoff said in conclusion: “Fire up that laser”. Indeed, we have to agree — even though this writer isn’t an ophthalmologist herself. Getting these patients treated to prevent disease progression and save vision is crucial. As they say, “an ounce of prevention is worth a pound of cure”.



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Backed by Science Newer imaging modalities that add value to clinical practice by Brooke Herron


t doesn’t take an expert to tell you that without the capability to image the posterior segment, many visionthreatening retinal diseases would be difficult (or perhaps, impossible) to diagnose, manage, and treat. Today, there are various imaging systems available, each with their own advantages and specifications.

with his discussion on The Impact of Image Processing Algorithms on Quantitative Optical Coherence Tomography Angiography (OCTA) Metrics in Diabetic Retinopathy (DR).

Image processing algorithms & OCTA

He began by explaining that calculation of OCTA metrics like vessel density (VD), skeletonized vessel density (SVD), and fractal dimension (FD) requires image processing. One of the issues with image processing, however, is that there are many different ways to do each step, he explained. Thus, he shared data from a study that evaluated the impact of using different image processing algorithms to calculate commonly reported quantitative metrics in OCTA images in patients with various stages of DR using the Cirrus HDOCT 5000 Angioplex (Carl Zeiss Meditec, Jena, Germany).

Dr. Jay Wang kicked off the symposium

Overall, 301 scans from 104 patients

On Day 2 of American Society of Retina Specialists (ASRS 2021) Scientific Meeting, imaging experts convened in the Imaging, Digital, Angiography Symposium to discuss disease characteristics and biomarkers as seen in the various modalities.

s s since its inception.


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11 October 2021 | Issue #3


were included with 90 excluded for poor signal strength or significant artifact, leaving 211 scans remaining. Of these, 67 had no DR, 99 had nonproliferative diabetic retinopathy (NPDR), 45 had proliferative diabetic retinopathy (PDR), and 48 of 211 scans had diabetic macular edema (DME). Using the Otsu, Huang, Niblack, and Phansalk algorithms, Dr. Wang found that the thresholding algorithm used significantly impacted VD, SVD, and FD even when controlling for age, DME, and DR stage (all p-values < 0.001). As a result, Dr. Wang said that image processing not only affects the values of quantitative OCTA metrics, but it can also affect the conclusion of any given study. Thus, he urges caution in the interpretation of such studies. He added that this also suggests that there is a need for standardization for image processing and transparency of methods used in built-in software, especially for clinical trials involving OCTA and patient care.

Can OCT predict IOI? Could OCT be the crystal ball to predict intraocular inflammation (IOI)? That’s the question Dr. Justis Ehlers set out to answer in his presentation on Higher Order OCT Analysis for Inflammatory Signal Biomarkers in the HAWK Study.

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

To learn more, a comparative discovery assessment was performed to evaluate the presence of OCT features that may precede or develop in association with IOI, which may then serve as OCT biomarkers for IOI. He noted that this particular analysis included qualitative comparative OCT assessment, radiomics evaluation, and machine learning characterization.

characterize the implementation of UWF SS-OCT in routine clinical practice. All in all, 82 eyes from 72 patients were included, of which all were dilated. The images were then interpreted by two providers in a blind review. These images were evaluated for the total number of image series: the number of interpretable series with adequate signal strength

OCTA findings in pediatric retina We know that different imaging modalities allow for different diagnostic and treatment findings — and, of course, this is no different in pediatric retina. Interestingly, in a presentation from Dr. Audina Berrocal, she revealed that using OCTA allowed them to view disease characteristics not previously seen before. To describe these new findings, they evaluated intraoperative OCTA in a busy pediatric retina practice. The intraoperative OCT and OCTA images were acquired with the Flex imaging module from Heidelberg Engineering. In total, 236 patients were imaged and 123 were ultimately included based on diagnosis and image quality. The top four diagnoses found were familial exudative vitreoretinopathy (FEVR), retinopathy of prematurity (ROP), Coats’, and Leber congenital amaurosis (LCA).

So, what did they find? Well, expert readers identified hyperreflective vitreous debris or preretinal hyperreflective deposits in 20 of 34 eyes with IOI (59%) compared to 1 of 34 eyes (3%) in the control group. Importantly, in 9 of the 20 eyes with qualitative OCT, these features were found prior to the IOI event — meaning that these OCT biomarkers could facilitate the identification of eyes at-risk for developing IOI-related events. Dr. Ehlers shared that in this preliminary discovery evaluation, the presence of abnormal hyperreflective foci may be supportive of IOI-related OCT findings. “Further investigation is required as this IOI assessment only included eyes treated with brolucizumab, not the aflibercept treatment arm, and did not evaluate eyes from the HARRIER trial,” he concluded, adding that an expanded assessment from both phase 3 trials is underway.

On the feasibility and clinical utility of UWF SSOCT “Visualization is paramount to the retinal practice,” began Dr. Kyle Kovacs. One modality that allows surgeons to see further than ever before is ultrawidefield navigated swept-source optical coherence tomography (UWF SS-OCT). In this presentation, Dr. Kovacs shared details from a study that aimed to

and no limiting mirror inversions, the number of diagnostic series of the lesion in question, and the duration of image acquisition. According to Dr. Kovacs, a wide spectrum of lesions was successfully imaged — 90.9% of acquired images were interpretable and 86.4% were diagnostic of the retinal lesion. These images were obtained in 4.1 minutes and supported clinical decision-making in 38% of patients, he shared. These images produced a range of diagnoses, including retinal detachment combined with retinoschisis, retinal hole with overlying vitreous traction and subretinal fluid, vitreous inflammation overlying a peripheral scar, Coats’ disease, and peripheral retinal traction in sickle cell retinopathy. These results show that navigated UWF SS-OCT imaging is clinically practical and provides a highquality characterization of peripheral retinal lesions for all eyes. Not only that, these images directly contributed to management plans for a clinically meaningful set of patients. Dr. Kovacs added that further work is needed on the longitudinal implications of these findings.

According to Dr. Berrocal, the OCTA provided supplemental information that assisted in disease management in 63% of cases, while a change in management was made based on the OCTA in 17% of cases. For example, in a 2-year-old girl with incontinentia pigmenti, the initial FA did not identify significant FAZ vascular alterations, while vascular flow alterations were highlighted with OCTA. She concluded that “intraoperative OCTA is an important non-invasive alternative to conventional fluorescein angiography”. Further, in a majority of cases, intraoperative OCTA provides imaging analysis that is supportive of the diagnosis, treatment approach and response, surgical planning, and visual prognosis.


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CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

Eye Care Heroes

The Retina Research Foundation’s Gertrude D. Pyron Award


This year’s award was presented to Dr. Cynthia Toth. Dr. Toth has been a member of the research faculty at Duke University since 1993, where she led the surgical instrument prototyping laboratory, and later transformed it into the Duke Advanced Research in SD/SS OCT Imaging (DARSI) Laboratory.

Presenting… the winners of the 2021 ASRS Awards by Nick Eustice

ach year, the American Society of Retina Specialists (ASRS 2021) Scientific Meeting presents several awards as part of its annual conference in recognition of leaders and innovators in the field of retinal medicine. Following right on the heels of last year’s awards ceremony, the 2021 ASRS Awards presentation ceremony began just before lunch on the 3rd day of this year’s ASRS Conference. As no in-person conference could be held last year due to COVID-19, it was a great relief to be able once again to hold such an event with many recipients in attendance.

The Founder’s Award The ceremony began with the host, Dr. Judy Kim, announcing the winner of this year’s Founder’s Award. Each year, the

Society presents the Founder’s Award, named after the three founders of the ASRS: Dr. Jerald Bovino, Dr. Roy Levit, and Dr. Allen Verne. This year, this award is presented to a doctor who has made major contributions to the advancement of vitreoretinal surgery, treatment, research, surgical instrumentation, and patient care — Dr. Stanislao Rizzo of the Agostino Gemelli University Hospital and the Catholic University of Rome, Italy. Unfortunately, as a reminder that COVID-19 is still very much a part of our lives, Dr. Rizzo was not able to attend the ceremony due to travel restrictions. Dr. Rizzo was chosen to receive the award for his diverse contributions throughout the field of retinal surgery and patient care, and he is credited with many inventions and new techniques in ocular surgery.

The next award presented was The Retina Research Foundation’s Gertrude D. Pyron Award. This award was established to provide recognition and research grants to internationally known retina scientists for their entire body of work.

She was the first surgeon to use optical coherence tomography (OCT) during retinal surgery. Her lecture, “Retinal OCT at 29: Forever Young and For the Young” told the story of her involvement with the evolution of OCT. She also has made tremendous strides in the application of OCT in treating children and infants, and her lecture focused largely on that as well. OCT is known for its diagnostic imaging uses, with its tremendous capabilities for producing high-quality images of the posterior segment. Due to the device’s ability to produce immediate, high-resolution images of the retina, Dr. Toth introduced its applications to the



11 October 2021 | Issue #3

operating room. This introduction of new technology was altogether pioneering and involved developing new techniques for its use as it was happening. Initially, Dr. Toth recalled, the OCT device was statically mounted on a moveable arm. This resulted in a cumbersome intrusion into the operating space. Instead, the device was recalibrated to make it hand-held and be able to be positioned at whatever angle was necessary, and taken out of the way when required. This was merely one evolution in what was then a pilot program to bring a diagnostic imaging device into the operating room, where it is now very much at home. Dr. Toth has also been very proactive in using OCT for diagnosing potential visual conditions in young children, including infants. She related her experiences developing a system for measuring infant discomfort during an OCT scan based on the CRIES neonatal pain measurement score, which revealed that OCT creates no detectable discomfort based on an infant’s facial expression, heart rate, and audible cries. Her pioneering work here has aided in the development of new methods of diagnosing potential visual problems at the earliest stage possible.

The Crystal Apple Award The next award presented was to Dr.

R.V. Paul Chan, who was recognized for his contributions to education and mentorship with the Crystal Apple Award. The Crystal Apple Award is a special recognition that is presented to an ASRS member who has gone to great lengths to advance the education and professional development of young vitreoretinal specialists. Dr. Chan spoke later in the conference at a special luncheon for the Early Career Section.

The ASRSF President’s Young Investigators Award This was followed by the presentation of the ASRSF President’s Young Investigators Award. In honor of the foundation’s past presidents, this award is presented each year to a medical professional under the age of 45 who has made substantial contributions to retinal care. This year’s recipient was Dr. Arshad M. Khanani, who, as the founder and director of the Sierra Eye Institute in Reno, Nevada, has made the institute a major center for retinal research. Dr. Khanani’s lecture, entitled “Innovation and Collaboration: A Decade of Learning from Managing Clinical Trials”, focused strongly on strategy and fellowship within the field of retinal research. He advocated for an open philosophy of leadership,

encouraging colleagues to learn from and listen to everyone involved in a project, seeking to advocate for patient care, and making the best use of the strengths of colleagues.

The Packo Services Award Next up was the Packo Services Award, which was presented to Dr. Reginald J. Sanders. Dr. Sanders has worked many years toward the development of the ASRS and its many programs and functions, especially in the area of management and policy. The award was established in 2019 and was named after its inaugural recipient Dr. Kirk Packo. Though he was not in attendance, Dr. Packo sent a video recording to congratulate Dr. Sanders for his excellent work.

A special tribute Finally, to end the award ceremony, a special tribute presentation was made to honor Dr. Timothy G. Murray, in recognition of his presidency during the COVID year. A host of special challenges presented the Society during the past year and a half, and Dr. Murray’s leadership was invaluable in maintaining the mission of the ASRS during this difficult time. Dr. Judy Kim, the tribute’s presenter, remarked that Dr. Murray has always held to a firm belief in educating not just the Society’s membership of retinal specialists but the public as well on developments in the field. His long service to the ASRS and his special role as the president in such a unique time are surely worthy of special recognition.

Congratulations to the winners! Each member of this diverse group of practitioners and researchers has done tremendous work in improving the lives of patients and the work of their fellow professionals. It is always good to see such efforts duly recognized. Congratulations to all this year’s recipients. Our eye care heroes have done a great job in improving the lives of their patients and fellow professionals.

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

attending the physical meeting. “When I was getting ready for the meeting, I was really excited about it,” he shared. “Then my plane got delayed for three hours and I was stuck in some random airport. I was like, why am I not just doing this virtually. But then, I’m here and I’m seeing everybody’s noses and I haven’t seen noses in a year — and that’s very exciting.”

Continuing the tradition for the younger generation

Still At It

The continuing effects of the COVID-19 pandemic among retinal specialists by Hazlin Hassan


hile the deadly COVID-19 pandemic has shut down borders and forced many around the world into lockdown, many retinal surgeons conducted meetings online, with some even confessing they actually liked not having to meet people face-to-face. COVID-19 vaccines, how eye surgeons survived the pandemic, and other hot topics related to the coronavirus were discussed during a short but refreshingly frank 15-minute session on “Navigating Through COVID-19 for Retina Specialists” at the American Society of Retina Specialists (ASRS 2021) Scientific Meeting yesterday.

Virtual vs. in-person conferences Dr. Tarek Hassan, former president of ASRS, said: “We have learned a ton from this whole experience, mostly that I think we can still deliver and gain outstanding educational content online. I think optimizing that and trying to find a way that we can integrate it with the live meetings is going to be the key because you can tell at this wonderful meeting that people are very engaged and happy to see each other again.”

“It’s easy to share ideas and thoughts in person and to have that three-dimensional view of somebody,” he continued. “You get the vibe of a situation, which you just don’t get from a screen. Virtual education has been pushed forward by leaps and bounds, but now we have to integrate it into our process. I don’t think these are going away.” On the other hand, Dr. Dante Pieramici of The California Retina Consultants, USA, said candidly: “I like the virtual meetings a lot actually. I learned a lot in those meetings and I did quite a few of them. You did them when you had time and you could stop and go back later,” he shared. “When you were done, you close your computer and go out for a bike ride or something. I didn’t miss the airports and all that.” However, he admitted to missing fellow surgeons in and outside conferences. “One of the biggest things we get from these meetings is really the collegiality and the things I learned outside of the conference room,” he shared. “I certainly missed that, and I’ve realized last week in the retina society how valuable that is.” Meanwhile, session moderator Dr. Sunir J. Garg shared that he almost regretted

Dr. Jonathan Prenner, a retinal specialist at NJRetina, USA, said: “For the younger generations of people, we need to keep this thing going and make sure that they know retina is the greatest job in the world, and we have great colleagues. I don’t know anybody else that goes to meetings in their field that looks forward to seeing their colleagues. Bankers don’t do that.” While everything can be found online nowadays just by the click of a button, the panel agreed that there is no alternative to coming to live conferences. “I know there are outstanding resources online for education. I mean, you literally don’t need to leave your house to learn something new. But that should make you even more encouraged and more desirous of coming to a live meeting because then you get to have the other stuff, too,” enthused Dr. Hassan.

Take the vaccine shot (already)! On the topic of COVID-19 vaccinations, Dr. Prenner said he is pretty persistent about it with his patients and asks everybody as a conversation starter whether or not they have already taken the vaccine shot. “Now I ask, have you had your booster yet? And if they say no, then we talk about why. And then they’ll usually admit that they haven’t had any vaccines yet, much less a booster,” he shared. Dr. Prenner added that you just have to continue to be persuasive about it and talk about the science and the facts behind it. “Once I had my own booster, it was very easy to talk to them about it. You just have to be persistent,” he concluded.



11 October 2021 | Issue #3

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CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

Seeing Spots euvers Old and new techniques and man in treating eye floaters by Nick Eustice


hrough the years, many forms of visual impairment have been considered as just part of aging. Floaters are one of those visual problems which, even when diagnosed, are often just left alone. Of course, a lack of treatment options in the past has been a big motivator for this kind of thinking because when no treatment exists, what else could a patient do? There is also a strong tendency for patients in general, not just in ophthalmology, to “walk it off”, to just cope with the conditions if they aren’t all that severe. This kind of thinking can be very dangerous. Symptoms can sometimes be indicators of broader problems, and at the very least need to be checked out. But sometimes, even following an evaluation, a patient may choose to simply live with a condition instead of seeking treatment.

themselves to cause significant visual impairment. Two speakers at yesterday’s Surgical Symposium at the American Society of Retina Specialists (ASRS 2021) Scientific Meeting addressed treatments for floaters. Now, as in years past, there are three principal courses of action that are considered when a patient has issues with floaters. The first option is simply observation, whereby a patient learns to live with the spots in their vision and gets regular checkups to ensure that bigger problems do not develop. The second includes laser therapies, such as YAG laser vitreolysis. This option uses a laser to break up and reduce the presence of the floaters within the vitreous humor. The third option — the subject discussed by both of these speakers — is vitrectomy.

Three ways to treat eye floaters

Vitrectomy and YAG lasers

Frequently enough, floaters aren’t seriously debilitating and only pose a minor inconvenience to the patient. Other times, however, they can be a sign of a greater problem, such as a retinal tear, or the spots can even be large enough

For various reasons, clinicians in the past have been reluctant to conduct vitrectomies to address floaters. The procedure has always been considered too severe and invasive for what is often a minor visual impairment. Complications

such as cataracts or a torn or detached retina are possible results from a vitrectomy. And there has been hope in the past that laser therapy can improve to a point where it is the safer option. YAG lasers have come a long way as a treatment option. Showing statistics from a randomized trial, Dr. Daniel Adelberg noted that 54% of patients showed symptomatic improvement in treated eyes, with no adverse effects. In a separate study, however, he noted that severe complications are still associated with YAG laser vitreolysis, including elevated intraocular pressure (IOP), leading to glaucoma, cataracts, scotomas, and even an increase in the number of floaters. On the other hand, the strides made in vitrectomies have been shown to be much more effective in a recent study. Dr. Adelberg noted that a mean subjective improvement of 92 was reported in a study of 76 eyes in 66 patients. In addition to these positive subjective reports, wavefront aberrometry, which provides an objective analysis of visual acuity, showed substantial improvement as well. While retinal tears occurred in three of these procedures, they were corrected during the procedure, and there were no postoperative complications. Dr. Matthew Cunningham asked a similar question leading into his own study: should we be more open to considering pars plana vitrectomy for vitreous opacities? He argued that vitrectomy techniques have vastly improved in the past decade. Patients experience less discomfort and ocular inflammation than ever before due to smaller gauge needles, and side effects are significantly reduced. As in Dr. Adelberg’s study, he reported very few side effects with a high rate of patient satisfaction.

Proceed with caution While caution is always a good approach when considering an elective surgery, there has been a lot of progress in vitrectomy research in recent years. The high rates of success and patient satisfaction make vitrectomies a far more viable option for treating floaters than they have been in the past.







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