CAKE POST (APACRS 2021 Edition) - ISSUE 2

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ISSUE

08 | 01 | 21

cataract • anterior segment • kudos • enlightenment C A K E M A G A ZIN E ’ S D A ILY CO N GR E S S N E W S O N T H E A N T E R IO R S E G M E N T

HIGHLIGHTS shared clinical 03 Surgeons pearls in managing cataract complications... all about innovative 06 It’s IOLs ... find out more.

APACRS-SNEC 2021 Welcome and Lim Lecture

by Sam McCommon

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ay 2 of the 33rd Asia-Pacific Association of Cataract and Refractive Surgeons and Singapore National Eye Centre 30th Anniversary virtual meeting (APACRS-SNEC 2021) hosted the welcome address, as well as the famed Lim Lecture that often serves as the centerpiece of the conference. This particular bit of video hosted some big names and shed some light on those that deserve a bit more recognition.

We’ll start with the welcome address, and then move to the Lim Lecture — because that’s just how the APACRS did it.

Welcome Address: It’s Day Two, but Welcome We were visited by none other than Dr. Vivian Balakrishnan, Singapore’s minister

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01 August 2021 | Issue #2

for foreign affairs and an honorary senior consultant at the Singapore National Eye Centre (SNEC). It made sense for Dr. Balakrishnan to say a few words, considering his long history in ophthalmology — he was even appointed medical director of the SNEC in 1999, the same year the organization underwent a building extension worth $50 million SGD. As Dr. Balakrishnan noted, “More than ever before, the world has been dependent on the progress of medical science.” He’s absolutely right — anyone who’s paid the slightest bit of attention to the world over the past year and a half is fully and painfully aware of that truth.

Dr. Balakrishnan also pointed out that we’ve been through a pandemic of misinformation, misunderstanding and politics. It makes the context in which medical advancement takes place a little muddier. He advised doctors to avoid politics and politicians — his presence notwithstanding. We’re happy to see politicians who are comfortable with being self-effacing.

Dr. Balakrishnan invoked the spirit of Dr. Arthur Lim, who helped found the SNEC. Despite his self-awareness of his excellence, Dr. Lim was eager to share his skills and knowledge, and to elevate other ophthalmologists’ abilities and confidence.

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Dr. Abhay Vasavada, president of the APACRS, followed, offering gratitude to speakers and sponsors, and to highlight a few names. One of those names deserves a bit of recognition.

Dr. Chan Wing Kwong is that name, and if you think that APACRS meetings have gone well over the last 10 years you likely have him to thank. If you see him at next year’s APACRS, give him an extra bit of appreciation for all the hard work he does to make sure the conference comes together well.

The 2021 APACRS Lim Lecture: Dr. Ike K. Ahmed

Dr. Ahmed also looks outside mastering motor skills or techniques to manage complex cases. In his mind, they’re simply one aspect of the trifecta of any complex learning — with the others being mindset skills and cognitive skills.

As he put it, “I’m somebody who really focuses a lot on approaching these cases with the right attitude. I’m one that’s big on imagination and visualization, spending much time in the wet lab, imagining what it will be like to handle these difficult cases. The night before, the morning of — really going through these cases and thinking about how I’ll handle any complications that may happen.”

The prestigious Lim Lecture is given by one outstanding ophthalmologist each year. This year, the recognition went to one of ophthalmology’s brightest stars: Dr. Ike K. Ahmed of Toronto, Canada, representing the Prism Eye Institute, the University of Toronto, and Trillium Health Partners.

In addition to imagination, of course, he also recommends simulation and practice for difficult cases. That may sound like simple advice, but simple advice is often the most actionable.

If you want something a little more specific, one of his mantras is the retention of the capsular bag.

Dr. Ahmed is a frequent speaker at ophthalmic conferences, and has made significant waves in the industry. Just for reference, he coined the term “MIGS,” which has been universally adopted.

So, even if you haven’t heard of him yet, you’re likely already using his terminology. He’s got a valuable YouTube channel as well, demonstrating all sorts of surgical techniques.

He’s developed specific tools for micro instrumentation — the Ahmed micrograspers and Ahmed micro-tying forceps.

The graspers help grasp the iris with a minimum of trauma as well as various IOL structures. The forceps are the world’s first completely intraocular tying forceps, which deserve a fair bit of page space we can’t afford to spare here. The types of surgeries these are used for are not necessarily expensive surgeries, and don’t rely on electronic tools — just hands, brain and hand tools.

The topic of his lecture was Approaching Complex Anterior Segment Surgery. Like any true expert in a field is able to do, he managed to break things down to their simplest parts so that they could be as understandable as possible.

Indeed, breaking things down to their smallest components is one of his philosophies for dealing with complex cases. As he put it, “Complexity is simplicity multiplied.” In other words, there’s no such thing as one particular complex case — just a number of individual, simple components combined. This leads to simple approaches for extreme cases.

Using these tools, Dr. Ahmed can help “restore the magnificence of the iris,” as he poetically put it. He sees bringing the eye back to its normal state as a holy mission of sorts — as it can help restore not just a person’s vision, but sense of self.

Kudos to Dr. Ahmed for his work, and we look forward to seeing him at the next conference, where we reckon he’ll turn up. This lecture and the press it brings was well deserved.

PLEASE NOTE that this is an independent publication of Media MICE Pte Ltd (“Media MICE”) in our role as independent media and is not affiliated with [Hanita Lens]. Media MICE is in no way affiliated to or with any person, organization, or entity mentioned in this publication, [including (APACRSSNEC], nor is this publication published in any way intended to convey any such affiliation.

CAKE Magazine’s Daily Congress News on the Anterior Segment

Management Strategies for Cataract Complications

by Tan Sher Lynn

anterior chamber and the I/A tip is ready to aspirate the white cortex. With this technique, the extension of tear can be prevented because the pressure is relieved quickly enough,” he said.

syringe; and postoperatively, high intraocular pressure (IOP) can occur when most of the viscoelastic was not aspirated, especially with large molecules viscoelastics,” he said.

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n general, cataract surgery is a very safe procedure. However, complications can still occur and managing them well is the key to good outcomes. Surgeons from different countries shared their surgical pearls on Day 2 of the 33rd Asia-Pacific Association of Cataract and Refractive Surgeons and Singapore National Eye Centre 30th Anniversary virtual meeting (APACRS-SNEC 2021). Here are some of the highlights...

Solving viscoelastic troubles Dr. Pannet Pangputhipong of Mettapracharak Hospital and Eye Institute, Thailand, discussed various viscoelastic problems that can occur during cataract surgery, as well as how he prevented the Argentinian flag sign (AFS) in intumescent cataract using I/A capsulotomy.

“Viscoelastic is a very useful tool for cataract surgery but it can cause various problems, such as Descemet’s detachment, which occurs when the viscoelastic cannula is placed at the incision. This can be avoided by placing the cannula well beyond the incision before injecting. Besides, cannula missile can happen when the cannula does not fit well with the viscoelastic

Another problem is AFS, which he believes, is caused by the presence of viscoelastic in the anterior chamber during capsulorhexis in eyes with intumescent cataract. “AFS is the radicalization of the capsulorhexis which can happen once we make an initial puncture on the lens capsule. It may lead to posterior capsular tear in the beginning.

“In intumescent cataract, the lens becomes swollen with high pressure inside. The lens capsule in mature cataract may be thin and trypan blue dye may also make it brittle. After staining the capsule, we usually inject viscoelastic to deepen the anterior chamber before capsulorhexis. In tumescent cataract, viscoelastic may be the cause of radial tear. The white cortex is trying to escape but it is blocked by the viscoelastic. The pressure inside the lens then drives the tear to perforate,” he said.

To prevent this from happening, Dr. Pangputhipong developed the I/A capsulotomy technique which allows rapid pressure release without viscoelastic block. The I/A tip is used for the main incision and a 27-gauge needle is inserted from the side port.

“The needle is used to make the initial capsulotomy in the middle of the lens.

White cortex can easily escape to the

Managing capsular rupture Dr. Michael Knorz from the University of Heidelberg, Germany, shared how capsular rupture in the presence of trifocal IOL should be managed.

“Refractive lens exchange with trifocal IOL implantation is the gold standard in presbyopia surgery. Modern trifocal IOLs, however, are not available for sulcus implantation,” he said.

There are different types of capsular rupture: anterior capsular rupture, posterior capsular rupture (with anterior capsule intact), and anterior plus posterior capsular rupture.

“When it comes to capsular rupture, we need to maintain a few basic rules. We need to maintain the anterior chamber, so, do not withdraw the phaco or I/A handpiece, maintain irrigation and lower infusion pressure by lowering the bottle, and fill the bag and the anterior chamber with viscoelastic prior to removing the phaco handpiece. This is important to help avoid large capsular rupture or vitreous prolapse.”

He noted that in the occasion of anterior capsule rupture, it is safe to implant trifocal IOL in the bag. “Use soft haptics only and not plate haptics because they may tear the posterior capsule.

“In the case of posterior capsule rupture (with the anterior capsule intact), trifocal IOLs with reverse optic capture can be used. Monofocal IOL plus add-on trifocal IOL is also possible.

“Lastly, in the case of anterior plus posterior capsule rupture, the ideal option is to use a sulcus-based trifocal IOL, but unfortunately it is not available currently,” he said.

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Hyderabad, India. He focused on the Big Bubble technique in DALK, a branch of dDalk (Descemetic DALK) as opposed to pdDALK (predescemetic DALK).

The Big Bubble technique relies on — you guessed it — a bubble. Specifically, Big Bubble refers to an air bubble injected into the stroma, as opposed to a viscoelastic or fluid bubble.

Dr. Fogla shared a case that went something like this: 85-90% depth trephination, followed by the placement of an air injection cannula and a type 1 Big Bubble with air injection. The bubble was deflated and the residual stroma was excised, exposing the pre-Descemet’s layer. Then the donor graft is secured in position. Voilà!

When selecting patients for BB (Big Bubble) DALK, Dr. Fogla has a few criteria. These include: • Ectatic disorders (keratoconus, postLASIK ectasia, Pellucid marginal corneal degeneration) • Stromal dystrophy (granular, lattice, macular dystrophy)

Cornea Talk

Dive Into the Future by Sam McCommon

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t wouldn’t be an APACRS meeting without a session focusing on the cornea, and they didn’t let us down. There was a wealth of valuable information about up-and-coming corneal treatments and options, and we’ll be happy to revisit these talks in future articles as well.

We’ll dive right in, since this pool is pretty deep.

Walk the walk, DALK the DALK If you wanted to know what was new in the world of DALK, you’ve come to

the right place. For the uninitiated, DALK stands for deep anterior lamellar keratoplasty. This procedure removes the corneal stroma down to Descemet’s membrane. It’s most commonly used in patients with a healthy, functioning epithelium. It can offer an alternative to penetrating keratoplasty (PK), for example, because it leaves the Descemet’s membrane and endothelium intact. This can help avoid some of the complications that are known to accompany PK. We were introduced to what’s new in the world of DALK by Dr. Rajesh Fogla, the director of the Cornea Clinic and senior consultant at Apollo Hospitals in

• Corneal scars not involving the Descemet’s membrane Additionally, he suggested avoiding advanced keratoconus, extreme thinning, or scars involving the Descemet’s membrane.

When conducting preoperative evolution, Dr. Fogla recommended these diagnostic tests: • Regional pachymetry • Corneal ASOCT • Tomography • Specular microscopy • Slit lamp photography So, when you’re blowing this bubble, how do you know when you’ve reached the ideal plane for air injection? Some of it is a feel thing — Dr. Fogla said you’ll feel a sudden ease of resistance to advancement of the cannula in the deep stroma. You should also see a reflection against the air bubble in the anterior chamber, and will see wrinkles in the posterior layer, or the Descemet’s

CAKE Magazine’s Daily Congress News on the Anterior Segment

membrane against retroillumination with a dilated pupil. The surgery can be pachymetry guided to 90-95% depth using a diamond knife, or iOCT guided to ensure the track is at the right depth.

Additionally, a surgeon could use a femtosecond laser to create a track in the stroma, guided by ASOCT. Dr. Fogla concluded that DALK should be considered a procedure of choice for corneal diseases with a healthy endothelium. The surgical techniques are continuing to evolve, and BB DALK may grow in popularity and success in the near future. Additionally, femtolaser technology and ASOCT may help improve future outcomes — because who doesn’t like playing with their favorite laser toy or imaging tool?

Artificial DMEK We got a peek inside the present and future of artificial descemet membrane endothelial keratoplasty (DMEK) courtesy of Dr. Gerd Auffarth, hailing from the Department of Ophthalmology at Ruprecht-Karls-University of Heidelberg, Germany, among other esteemed organizations.

Currently, there are 12.7 million people waiting for corneal tissue from a donor.

So, why aren’t corneas available to all? Dr. Auffarth provided three simple answers to this question: There are too few of them, the procedures are too complex, and the whole process is too expensive.

Such a topic easily deserves its own article, but we should expand a little on those ideas here. There is currently only 1 cornea available for every 70 needed; there are only 25k trained cornea surgeons in the world, and cornea transplants are a difficult procedure; and everything from the infrastructure to handling and storage make cornea transplants expensive.

Germany is a very advanced country in medical terms. For example, 60-70% of corneal transplants in Germany are DMEK procedures. However, with about 8,000 cornea transplants per year in Germany, there is still a waiting list of some 3,500.

This leads to a fairly obvious conclusion: Why not just make artificial corneas? As Dr. Auffarth put it, “An artificial DMEK layer could help to treat chronic corneal edema temporarily or permanently, especially in countries with limited access to donor tissue.”

The product Dr. Auffarth put forward is

called the EndoArt® (EyeYon, Nes Ziona, Israel). It’s an artificial endothelial layer for the treatment of chronic corneal edema. The working principle is to impede the transfer of aqueous humor into the cornea and to decrease chronic corneal edema.

EndoArt is the first routinely usable artificial corneal transplant, and helps bring corneal thickness back to normal.

There’s no immunological reaction expected, and it isn’t as brittle as human DMEK lamella — so it’s easier to handle. Repositioning or other secondary interventions are possible if necessary.

A brief bit on artificial irises in complex DMEK cases We had to touch on Dr. Donald Tan’s talk on artificial iris and DMEK in complex cases before we ran out of space here. You may be familiar with the name, but Dr. Tan holds multiple titles, including president of the Asia Cornea Society, president of the Association of Eye Banks of Asia, and visiting senior consultant at the Singapore National Eye Centre. So, what he says carries a fair bit of weight.

When speaking specifically about complex cases for DMEK, he gave a few examples. There could be situations where the anterior chambers are limited

by PAS (peripheral anterior synechiae), iris adhesions, IOLs or tubes. There could additionally be inadequate posterior surface of the anterior chamber — it could be aniridic, there could be dilated pupils, an open vitreous cavity or aphakia. Previous failed PKs, DALKs or DSAEKs could lead to complications as well.

In many of these cases, even when DMEK is successful, PAS recurred after a few weeks to months, which can lead to graft rejection and DMEK graft failure.

To help make things a bit easier, Dr. Tan now suggests using an artificial iris in these cases.

As he noted, “My latest approach for complex cases is to first reconstitute the anatomy of the chamber by removing an abnormal iris, and replacing it with an artificial iris. DMEK can therefore be more easily performed as a second stage.”

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01 August 2021 | Issue #2

Innovations in IOL Technology

by Tan Sher Lynn

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dvances in intraocular lens (IOL) design are poised to change the future of vision care and visual outcomes. The IOL symposium on Day 2 of the 33rd Asia-Pacific Association of Cataract and Refractive Surgeons and Singapore National Eye Centre 30th Anniversary virtual meeting (APACRS-SNEC 2021) explores some of the latest IOL innovations.

New approaches in EDOF technology Dr. Chandra Bala from personalEYES, Australia, noted that there has been significant change in optic and haptic designs over the course of history.

“The current success is owed to pioneering work of engineers, doctors and their patients. It is astonishing how many times IOL design has preceded biometry and surgical technique,” he said, adding that the recent trend is towards “less is more” in the form of extended depth of focus (EDOF) lens.

Presenting on new EDOF technologies, Dr. Gerd Auffarth from the RuprechtKarls-University of Heidelberg,

Germany, said the Alcon Acrysof IQ Vivity (Geneva, Switzerland) was developed with a non-diffractive concept based on wavefront shaping technology that creates a continuous extended focal range instead of multiple focal points.

Meanwhile, the PhysIOL FineVision Triumf (Wallonia, Belgium) combines trifocal technology and EDOF optics with the goal of reducing side effects in low light conditions. “It is designed to improve intermediate vision and is free of lateral chromatic aberrations (LCA) at far and intermediate focus points where glare and halos appear.

It has higher contrast sensitivity and less risk of photic phenomena, provides improved vision in low light conditions and reduces dysphotopsia.

“Another hybrid optical technology is the Johnson & Johnson TECNIS Synergy (Florida, USA) which combines EDOF with multifocal diffractive patterns to deliver continuous high-contrast vision across the entire range and optimizes vision in low light conditions,” he said.

Dr. Auffarth also spoke on monofocal

plus lenses, namely the Johnson & Johnson TECNIS Eyhance and Bausch + Lomb LuxSmart (Laval, Canada). “The TECNIS Eyhance is a monofocal IOL with enhanced uncorrected intermediate visual acuity (UCIVA). Its continuous alteration of refractive power from the edge to the center of the lens provides a unique anterior surface that offers enhanced intermediate vision in comparison to other aspheric monofocal IOLs, and delivers distance visual acuity that is comparable to other aspheric monofocal IOLs. “On the other hand, the Bausch + Lomb LuxSmart has 2mm of EDOF center with increased depth of focus created by the combination of the fourth and sixth order spherical aberration of opposite signs. This combination increases the subjective depth of field by 118%,” he said.

Small aperture IOL: Better depth of field Dr. Sathish Srinivasan from the University Hospital Ayr, Scotland, United Kingdom, talked about the small

CAKE Magazine’s Daily Congress News on the Anterior Segment

aperture optics, a new technology for the management of presbyopia.

According to him, the small aperture IOL is based on the camera aperture concept where the depth of field increases as the size of the aperture decreases.

“The IC-8 IOL is a small aperture IOL manufactured by AcuFocus (California, USA). The IC-8 IOL post-market study design involves 108 subjects across six countries in Europe with contralateral implantation of IC-8 IOL in one eye (with a refractive target of -0.75D) and an aspheric monofocal IOL in the fellow eye. Results showed that good monocular uncorrected visual acuity (VA) at 6 months was achieved at 0.87 for far, 0.83 for intermediate and 0.66 for near.

Very good binocular uncorrected VA at 6 months was achieved at 1.15 for far, 0.91 for intermediate and 0.69 for near. Binocular contrast sensitivity is equivalent to the contrast sensitivity in the monofocal IOL eye.

Neuroadaptation and retinal response to illumination will further boost the contrast performance in the IC-8 eye,” he said.

He noted that the small aperture design

provides uninterrupted, extended depth of focus for cataract patients, and near vision range can be extended by targeting for a small amount of myopia in the IC-8 IOL eye. Providing high patient satisfaction, the IC-8 lenses might have additional application in challenging eyes, such as postrefractive and post-cornea transplant cases.

Adjustable IOLs: Light at the end of the tunnel?

According to Dr. Robert K. Maloney of the Maloney-Shamie Vision Institute, USA, the Light Adjustable Lens (LAL; RxSight, California, USA) is the most accurate IOL and allows customization of vision after surgery.

“The LAL has an important place in any cataract practice. It is ideal for patients who want excellent uncorrected vision, patients who aren’t sure of their desired outcome and those with a monovision goal. It is great for low to moderate astigmatism and post-refractive eyes.

However, it is not a great option for pupils which do not dilate well (<7mm), corneal astigmatism above 2.5D, and patients who have trouble going to the clinic for adjustments,” he said.

He noted that studies have found that LAL eyes achieved UCVA of 20/20 or better at 6 months postoperatively at approximately twice the rate of patients receiving a monofocal lens.

According to Dr. Maloney, a new technology to be incorporated into the LAL is the ActivShield UV protection.

During light treatments, the ActivShield automatically opens to allow delivery of UV light from the light delivery device. After the treatment is complete, ActivShield is automatically engaged to once again protect the lens from external UV rays.

“In my practice, the LAL is the preferred lens. I tell my patients that if they aren’t certain of the vision they want, we can figure it out after the surgery. However, the benefits come with additional costs and visits. On the other hand, the multifocal IOL offers great range of vision but is not as clear for distant vision. It is less expensive, but its night vision is not as good as the LAL. EDOF IOLs are offered to patients who can’t afford the LAL but want the increased range of vision without glare from multifocals, while the toric IOL is offered to patients with 2.5D of corneal cylinder or more, or patients who can’t afford the LAL,” he shared.

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