CAKE & PIE POST (Virtual ESCRS & EURETINA 2020 Edition) - Issue 1

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& cataract • anterior segment • kudos • enlightenment

02 | 10 | 20 posterior segment • innovation • enlightenment

C A K E A N D P I E M A G A Z I N E S ’ D A I LY C O N G R E S S N E W S O N T H E A N T E R I O R A N D P O S T E R I O R S E G M E N T S Published by

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EURETINA and ESCRS 2020 Double the (Virtual) Excitement!

by Joanna Lee

Editor International Business Development

Ruchi Mahajan Ranga Brandon Winkeler Writers

Andrew Sweeney Hazlin Hassan Joanna Lee Olawale Salami Sam McCommon Tan Sher Lynn Maricel Salvador Graphic Designer

Introducing a preview of the upcoming EURETINA 2020 Virtual and the 38th Congress of the ESCRS — all virtual, but still jam-packed with interesting and educational content . . .

EURETINA 2020 Virtual Congress (Oct. 2-4, 2020) It’s double the excitement in the year of the double 20-20: This weekend, delegates can attend two congresses, virtually. Sit back with a meal or coffee, and feast on a smorgasbord of learning, new insights and discussions from the industry’s leading experts.

ZEISS Ophthalmic Virtual Experience ESCRS-EURETINA Spotlight 2020 October 1 – Virtual 4,Virtual 2020 ZEISS Ophthalmic Experience ZEISS Ophthalmic Experience

This year, EURETINA (European Society of Retina Specialists) returns with a virtual edition of its annual congress, with 50 sessions with the latest scientific content spread over four channels and three days. Covering all aspects “posterior,” EURETINA zooms right into the core issues of the day with a concrete offering of the latest discussions and developments in vitreoretina from Europe and other parts of the world. According to EURETINA President, Prof. Frank Holz, the sessions will be categorized into four channels where Keynotes (available Cont. on Page 3 >>

ESCRS-EURETINA Spotlight 2020 2020 ESCRS-EURETINA Spotlight October 1 –14, 2020 October – 4, 2020

Join and more Join us us for for the thevirtual virtualexperience experience andlearn learn more about in in eyecare. WeWe have an an about the thelatest latesttechnologies technologies eyecare. have exciting thethe unveiling of of excitingprogram programlined linedup, up,including including unveiling our our all-new all-newvirtual virtualshowroom! showroom! Join us for the virtual experience and learn more about the latest technologies in eyecare. We have an Register Registerhere: here: exciting program lined up, including the unveiling of our all-new virtual showroom!



02 Oct 2020 | Issue #1

EURETINA 2020 Virtual Congress Join our EURETINA 2020 symposium to hear our renowned experts discuss how to achieve clinical trial–like outcomes in patients with DME. Saturday, October 3, 2020 | 11:30–12:15 (CEST) (EURETINA channel 1) Vision in focus: Delivering optimized patient outcomes in DME in the real world Chair: Prof. Ian Pearce Join Prof. Jean-François Korobelnik, Dr. Varun Chaudhary, and Prof. Francine Behar-Cohen as they share expert guidance for optimizing management of patients with retinal vascular diseases. Our faculty will be available for a live Q&A on Saturday afternoon at the Bayer Networking Lounge. Learn more about Bayer Ophthalmology by visiting our online channels: DME, diabetic macular edema. The summary of product characteristics (SPC) of aflibercept solution for injection as approved by the European Commission can be found here. BAYER and the Bayer Cross are registered trademarks of Bayer. © Bayer AG 2020. All rights reserved. Bayer (South East Asia) Pte Ltd, 2 Tanjong Katong Road Paya Lebar Quarter 3 #07-01, Singapore 437161. September 2020 | PP-PF-OPHT-ALL-0045-1 | PP-PF-OPHT-SG-0001-1 (09/20)

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

engineering for retina surgeries, while the International Ocular Inflammation Society looks at the treatment of non-infectious posterior, intermediate and panuveitis with its pitfalls and tips in 2020. Other can’t-miss segments of EURETINA are the Instructional Courses with doctors from around the world sharing their tips and how-to’s on various ongoing challenges, such as posterior segment complications in cataract surgery, dealing with intraocular foreign bodies, new frontiers in treating diabetic macular edema, and new diagnostics in AMD. There’s also a talk on vitreomacular interface abnormalities and how clinicians should read clinical trials. Watch out for new insights on central serous chorioretinopathy, medical retina mystery cases, and other gems encapsulated in the 14 courses in this segment.

Congresses, like bicycles, are sometimes better together! >> Cont. from Page 1

on Channels 1 and 2) will feature International Symposia; Channel 3 will deliver Instructional Courses; while the highest scoring free papers will be presented on Channel 4. There will be an ongoing Virtual Exhibition as well as a Networking Lounge, besides the industry-sponsored Satellite Symposia. There are 15 EURETINA Sessions on Friday, Saturday and Sunday, with topics like: The EURETINA Guidelines for the Management of Retinal Disease: The Next Steps, Management of Complex RRD (Rhegmatogenous Retinal Detachment); and Better Patient Counselling: Using Epidemiological Evidence in Day to Day Clinical Practice. There will also be updates on big data and artificial intelligence in retinal imaging, AMD, diabetic retina, uveitis, endophthalmitis, the impact of COVID on

retinal anti-VEGF outcomes, and many more. Keynote sessions will include the Gisbert Richard Lecture (Friday, Oct. 2) with Prof. Stanislao Rizzo from Italy speaking on The Restless Fight Against Inherited Blindness. In the EURETINA Lecture (Saturday, Oct. 3), Prof. Richard Speide will be speaking on Reconsidering Pachychoroid and What It Means, while in the Kressig Lecture (Saturday, Oct. 3) Prof. Marta Figueroa will touch on Plasma Rich in Growth Factors for Macular Holes in High Myopia. The organizers have also lined up many interesting symposia on all three days featuring talks on OCT-A like UNICORN – Standardization and Definition of Qualitative and Quantitative OCT-A Parameters, an international panel on AI applications for AMD and a EuroVeRsion Case Contest. There’s also more on bio-

For a glimpse of the latest in the minds of curious doctors and researchers, there are 555 free papers, 580 poster abstracts and prize paper sessions, which will be shared on the abstract channel (Channel 4). We expect participants of EURETINA to benefit from the solid and diverse range of topics with in-depth updates lined up this year.

ESCRS 2020: 38th Congress of the ESCRS (Oct 2-4, 2020) Happening at the same time as EURETINA 2020 is the ESCRS (European Society of Cataract & Refractive Surgeons) 38th Congress. The congress will kick off on Friday (Oct. 2) with Industry Day, where attendees can set up a virtual profile and explore the Interactive 3D exhibitions to find out about the latest products and devices in ophthalmology. Delegates can also attend Satellite Meetings. Some of the main symposia include ESCRS and EuCornea’s joint session on dealing with traumatized cornea (Friday, Cont. on Page 5 >>




02 Oct 2020 | Issue #1

Chec OCT k Diana resu lts.

OZURDEX® has multiple modes of action,1–3 a low treatment burden4–7 and a manageable safety profile.6–8


DME, diabetic macular edema; OCT, optical coherence tomography. 1. Nehmé A and Edelman J. Invest Ophthalmol Vis Sci 2008;49(5):2030–2038. 2. Holekamp N. The role of corticosteroid implants in DME. Available at: the-role-of-corticosteroid-implants-in-dme. Accessed March 2020. 3. Campochiario PA et al. Am J Ophthalmol 2016;168:13–23. 4. Malclès A et al. Retina 2017;37(4):753–760. 5. Matonti F et al. Eur J Ophthamol 2016;26(5):454–459. 6. Aknin I and Melki L. Ophthalmolgica 2016;235:187–188. 7. Allergan. OZURDEX®. Summary of Product Characteristics. October 2019. 8. Boyer SB et al. Ophthalmology 2014;121(10):1904–1914.

INDICATIONS & USAGE: OZURDEX® contains a corticosteroid indicated for the treatment of macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO), for the treatment of non-infectious uveitis affecting the posterior segment of the eye, and for the treatment of patients with visual impairment due to diabetic macular edema (DME) who are pseudophakic or who are considered insufficiently responsive to, or unsuitable for non-corticosteroid therapy. DOSAGE & ADMINISTRATION: For ophthalmic intravitreal injection only. The intravitreal injection procedure should be carried out under controlled aseptic conditions. Following the intravitreal injection, patients should be monitored for elevation in intraocular pressure and for endophthalmitis. DOSAGE FORMS & STRENGTHS: Intravitreal implant containing dexamethasone 0.7 mg in the NOVADUR™ solid polymer

drug delivery system. CONTRAINDICATIONS: Ocular or periocular infections. Advanced glaucoma. Aphakic eyes with ruptured posterior lens capsule. Eyes with ACIOL, iris or transscleral fixated IOLs and rupture of the posterior lens capsule. Hypersensitivity. WARNINGS AND PRECAUTIONS: Intravitreal injections have been associated with endophthalmitis, eye inflammation, increased intraocular pressure, retinal detachments, and implant migration into the anterior chamber. Patients should be monitored following the injection. Patients who has a tear in the posterior lens capsule (e.g., due to cataract surgery), or who had an iris opening to the vitreous cavity (e.g., due to iridectomy) are at risk of implant migration into the anterior chamber. Use of corticosteroids may produce posterior subcapsular cataracts, increased intraocular pressure, glaucoma, and may enhance establishment of secondary ocular infections due to bacteria, fungi,

or virus. Corticosteroids should be used cautiously in patients with a history of ocular herpes simplex. ADVERSE REACTIONS: In controlled studies, the most common adverse reactions reported by 20–70% of patients were cataract, increased intraocular pressure and conjunctival haemorrhage. Licenses may vary by country, please consult your local Summary of Product Characteristics. Adverse events should be reported to your Ministry of Health and local Allergan office. Date of preparation: March 2020 INT-OZU-2050060 OZURDEX® is not licensed for use in DME in China.

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

>> Cont. from Page 3

Different (on Friday, Oct. 2 right before the opening of the congress), where Prof. Marcel Levi will speak on Tackling the Covid-19 Crisis: Professionals in the Lead. Doctors from France, Italy, the U.K. and Ireland will speak about their experiences practicing during the pandemic, challenges and limitations, and insights gained in Covid-19: Lessons Learned.

Oct. 2); ESCRS and EURETINA’s joint symposium on cataract surgery in AMD patients (Saturday, Oct. 3); and taking a look at “20/20 in 2020” for the lens (Oct. 3) and cornea (Oct. 4). What’s the scenario in the near future? We’ll find out in The Next Decade of Cataract Surgery and What to Do When the Unexpected Happens. The prestigious Ridley Medal Lecture (Friday, Oct. 2) will honor Prof. David F. Chang, clinical professor at the University of California, San Francisco. He will share on Five Compelling Lessons from the Greatest Team of Cataract Surgeons. Over at the ESCRS Heritage Lecture (Sunday, Oct. 4), Prof. Theo Seiler will speak on Cataract Surgery and Laser Vision Correction. The congress, besides being a hotbed of discussions and debates, might be a time of reflection as well with talks surrounding the pandemic like Covid-19: And Then Everything Was

How can you not have more videos at virtual summits? The Video Symposium on Challenging Cases (Saturday, Oct. 3) promises a comprehensive and rigorous overview of difficult cases covering preoperative challenges, intraoperative challenges and postoperative surprises. On Sunday, look for Video Symposium on Surgical Complications: You Make the Call (Sunday, Oct. 4). There will also be a surgical video session on When Cataract Surgery Goes Wrong: How to Deal with It, with 8 case studies lined up. Hop in for hot debates on Friday, Oct. 2 at the Journal of Cataract and Refractive Surgeries Symposium for two sides (or


more) of the story in Controversies in Cataract and Refractive Surgeries. Find out which is better: LASIK vs. SMILE or Which IOL is better after LASIK: Monofocal or EDOF/Multifocal. There will also be several industrysponsored lunchtime symposia under the Satellite Education Programme. Follow congress tweets @ESCRSofficial for updates, interesting information and inspiration. Finally, don’t forget to start out with the Virtual Social Programme (Friday, Oct. 2 at 8 p.m.), which will feature “Europe’s most uplifting DJ’s” — electronic dance music meisters Lucas and Steve playing an exclusive live gig for ESCRS delegates. On Saturday Oct. 3 (at 8:30), get some rhythm when you register to watch the world renowned Royal Concertgebouw Orchestra (KCO) with music by Gershwin. Please note that program times on the websites are in Central European Summer Time (CEST).









02 Oct 2020 | Issue #1

Of Windmills, Wheels and Waters Welcome to (Virtual) Amsterdam by Joanna Lee


hink Amsterdam — and immediately hordes of bicycles crossing over countless canals, picturesque narrow old houses, coffee shops, the Red Light District, and laid back vibes come to mind. There’s more to this welcoming, historic European city and since EURETINA and ESCRS 2020 are taking place in Amsterdam this year (virtually), a little exploration of the city might make up for the lack of physical presence this year.

Sights and sounds Amsterdam is home to 881,000 bicycles — and there are four times more bikes than cars. So, you could ride around the city, or walk around to explore its mixture of attractions, buildings and walkways . . . everything from the old to the avant garde, with secret spots of serenity slipped in between. Most people will know about the cultural heart of Amsterdam — Museumplein, where all the famous museums stand; Rijksmuseum, which houses Rembrandt and Vemeer’s works; the Van Gogh Museum; and the Stedelijk Museum of modern art. Satisfy your curiosity with

this city’s iconic attractions all within a common ground. Stroll about in this vicinity and you could listen to free concerts at the Royal Concertgebouw, which is exactly what will be featured in the Saturday Oct. 3 virtual show program of the ESCRS 2020 congress. Amsterdam’s canals have been listed as a UNESCO World Heritage site, thanks to their 400-year-old history . . . so, you could wander around to take in those sights. Or take a pleasant river tour to appreciate these intricate connections from a different view. Curious about Amsterdam’s history? Then head to the Stadsarchief (Amsterdam City Archives), which house evidence of the city’s long past. You’ll find a treasure trove of maps and documents pertaining to the city’s development through the centuries.

Make your eyes happy Many would love to travel about 40km away from the city to savour the famous tulips of Keukenhof Gardens. Spring

time is the best to see tulips, but if you’re venturing just around Amsterdam, do wake up early to catch the freshness of colourful blooms at Bloemenmarkt in Singel. It’s a floating flower market which is popular among the locals. From flowers, perhaps you might fancy films. Amsterdam has the largest film library in the country in the Eye Film Instituut of Netherlands. It’s the iconic EYE building that is quite a magnificent sight. Built in 2012, it houses four cinemas, a 1,200-square-meter exhibition space apart from the library, and makes for excellent photographic opportunities. Take a good guess of how our friends in Amsterdam might take time out to chill in a city that is already easygoing. You can’t get more relaxed than stretching out your feet at Vondelpark. Ideally, it would be a sunny day where you could watch the crowd playing games, take in some vitamin D or have a snooze under shady trees overlooking a lake. In homage to its ship-building past, you could take a free ferry ride to Noord and explore this refurbished shipyard. The ferry features several stops where you

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

can find local cuisine, visit artistic hubs like NDSM yard, and hang out there to soak in the cool vibes. Here is also where the largest flea market in Europe happens, inside the IJ-hallen building once a month, so get ready to go crazy bargain hunting or take crazy numbers of instagram-worthy shots. Back to the city, you might want to visit the Anne Frank museum at Prinsengracht 263 for contemplations on this city’s most famous past resident. For those who want a workout, go to Amsterdamse Bos (Amsterdam Forest) which is more of a park than a forest, where you can go biking or jogging around its trails. Now, a visit to Amsterdam wouldn’t be complete without getting up close to windmills. Zaanse Schans is where the open-air museum of windmills stand and you can learn about the role of this unique ancient device in the daily lives of the old Dutch.

Tastes of Amsterdam Take time to sample from any of the city’s microbreweries and craft beer spots. To go with the drinks, the Dutch have a variety of foods that has found its present day taste and form, thanks to its long history as a melting pot. Dutch fries (or patat frites) are simply rich and fun. Slathered with mayonnaise, ketchup, and sometimes with curry sauce and onions, these carb-loaded sticks add some happiness to any meal or snack time. This street food was made popular in “Pulp Fiction” in 1994. There are also Dutch pancakes, thin crepes that are usually topped with a variety of fruits. Bitterballen are deep-fried crispy meatballs, which go perfectly with your favourite drinks, and are an ideal comfort food for when those munchies arise. Raw herring is another specialty — you can spot them at harringhandels (herring carts) around the city, and they’re usually eaten with pickles and onions.




You could also try Stamppot — another traditional Dutch comfort food made with potatoes mashed with vegetables — served with a sausage, this meal usually warms up souls during Dutch winters. Another popular treat are Stroopwafels, which are flat, little brown delights with a heavenly caramel taste. Finally, there is also Rijsttafel, which means “rice table” and is a Dutch meal inspired by Indonesian nasi padang which comprises many small dishes of savory, spicy and sweet dishes of meats and vegetables, usually accompanied with rice. From history to architecture and the arts, Amsterdam is a vibrant cultural hotspot and melting pot to the most modern startups — and indeed, the city has been a host to ideas and meetings of minds from all over. In the words of Marcel Wanders, “what’s special about Amsterdam is that the city is able to connect worlds that are not otherwise connected.” And truly, there are many worlds of wonder within its windmills, wheels and waters.




02 Oct 2020 | Issue #1

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

New Eye Care Realities Distancing safely while using your OCT device


ocial distancing is the new reality in current eye care practices. However, most ophthalmic diagnostic devices require close proximity between patients and the scan operator, making physical distance an impossibility. This is reality is set to change with the new Canon Medical Xephilio OCT-A1 – where within just three clicks of a mouse, optical coherence tomography (OCT) scans can now be done a few meters away, from another room or even a remote location. Imagine the ease of mind your patients and staff members would experience with the safe distancing provided. Three safer scenarios would now be possible with the following distancing solutions whenever your patients need to be examined with the Canon Medical Xephilio OCT-A1.

Solution 1: Operating the Canon Medical OCT at safe distance in the same room The operator can control the OCT from a different desk that can easily be 2 meters or further from the patient. This is achievable using a longer monitor cable and a wireless keyboard and mouse (or by using a USB extension cable). The monitor’s cable could be up to 5 meters long while the USB extension cables could go up as long as 6 meters for the keyboard and mouse.

even more flexibility with the ability to still communicate with the patient while keeping a safe social distance.

Solution 3: Operating the Canon Medical OCT from another room or location The Canon Medical Xephilio OCT-A1 can be operated over the hospital network or via the internet. This would require a remote desktop solution (e.g. TeamViewer) which would essentially enable the device to be operated from another room in the hospital or even a different location. Using this remote access solution, monitoring and communicating with the patient can even be done over popular video meeting software like Skype, for instance. Safe physical distance is but only one of the key innovations the Canon Medical Xephilio OCT-A1 brings to the table apart from its exceptional imaging quality and efficiency. The Canon Medical Xephilio OCT-A1 gives a cutting edge to imaging results with the first commercially available Intelligent Denoise capability, a deep learning feature that effectively removes noise while enhancing details within a single scan.

A tomography scan with the Canon Medical Xephilio OCT-A1 can be done in just 2 seconds, resulting in less motion artefacts. This not only helps you save time and enhance your efficiency, but ultimately, the shorter examination time also increases your patient’s comfort. Revolutionizing the future of OCT scan innovations, the Canon Medical Xephilio OCT-A1’s digital resolution of up to 1.6 µm enables excellent differentiation of structures and individual layers of the cornea and retina, thanks to Canon’s long history in recognized optical expertise. In OCT imaging, optical axial resolution should not be confused with digital sampling resolution since axial resolution depends on the bandwidth and light source wavelength. The Canon Medical Xephilio OCT-A1 has a unique resolution in the market with a 3-micron native optical axial resolution combined with a spectral domain bandwidth of 100 nm, which anterior and posterior ophthalmologists appreciate very much due to the high imaging definition output. Finally, the best part of Canon Medical Xephilio OCT-A1 is its ease of use with its three-click function to complete an exam. It offers a complete range of intelligent functions to enable fully automated examinations. This makes it easy for you to delegate the scanning operations to nurses or assistants. All in all, safety in physical distance and deep learning imaging capabilities is now a sharper, new reality.

Solution 2: Operating the Canon Medical OCT remotely over a network in the same room The operator can control Canon Medical Xephilio OCT-A1 from a tablet PC over a network. The tablet PC uses a remote desktop solution (e.g. TeamViewer) to communicate with the PC that controls the OCTA. This would offer the operator

Canon Medical Xephilio OCT-A1 helps you maintain safe distance. Yours and your patients’ safety comes first!




02 Oct 2020 | Issue #1

Highlights from the Retina Virtual Forum by Olawale Salami

AI in retinal imaging and beyond: Can we trust the algorithms? “Who is responsible for wrong decisions made by AI algorithms and what are the implications of physicians not following AI recommendations?” — Dr. Tien Yin Wong

The Retina Virtual Forum got off to a futuristic start. Led by Drs. Tien Yin Wong and Adnal Tufail, panelists discussed current applications of AI in ophthalmology, what the future should look like, and key ethical concerns. “Apart from glaucoma, one interesting area where we should consider using AI is in keratoconus, and some of the datasets we generate may be quite suitable for tracking disease progression,” said Dr. Wong.

He then stressed a vital ethical and regulatory dilemma by asking the question: “Who is responsible for wrong decisions made by AI and what are the implications of physicians not following AI recommendations? Should we trust the AI against our clinical judgments? These are interesting ethical hurdles that we need to address today as we expand AI into other parts of ophthalmology.”

Anti-VEGF drugs for retinal disease: When efficacy is not enough “We have the most confidence now around subretinal injections because of the extensive experience with this route of delivery.” — Dr. James Bainbridge

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

“Anti-VEGFs have become the first-line treatment — and the only available way of treating many retinal diseases — but this was not what we planned,” explained Dr. Francesco Bandello, while chairing a session at the Retina Virtual Forum. “In recent years, there has been a renewed interest in the use of combination therapies to target different steps in retinal disease pathogenesis. This was our initial thinking when we started using intravitreal therapies, to use different drugs at each disease step, similar to what happens in oncology. “The emergence of newer anti-VEGFs and other drug classes raises more questions,” according to Dr Bandello. One of them is “should we focus on improving efficacy and effectiveness, or should we improve durability?” In response, Dr. David Silverman commented, “There are great products that can reduce VEGF, but not all patients respond. Efficacy in the real world may depend more on durable products.”

Gene therapy delivery: Navigating the best path to the retina Gene therapies have the potential advantages of long-term therapeutic effect and the capacity for celltargeted therapy — which could transform the management of many retinal disorders. However, finding the best route to deliver these treatments remains challenging. During a panel discussion, Dr. James Bainbridge explained: “We have most confidence at the moment around subretinal injections because of the extensive experience with this route of delivery. “Subretinal injection is invasive, with predictable adverse effects, as well as

the risk of unpredictable harm. There are other alternative delivery systems, which may be easier to scale up, but we have less certainty of the risks and benefits,” said Dr. Bainbridge. ‘“The intravitreal approach remains attractive, but the risk of targeting the outer retina is limited in a large eye, and there are concerns about inflammation in the vitreous. While alternative approaches such as subretinal or suprachoroidal remain interesting, we are yet to see the real world evidence of these alternative routes in a large eye,” he concluded.

Financing new surgical instrumentation and microscopy: A case for improved return on investment “Suprachoroidal drug delivery, the microneedle approach and intraoperative OCT are instrumentbased procedures where we have seen fast-paced innovation,” said Dr. Steve Charles during a panel discussion at the Retina Virtual Forum.

Research and practice in the era of COVID-19 In a panel discussion at the Retina Virtual Forum, Dr. Sally Tucker shared her experience on the impact of COVID-19 on research activities from a CRO perspective. She noted that “COVID-19 has provided an opportunity to accelerate a lot of technology for remote monitoring of clinical trials, patient engagement, greater usage of telemedicine, and improved methods of patient prescreening.” Commenting on how COVID-19 has affected the uptake of remote patient monitoring technology, Dr. Kester Nahan said: “Home OCT is the future and will eventually be used by patients — COVID has accelerated this development and will accelerate the uptake.” In addition, he noted that “increased need for Home OCT and better data analytics are needed to ensure that this is applicable in a wide variety of indications, such as monitoring conversion from dry to wet AMD or following up with patients on longacting drugs.”

What is the value in the market for new retinal injection technologies? According to Dr. Ron Schneider, “We are seeing the emergence of expensive bionic technology: Will these become more available or will they remain restricted to centers of excellence? “We can’t keep these at centers of excellence because we need more reach. Access is vital and the industry needs to do more on this. We need technology but it needs to be affordable.” Can big pharma provide the needed financing to expand access to some of these new injection devices? Dr. Schneider said: “There is a need to show additional value of subretinal injection instruments in improving the delivery of many expensive new drugs.”

Editor’s Note: The Retina Virtual Forum 2020 took place on September 30. Reporting for this story also took place during the Forum.




02 Oct 2020 | Issue #1

ZEISS Unveils Innovative Digital Solutions for a Better, Smoother Workflow by Hazlin Hassan


head of the official opening of the 2020 Virtual ESCRS and EURETINA congresses, Carl Zeiss Meditec (Jena, Germany) introduced its latest digital solution enhancements aimed at helping doctors boost their clinical efficiency and improve patient care — from assessment, diagnosis to treatment. These innovative offerings from ZEISS include the ZEISS IOLMaster 700 with Central Topography and the CT LUCIA® 621P/PY, both of which are designed to optimize the way cataract surgeons work.

The LVC portfolio and cloud services “ZEISS is offering cataract surgeons and patients an improved surgical experience with innovative solutions such as the IOLMaster 700 with Central Topography and the CT LUCIA 621.” – Dr. Ludwin Monz The ZEISS Laser Vision Correction (LVC) portfolio, one of the most comprehensive in the industry, offers alternatives such as photorefractive keratectomy (PRK), laser-assisted in situ keratomileusis (LASIK) and small incision lenticule extraction (SMILE), to commonly used procedures, enabling surgeons to make efficient decisions and deliver better results with tools such as the ZEISS Nomogram Service. It has recorded more than 3 million SMILE® procedures worldwide, and also offers a treatment

option for presbyopic patients with PRESBYOND. The FORUM® Cloud Viewer will allow doctors to review their patients’ data from anywhere, anytime, and collaborate with their colleagues for a second opinion, which is an important tool at a time when lockdowns and physical distancing may be taking place to curb the spread of the coronavirus outbreak. “ZEISS is offering cataract surgeons and patients an improved surgical experience with innovative solutions such as the IOLMaster 700 with Central Topography and the CT LUCIA 621,” said Dr. Ludwin Monz, President and CEO of Carl Zeiss Meditec. These digital solutions, which capture and integrate data across clinical workflows, help doctors to make informed clinical decisions.

These latest technologies enhance the cataract procedure, making them more efficient, and cost effective, and most importantly, maintaining established standards and assuring patients of the best possible outcomes.

Of IOLs, measurements and CT features The IOLMaster® 700 with Central Topography (CT) allows surgeons to obtain additional information and detect visually relevant asymmetries on the central corneal shape with the standard ZEISS IOLMaster 700 measurement, without requiring extra measurements, hardware, or time. The new IOLMaster 700 with CT also features an update to the Barrett Suite with the True-K TK formula allowing up to 12% more post-myopic LASIK patients to be within ±0.5 D compared

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

“The ZEISS optic of the CT LUCIA 621 makes the lens more forgiving, or less sensitive, when it comes to decentration.” – Dr. Andreas F. Borkenstein

senior ophthalmologist at Ama Optimex Eye Clinic in Bucharest, Romania. “Since we added SMILE and PRESBYOND to our ZEISS portfolio our business is booming, and now we are able to find the right solution for every patient’s lifestyle. This is every doctor’s dream, isn’t it?,” added Dr. Filip.

ZEISS Nomogram Service Another recent enhancement to the corneal refractive workflow is the ZEISS Nomogram Service. Nomograms can improve the predictability in Laser Vision Correction, which can lead to higher postoperative uncorrected distance visual acuity (UDVA) and has a direct impact to patient satisfaction.

to the classic K calculation formula. The update also includes ZEISS EQ Mobile cloud connectivity, which enables doctors to access IOL calculation reports on their mobile devices and transfer surgical plans via the cloud to the operating room. “Scaling and hues of the ZEISS IOLMaster 700 with Central Topography are optimized for easy and intuitive cornea checks,” said Dr. Douglas D. Koch, MD, a co-developer of the Central Topography software feature. As an additional workflow enhancement, the CT LUCIA® 621P/PY from ZEISS with unique ZEISS optic design is the new-generation aspheric monofocal c-loop IOL in the hydrophobic ZEISS portfolio. The patented aspheric optic design of the ZEISS CT LUCIA device mitigates

against potential decentration issues while still providing excellent visual outcomes. “The ZEISS optic of the CT LUCIA 621 makes the lens more forgiving, or less sensitive, when it comes to decentration,” said Dr. Andreas F. Borkenstein, MD, co-founder of Borkenstein & Borkenstein, Private Practice at the Clinic of Kreuzschwestern Graz, Austria. It also comes in a new and improved fully preloaded injector that promotes an easy and safe cataract workflow. “In Romania when we say that something is “ZEISS”, it means that everything works perfectly. We have a long history working with ZEISS technology and this was the foundation on which we created the PREMIUM market in my country,” said Dr. Andrei Filip, MD, PhD, FEBO, cataract and refractive surgeon, and

The ZEISS Nomogram Service supports the refractive surgeon in generating their own personal nomogram. The service includes counselling about data requirements, help with data collection, data analysis and analysis debriefing. All these are just some of the latest in cutting edge technology solutions being offered today, further enhancing the patient’s experience and maximizing the eye surgeon’s clinical workflow efficiency. Carl Zeiss Meditec AG which is listed on the MDAX and TecDAX of the German stock exchange, supplies innovative technologies and application-oriented solutions designed to help doctors improve the quality of life of their patients. The Company offers complete solutions, including implants and consumables, to diagnose and treat eye diseases. For further information visit: www.zeiss. com/med




02 Oct 2020 | Issue #1

with Coats’ disease in the left eye. At presentation, the vision was limited to light perception in the left eye and 6/6 in the right eye. “On examination, the anterior segments of both eyes were within normal limits, and the right eye examination findings were normal. The left fundus at presentation showed total retinal detachment with organized hard exudates, macular scars, telangiectatic vessels and multiple cysts,” said Prof. Natarajan. According to Prof. Natarajan: “Initial management, in this case, consisted of peripheral scatter laser and Avastin injection. Subsequently, the patient developed exudative retinal detachment of the left eye, which warranted using a novel method, consisting of Avastin injection, combined with subretinal fluid drainage and cryotherapy.”


The Optimal Global Platform for Knowledge Sharing in Retinal Surgery by Olawale Salami


etinawesome is a virtual meeting of retinal experts from several countries, with one sole purpose: To share the knowledge on state-ofthe-art techniques in vitreoretinal surgery. The theme of this 5th edition (RETINAWESOME V) was The optimal time for reaching out the right decisions into Vitreoretinal Surgery. Ahead of the EURETINA 2020 congress, it attracted dozens of retinal surgeons worldwide and featured insightful presentations, audiovisuals, and discussions on cuttingedge procedures in retinal surgery.

Less is more: Minimally invasive drainage of subretinal fluid in Coats’ disease First on the virtual podium was Prof. S. Natarajan, who has been part of

“This is a wonderful technique because it uses a small gauge and no external breaks, therefore is a much safer technique.” – Dr. Yusike Oshima Retinawesome from the first edition. His presentation focused on novel approaches to the surgical management of Coats’ disease, specifically on techniques of external subretinal fluid drainage in exudative retinal detachment, secondary to Coats’ disease. Here, Prof. Natarajan presented the case of a 5-year-old girl diagnosed

Prof. Natarajan explained further, noting that this method of minimally invasive subretinal fluid drainage starts with infusion of the eye, using a 27G infusion line. “Postoperatively, we found that the patient’s exudative retinal detachment was resolved and vision was maintained,” he shared. In this procedure, Prof. Natarajan highlighted the primary aim, which was to ensure anatomical success and prevent sequelae such as secondary angle-closure glaucoma, neovascular glaucoma, and eye loss. He has since published this technique in a peerreviewed journal. Commenting on the technique Dr. Yusike Oshima stated: “This is a wonderful technique because it uses a small gauge and no external breaks, and therefore is much safer.” And what about tips for young surgeons performing this procedure? Prof. Natarajan advised to always be careful and investigate a white reflex, thinking first of retinoblastoma as the most likely diagnosis. “In Coats’ disease, you will find peripheral telangiectatic vessels and subretinal exudates, which strongly support your diagnosis. When there is no exudative retinal detachment, laser treatment works, and no interventional surgery is needed,” he explained. During the discussions that followed, Dr. Yoshihiro praised Prof. Natarajan’s technique: “I think your surgery was beautiful, I have never seen that type

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

of non-invasive surgery for exudative Coats’,” noted Dr. Yoshihiro.

Massive subretinal hemorrhage in AMD: There’s more than meets the eye “In a massive hemorrhage, for fresh or dark clot cases, I try to use pars plana vitrectomy with tPA injection, while in old cases, I only observe because these clots are difficult to liquefy.” – Dr. Yusike Oshima In his introductory statement, Dr. Yusuke Oshima highlighted studies showing the causal link between massive subretinal hemorrhages and age-related macular degeneration (AMD). “Vision can become highly compromised, especially when the hemorrhage is massive and extends to the periphery,” he said. What about anti-VEGFs for subretinal hemorrhages? Dr. Oshima explained that recently, anti-VEGFs have gained prominence as a treatment option, and many doctors still see this as the first choice. However, though anti-VEGFs can stabilize neovascularization activity, they may not stop the subretinal hemorrhage over long periods. “Besides, such hemorrhages may leave a large scotoma, with the fixation point shifted near the arcades, resulting in poor visual outcomes,” said Dr. Oshima. There are options available to treat these massive subretinal hemorrhages. “A less invasive approach is to perform a pneumatic displacement of the hemorrhage. A critical factor in determining the right technique is the duration of the hemorrhage,” advised Dr. Oshima. Further, he explained that in cases of old subretinal hemorrhage, a gas tamponade may not always be efficacious, and combining pneumatic displacement with tissue plasminogen activator (tPA) injection has been shown to provide optimal results. “The advantage of this procedure is based on two complementary actions: pharmacologically induced subretinal

hemolysis by intravitreal tPA using a 27G needle, and the mechanical drainage of liquefied blood assisted by perfluorocarbon liquid intraoperatively and by gas tamponade postoperatively,” Dr. Oshima shared.

two sessions of penetrating keratoplasty, a lensectomy, and the patient developed corneal decompensation. There was anterior traction with anterior displacement of the retina,” shared Dr. Lam.

In the case presented by Dr. Oshima, he noted that “sometimes it is preferable, in old hemorrhages, to wait for about 30 minutes after the tPA injection for the clot to liquefy. Then we use the shaking technique to make a wider area of detachment.”

There were additional complications in this case. According to Dr. Lam, one of the main procedures that he did in this patient was an endoscopy-assisted ciliary body dissection to remove the membranes responsible for the traction on the anterior retina. “However, two months later, the patient developed posterior pole tractional detachment,” he said.

Dr. Oshima outlined his personal choice of surgical options for subretinal hemorrhage treatment. He provided clarification and said: “In a massive hemorrhage, for fresh or dark clot cases, I try to use pars plana vitrectomy with tPA injection while in old cases, I only observe because these clots are difficult to liquefy.” Furthermore, Dr. Oshima advised that there is the option to perform vitrectomy with subretinal injection of tissue plasminogen activator or antiVEGF followed by gas tamponade. “This depends on the size of the hemorrhage,” he explained.

Exploring the open sky: A case of combined anterior and posterior segment pathologies “Open sky vitrectomy is indicated in extremely small eyes and requires bimanual dissection for adherent tractional membranes.” – Dr. Wai-Ching Lam Dr. Wai-Ching Lam presented an exciting case of a 2-year-old boy with bilateral Peters anomaly associated with concurrent familial exudative vitreoretinopathy and microphthalmia. To treat this case, multiple surgeries were performed on the left eye, including a penetrating keratoplasty, lensectomy and tractional retinal detachment surgery — which unfortunately, resulted in total retinal detachment. “In the right eye, the patient underwent

Additional procedures were needed to treat the posterior pole traction. “Because of the anteriorly displaced retina, I decided to insert an anterior chamber maintainer during the dissection procedure. Finally, the cornea had to be removed to allow for an open sky vitrectomy and bimanual dissection of the pathological membranes,” said Dr. Lam. “Open sky vitrectomy is indicated in extremely small eyes and requires bimanual dissection for adherent tractional membranes. However, it may be associated with a risk of hypotony and suprachoroidal hemorrhage,” he noted.

HASHTAG #Sweet dream to nightmare “At the beginning, I didn’t think the hashtag was sufficient to hold an IOL, but now you have shown that this is safe, particularly in aphakic patients, the hashtag is a fantastic way to keep the silicone oil from getting into the anterior chamber.” – Dr. Wai-Ching Lam A compelling case presented by Dr. Francyne Veiga Reis Cyrino illustrates how simple cases may suddenly take a complicated twist. The case is that of an 18-year-old man who presented with lens dislocation following blunt mechanical trauma to the side of the head.




02 Oct 2020 | Issue #1

known as the “death road� due to its steep tracks where mountain bikers descend from an altitude of 4,000 to 100 meters in 15 minutes. Dr. Murillo discussed the case of a biker who presented with a 24-hour history of ocular contusion trauma and flagstone corneal laceration following an accident on the death road.

With a name like “death road,� this accident seems inevitable . . .

“The examination revealed round-shaped lesions and corneal thinning. Twelve hours later, there was some evidence of hypopyon. An anterior OCT was performed, and this showed a corneal perforation,� shared Dr. Murillo.

“We examined the patient, then performed an intracapsular facetectomy anterior vitrectomy on a net-bed, also known as the hashtag technique and IOL implantation. The patient recovered well and was sent home,� said Dr. Cyrino.

“We suspected an ocular candida infection, and the patient was managed with intravitreal voriconazole. We then performed a vitrectomy and placed an amniotic membrane graft on the corneal perforation,� he added.

Thirty days later, things became more complicated when the patient got into a fight again and suffered a retinal detachment. According to Dr. Cyrino, “At that point, we were faced with the question: How are we going to perform the retinal detachment surgery, given that we have the IOL beneath the net bed? Available options we considered were IOL explantation, then gas tamponade, and finally, silicone oil, which might touch the cornea and necessitate a corneal transplant afterward.

This case became complicated 20 days later when, according to Dr. Murillo, the amniotic fluid membrane graft started thinning, with an increase in intraocular pressure. To resolve this, the next option was to cover the perforation with a corneal graft with an Ahmed valve. This helped reduce the IOP and the patient started to recover.

“Finally, the decision was made to retain the IOL under the hashtag and completed the silicone oil exchange. At the 4-months postoperative follow-up, the story had a happy ending: The cornea and retina had fully recovered, and the patient had achieved visual acuity of 20/60,� shared Dr. Cyrino. Commenting on the case, Dr. Lam said: “At the beginning, I didn’t think the hashtag was sufficient to hold an IOL, but now you have shown that this is safe, particularly in aphakic patients, the hashtag is a fantastic way to keep the silicone oil from getting into the anterior chamber.�

Ocular trauma on death road Next, Dr. Marcello Murillo Sasamoto presented the case of a patient who suffered an accident on the high altitude road in La Paz, Bolivia — popularly








magazine posterior segment • innovation • enlightenment

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The story took a different twist 15 days later when, according to Dr. Murilo, “despite several warnings to the contrary, the patient decided to start exercising. The patient was seen at the clinic, and we confirmed a diagnosis of fungal endophthalmitis and retinal detachment. We then performed a corneal transplant and inserted a temporary keratoprosthesis and tamponade. The patient is still on follow-up, and I will share more details at the next Retinawesome event.�

Editor’s Note RETINAWESOME V was held on 12 September 2020. Reporting for this story also took place during the said event.

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