THE WORLD’S FIRST FUNKY OPHTHALMOLOGY MAGAZINE
THE HAUTE COUTURE ISSUE PIE/CAKE Crossover edition September/October 2019 www.piemagazine.org
posterior segment • innovation • enlightenment
Posterior Segment Trends for
Fall 2019 Page 10
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magazine posterior segment • innovation • enlightenment
Inside this issue...
Posterior Segment Matt Young
CEO & Publisher
Robert Anderson Media Director
Production & Circulation Manager
Gloria D. Gamat Chief Editor
Brooke Herron Associate Editor
Ruchi Mahajan Ranga Project Manager
Director of Finance
Publications & Digital Manager
Can Biomarkers in the Aqueous Humor now be used in the Diagnosis, Prognosis or Management of Retinoblastoma? Game Changer: OD-OS Scores with Navilas® Microsecond Laser Platform
COVER STORY In Fashion:
Posterior Segment Trends for Fall 2019
Winson Chua Patalina Chua Writers
April Ingram Gerardo Sison Hazlin Hassan Joanna Lee Olawale Salami Tan Sher Lynn www.piemagazine.org Published by
Surgical Treatment of Advanced Retinopathy of Prematurity: When Less is More
Out of the Blue: The Zebrafish Animal Model for Ocular Research
When Fashion Meets Vision
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Asia-Pacific Academy of Ophthalmology
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PIE MAGAZINE LETTER TO READERS
Dear Reader, Is it getting ‘haute’ in here? Haute couture, that is.
n French, haute couture means ‘high fashion’ or ‘high dressmaking’; it refers to bespoke clothing, often made from high-quality fabric and sewn with precision, executed by prestigious fashion houses. The level of skill involved means that each garment is priceless. To be a recognized as a true haute couture designer, fashion houses must adhere to a stringent set of rules set by Chambre de commerce et d’industrie de Paris, like having a workshop based in Paris, employing a certain number of people, producing custom-clothing with one or more fittings, and publicly presenting a collection twice per year. Fresh from the runways of Paris, these public collections help set the trends in fashion each season. To determine if leather is ‘in’, or plaid is ‘out’, all eyes look to Paris and its trend-setting industry experts. And as PIE 11 brings us to Paris – the city of haute couture – we felt it was only appropriate to ‘up’ our fashion game in a nod to the stylish locale. Each quarter, the Vietnam-based PIE Magazine team motorbikes south to Hoi An to design and create conference attire – with each costume tailored to match that particular issue’s theme. From watermelon suits to Mozart costumes, we’ve worn it all . . . and we’re particularly proud to be known for our style (as it were). For the fashionably inclined, Hoi An, Vietnam, is a veritable shopping paradise. Numerous tailors line the streets of the ancient city – and here, anyone can become a fashion designer . . . even the team at PIE Magazine. While we’re admittedly not an acclaimed fashion house, our access to tailors has allowed us to create our own version of high fashion: Congress Couture, with individually tailored suits, colorful shirts and accessories, and stand-out shoes – the complete look for the savvy surgeon for the Fall 2019 Congress Season. The inspiration for PIE 11’s Congress Couture was inspired by apparel fresh from the famous catwalks of Paris. Much like Paris sets the trends in fashion, congresses like EURETINA help establish posterior segment trends through the sharing of knowledge and research. These ‘haute’ posterior segment trends in medical, surgical and innovations are the fabric, needle and thread of treating posterior segment conditions – all with the end goal of improving patient outcomes. In this haute couture-themed issue, the cover story looks at the trends shaping treatment for back-of-the-eye diseases, including new therapies, smaller instruments, the popularity of vitrectomy, and advances in imaging and visualization. In particular, new molecules for treating geographic atrophy due to dry AMD have been top-of-mind for many surgeons, and with recent promising research, it’s possible we might have a therapy for this currently untreatable disease. So, what’s next off the retina runway? Read on, for the hottest ophthalmic fashions of Fall 2019 . . . Fashionably yours, Brooke Herron Associate Editor PIE & CAKE Magazines P.S. This issue also features PIE Magazine’s ‘Congress Couture’ – our first-ever fashion photoshoot, complete exclusive behind-the-scenes photos . . . check out those Media MICE models!
PIE MAGAZINE ADVISORY BOARD MEMBERS Dr. Gemmy Cheung, MBBS(Lond), FRCOphth(UK) Dr. Cheung currently serves as deputy head and senior consultant of the medial retina service for Singapore National Eye Centre (SNEC), as well as senior clinician investigator for the Singapore Eye Research Institute (SERI). Her research interests include the study of risk factors and clinical features of macular diseases that may be unique in Asian populations. Dr. Cheung has published more than 150 articles, mostly regarding age-related macular degeneration, including polypoidal choroidal vasculopathy, and conducted several clinical trials in anti-vascular endothelial growth factor therapies. Dr. Cheung has also been actively involved in training and education, and has served as an instructor on Asia-Pacific Academy of Ophthalmology (APAO) and American Academy of Ophthalmology (AAO) courses and many other educational programmes. In addition, she is also a volunteer faculty member for the ORBIS Flying Eye Hospital Programme. Dr. Cheung has received a number of prestigious awards, including the Macula Society Young Investigator Award (2017), APAO achievement award (2017), APAO Nakajima Award (2014), APAO Outstanding Service in Prevention of Blindness Award (2013), the Bayer Global Ophthalmology Research Award (2012), the Roper-Hall Medal (2005) and the Elizabeth Hunt Medal (Royal College of Ophthalmologists, UK). [Email: email@example.com]
Prof. Mark Gillies, M.D., Ph.D. Dr. Gillies presently holds a number of positions including: director of research and director of the Macula Research Group for the Save Sight Institute; foundation fellow for the Sydney Medical School; professor in the Department of Clinical Ophthalmology at the University of Sydney; head of the Medical Retina Unit at the Sydney Eye Hospital; deputy chair for the Ophthalmic Research Institute of Australia; and director of Eye Associates in Sydney. Dr. Gillies has served as a principal investigator or associate investigator in more than 70 clinical trials, and his research regarding macular degeneration and drug safety and efficacy has been published in 188 journals. He has also received a number of grants to study treatments for age-related macular degeneration, retinal disease and Muller cell dysfunction â€“ among other treatments and studies. Dr. Gillies has also appeared in national media on numerous occasions, including the evening news of all major networks, on ABC radio as a local expert, as well as in print media. His dedication and research has resulted in multiple awards. Most recently, he received Gerard Crock trophies for the best papers at the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Annual Scientific Meeting (2013 and 2015), an achievement award from the Asia-Pacific Academy of Ophthalmology (APAO) in 2014, and an achievement award from the American Academy of Ophthalmology (AAO) in 2015. [Email: firstname.lastname@example.org]
Dr. Vishali Gupta, M.D. Dr. Gupta currently serves as a professor of ophthalmology at Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh in India. Throughout her career, she has completed original work in the fields of intraocular tuberculosis, optical coherence tomography, diabetic retinopathy, and fungal endophthalmitis. In addition, she is actively studying vitreoretina and uveitis diseases. She has been published in 65 per-reviewed journals, and has authored 17 book chapters and four complete books. Dr. Gupta also holds a US patent for the development of multiplex PCR for uveitis. In addition, she is a sought after speaker, and has made more than 350 presentations in various national and international meetings. Dr. Gupta has received several awards for her work, including the first JN Pahwa award from the Vitreo Retinal Society of India, the first NA Rao Award from the Uveitis Society of India, and the first NA Rao award from All India Ophthalmological Society (AIOS). [Email: email@example.com]
POSTERIOR SEGMENT AQUEOUS HUMOR
Can Biomarkers in the Aqueous Humor now be used in the Diagnosis, Prognosis or Management of Retinoblastoma? by April Ingram
etinoblastoma (RB) is the most common type of ocular cancer in children, and a devastating diagnosis to have to deliver to any family. When a child’s eyes are developing, the retinoblasts (or immature (progenitor) cells) are rapidly dividing to create what will eventually become their retina. Every retinoblast has two copies of the retinoblastoma 1 (RB1) gene. If there is a mutation present in both copies of RB1, the retinoblast cells can grow and divide out of control, forming the tumor we recognize as RB. Despite overall survival rates for RB being approximately 90% in developed countries, preserving the child’s globe and vision still present critical challenges. Typically, the way to manage solid tumors in the body begins with a direct biopsy, but historically, this has not been the practice with RB. Why not? Direct biopsy of the tumor or obtaining any ocular fluid for analysis was contraindicated for fear of causing tumor seeding (where malignant cells are deposited along the tract of the biopsy needle) and dissemination to other tissues. However, while it remains contraindicated to biopsy the RB tumor directly, advancements in therapeutic technique have permitted aqueous humor to be safely extracted from RB eyes undergoing therapy. These tiny samples may hold the key to unlock a unique opportunity for enhanced diagnosis, prognosis and management of RB. Dr. Jesse Berry and her colleagues in the United States agree and conducted a comprehensive review of aqueous humor marker research in RB, that was published in April 2019 in Translational Vison Science
Jump for joy: New developments could have a real clinical impact on children with retinoblastoma.
& Technology.1 Dr. Berry explains how RB management has changed: “Prior to 2012, it was completely contraindicated to place a needle into an eye with retinoblastoma unless it was enucleated. Francis Munier, MD, changed that paradigm in applying a new safety enhanced mechanism for delivering chemotherapy to the back of the eye.” Munier and colleagues describe the conditions of the RB eye that must be met in order to ensure safety of
the technique: (1) presence of clear medium, (2) absence of invasion of the anterior and posterior chamber on ultrasound biomicroscopy, (3) absence of tumor at planned entry site, (4) absence of vitreous seeds at entry site, and (5) the absence of retinal detachment at the entry site.2 Dr. Munier’s technique has led to the intravitreal injection of chemotherapy (melphalan and/ or topotecan) for seeding in RB being widely accepted and the risk of extraocular spread is considered extremely low, with no reported cases since the implementation of the enhanced safety procedure. The aqueous humor paracentesis is part of the standard protocol for these intravitreal chemotherapy injections. A small volume, 0.1mL, of aqueous fluid is aspirated to induce transient hypotony prior to the intravitreal injection of chemotherapy, not for diagnostic purposes, but as a safety measure, to prevent reflux to the injection site. Dr. Berry describes how aqueous samples had previously been handled as part of that procedure: “Once aqueous is removed from the eye in order to lower the pressure, it was initially tested for cells, which was routinely negative, and then after generally discarded as it had no other value to the procedure.” Dr. Berry and colleagues came up with the idea to test the fluid samples that would have been discarded for tumor DNA . . . which they found! Dr. Berry shares how this discovery has changed the RB landscape: “Not only did this open up a whole new body of research in using the aqueous as a liquid biopsy for retinoblastoma but revived old research as well.
Diagram used by Dr. Berry to show tumor DNA in the Aqueous Humor. Dr. Berry after extraction of aqueous from a child with retinoblastoma.
Previously, scientists had evaluated the aqueous for various clinical markers but because it could only be done AFTER enucleation, so the results had very little clinical value to the patient at that point. Now that it has been shown that aqueous is safe to extract in RB eyes, we can now revisit the clinical impact of this old research – thus, the point of the aqueous biomarkers paper.” They searched, reviewed and summarized all studies that have explored markers in aqueous humor, hypothesizing that these investigations may hold valuable insight into how these biomarkers may correlate with features of the intraocular tumor and provide diagnostic and prognostic value. The key feature is that this analysis is now able to be performed in current patients, not just in enucleated eyes. This means that the work previously done, identifying biomarkers in those enucleated eyes, may now have application to current clinical patients and impact management and diagnosis. Can a 0.1 mL sample be enough volume for analysis? Yes – in 2017 Dr. Berry and colleagues demonstrated that sufficient concentrations of RB tumor DNA was present and available for sequencing and analysis. This early work suggested that aqueous samples
held the potential to be a surrogate to direct tumor biopsy when actual RB tumor tissue was not available, and may even be predictive of aggressive tumor activity, without eyes having to have been enucleated.3 Presently, outside of active research protocols, there are no commercially available clinical tests that are indicated
for any type of diagnostic or prognostic evaluation of eyes with RB. Dr. Berry’s important work continues, “We hope that as we continue to develop the aqueous as a liquid biopsy, these markers will have diagnostic and prognostic significance that make a real clinical impact on these children with retinoblastoma.”
References: Ghiam BK, Xu L, Berry JL3. Aqueous Humor Markers in Retinoblastoma, a Review. Transl Vis Sci Technol. 2019;8(2):13. 2 Munier FL, Soliman S, Moulin AP, et al. Profiling safety of intravitreal injections for retinoblastoma using an anti-reflux procedure and sterilisation of the needle track. Br J Ophthalmol. 2012;96:1084-1087. 3 Berry JL, Xu L, Murphree AL, Krishnan S, et al. Potential of aqueous humor as a surrogate tumor biopsy for retinoblastoma. JAMA Ophthalmol. 2017;135:1221-1230. 1
About the Contributing Doctor Dr. Jesse Berry is the associate director of ocular oncology at the USC Roski Eye Institute and Children’s Hospital Los Angeles. In addition, Dr. Berry served as the associate residency program director for the Los Angeles County and University of Southern California Ophthalmology residency program until 2018. She received her undergraduate and medical degree from Harvard University in Massachusetts. Following her ophthalmology residency at the University of Southern California, she was the assistant chief of service at the Los Angeles County Medical Center. She then completed a fellowship in ocular oncology at Children’s Hospital Los Angeles under the mentorship of Drs. Jonathan Kim and Linn Murphree. Dr. Berry is the founder of WOO, Women in Ocular Oncology. Her clinical expertise includes anterior segment, intraocular and external tumors. Her research endeavors are supported by the National Cancer Institute and focus on clinical outcomes of retinoblastoma and choroidal melanoma and use of the aqueous humor to develop of a surrogate tumor biopsy for retinoblastoma. In addition to her work and research, Dr. Berry writes a blog about life in and out of the white coat on instagram as @_moda_md and online at www.modamd.com. She recently had a beautiful baby with her husband Paul Comas: Daphne Linn Comas named in honor of her mentor and wonderful ocular oncologist Linn Murphree, who established the RB program at Children’s Hospital Los Angeles, where she now works. [Email: firstname.lastname@example.org]
POSTERIOR SEGMENT LASER THERAPY
Game Changer OD-OS Scores with Navilas® Microsecond Laser Platform Results from subthreshold approaches in various posterior segment applications by Hazlin Hassan
t’s been nearly 60 years since the first ophthalmic laser was designed, and the technology has come a long way. Today, there are various types of lasers (i.e. argon, diode, multicolor, microsecond pulse and photodynamic), as well as different delivery systems (i.e. contact lens slitlamp, indirect ophthalmoscope-based photocoagulation and camera-based navigated retinal photocoagulation with eye-tracking), to treat posterior segment conditions.1 Of course, as any technology progresses, it’s improved upon – and for ophthalmic lasers, those improvements result in better patient outcomes. One of those developments is the Navilas® 577s (OD-OS, Teltow, Germany), an all-digital, eye-tracking retinal laser that integrates digital imaging and laser delivery, with live color and infrared imaging for focal and ultra-widefield pan retinal photocoagulation (PRP) as well as peripheral tear and iridotomy treatments.
Key advantages of navigation win big The Navilas® laser platform has several advantages over conventional or pattern laser systems. One of the
most noted benefits is treatment planning where targeted areas are digitally pre-planned and completed with the help of computer guidance. Meanwhile, the eye-tracking feature minimizes inadvertent laser applications – stopping immediately with eye movement – which significantly improves accuracy.2 Navilas® can integrate images taken with fundus autofluorescence, OCT, OCT-A , fluorescein angiography and indocyanine green angiography images – which helps achieve an effective laser treatment through precise targeting of treatment areas. Patient comfort is also a key advantage with Navilas® as the treatment can be performed in infrared mode and without a contact lens, so pain is significantly lower.3,4 For physicians, ease of treatment is another benefit: with a live fundus view, the system helps avoid a loss of orientation from inverted or reversed images. Plus, Navilas® delivers a photographic report of treatment plans and sessions, which provides enhanced control over the treatment especially in subthreshold approaches where the endpoint is invisible. Reports are also useful for follow-up or further treatment.5
Tracking the results from subthreshold studies To investigate these benefits, as well as safety and efficacy for treating retinal conditions using tissue-friendly microsecond pulsing approaches, several experts shared their experience with Navilas® during a satellite meeting at the recently held EURETINA congress in Paris, France.
Case #1: Repeatability and confidence in DME Dr. Carlos Orduna, (Oftalmologia Orduna, Spain) shared his experience using the Navilas® yellow laser in patients suffering from diabetic macular edema (DME). Twenty-two eyes of 14 patients were included in the study with a follow-up of up to 12 months. Dr. Orduna reported that laser treatment was effective in more than 55% of the cases based on a subjective evaluation and no rescue anti-VEGF was given; meanwhile 59% of the patients improved more than 5 letters in visual acuity (VA), which was statistically significant. Thirty-six percent showed an early anatomic response with an improvement in retinal thickness. The laser treatment was repeated in 64% of patients due to worsening or stability; the mean number of re-treatments was 3; the mean time
between treatments was 4.3 months. “This platform enables repeatability ... you can change one parameter and you can repeat the same treatment,” he explained. “The Navilas® could be a valid treatment alternative for low-grade DME, or when using anti-VEGF is controversial,” he said.
Case #2: Safe, painless and effective for CSCR Next, Dr. Nina-Antonia Striebe (University Hospital Goettingen, Germany) presented findings from a 100-case review of navigated microsecond pulsing treatment for central serous chorioretinopathy (CSC) in 102 eyes from various study sites. She indicated that the Navilas® 577s was used in this study because of the eye-tracking function, which facilitates exact planning to treat foveal hotspots, while digital guidance and documentation allows for easy comparison between sites. According to Dr. Striebe, 65% of eyes received one laser treatment, which was sufficient for the resolution of the subretinal fluid, while 23% received two treatments and 4% received three. Only ten percent of patients required additional treatment, like anti-VEGF. Following treatment, there was a reduction in macular thickness, an improvement in best corrected visual acuity (BCVA), and there were no side effects or scars. She concluded: “We have a safe navigated laser treatment . . . and without pain, as we don’t need to use a contact glass as with many other laser systems.”
Case #3: Significant VA improvements in BRVO
Following treatment, there was a statistically significant improvement of VA at month 3, as well as an improvement of retinal photoreceptor structures at months 1 and 3, with a mild effect on the reduction of central retinal thickness. There was also a strong correlation between the restoration of foveal integrity and postlaser VA improvements. The investigators observed no postoperative complications, no worsening of macular edema, no deterioration of VA, no worsening of vascular perfusion or presence of retinal hemorrhages, and no pain reported by patients during the procedure. Based on these results, Dr. Di Carlo concluded: “The Navilas® microsecond pulsing laser treatment represents an effective, safe and valuable tool to treat patients with macular edema due to BRVO in particular conditions, such as glaucomatous eyes and in patients with a high cardiovascular risk and who cannot undergo anti-VEGF therapy.”
Case #4: Avoiding complications in PRP Conventional pattern laser treatment isn’t without complications – in focal as well as peripheral applications. This can include loss of VA, increased intraocular pressure, risk of inadvertent laser to the macula, or patient discomfort leading to abortion of procedure and thus resulting in limited outcome. Therefore, Dr. Jay Chhablani (University of Pittsburgh Medical Center, USA) investigated whether microsecond PRP could be an alternative to conventional CW (continuous wave) PRP.
With the primary outcome of disease progression between the groups, Dr. Chhablani found that the results were comparable between both laser treatments. This led the investigators to propose that microsecond PRP could be a viable alternative to help avoid complications associated with conventional CW treatment. He continued: “Navilas® with its pre-planning, documentation and eye-tracking provides a valuable tool to standardize treatment with an invisible endpoint.” “It provides a comfortable position in terms of ergonomics – and it provides a true confluency while everything is being documented: You can go back and look at a previous plan and see the areas where treatment is required... that is where Navilas® makes a difference,” concluded Dr. Chhablani. Editor’s Note: The EURETINA 2019 congress was held in Paris, France, on September 5 to 8, 2019. Reporting for this story also took place at EURETINA 2019.
References: Kozak I, Luttrull JK. Modern retinal laser therapy. Saudi J Ophthalmol. 2015; 29(2): 137–146. Kozak I, Oster SF, Cortes MA, et al. Clinical Evaluation and Treatment Accuracy in Diabetic Macular Edema Using Navigated Laser Photocoagulator NAVILAS. Ophthalmology. 2011; 118(6): 1119–1124. 3 Inan UU, Polat O, Inan S, et al. Comparison of pain scores between patients undergoing panretinal photocoagulation using navigated or pattern scan laser systems. Arq Bras Oftalmol. 2016;79(1):15-18. 4 Chhablani J, Mathai A, Rani P, et al. Comparison of conventional pattern and novel navigated panretinal photocoagulation in proliferative diabetic retinopathy. Invest Ophthalmol Vis Sci. 2014;55(6):3432-3438. 5 Chhablani J, Kozak I, Barteselli G, El-Emam S. A novel navigated laser system brings new efficacy to the treatment of retinovascular disorders. Oman J Ophthalmol. 2013; 6(1): 18–22. 1
To assess the efficacy and safety of navigated microsecond pulsing laser treatment in patients with macular edema after branch retinal vein occlusion (BRVO), Dr. Emiliano Di Carlo (Staedtisches Klinikum Karlsruhe, Germany) and colleagues evaluated morphological and functional early outcomes of 18 eyes of 17 patients.
Trends for Fall 2019 by Brooke Herron
tylish physicians aside, ophthalmology is typically not associated with haute couture – however, like fashion, it is an industry that plays close attention to trends, be it in innovation, medical or surgical technique. So, as we kickoff the ‘Fall 2019 Congress Season’ at EURETINA in Paris – the home of high fashion – PIE Magazine got the scoop on what’s ‘haute’ on the minds of posterior segment doctors. Below, trend-setting vitreoretinal specialists from the U.S. and India, discuss the fabrics, needles and threads shaping patient outcomes for back-of-the-eye conditions.
The Fabric When creating a new design, selecting the right fabric is crucial – you wouldn’t want a summer dress made from wool, or a winter jacket made from chiffon! Like fabrics are chosen to fit the season, drugs are designed to fit the condition or disease pathway. And although we’re not dressing eyeballs for the catwalk, determining the right ‘fabric’ is key for patient’s visual
In medical, newer molecules targeting pathways other than VEGF are trending. – Dr. Alay Banker
outcomes . . . and this season, new molecules are trending. Evidence of this trend was found at the Ophthalmic Innovation Summit (OIS) held recently in Chicago, where a collection of upcoming therapies – including potential new drugs for dry age-related macular degeneration (AMD) – modelled their benefits to a decidedly stylish crowd. [Ed. Note: See page 41 for more OIS highlights!] Dr. Brett Foxman, the chief of the Division of Ophthalmology at Shore Medical Center in New Jersey, USA, has also noted that new molecules are in vogue: “Intravitreal therapies with new mechanisms of action and classes of chemicals are currently trending – as well as those targeting
different diseases and those decreasing treatment regimens.” From India, Dr. Alay Banker, the director and chief vitreoretinal surgeon at Banker’s Retina Clinic, in Ahmedabad, agrees that newer molecules, which target pathways other that VEGF – as well sustained delivery devices, including nano and suprachoroidal delivery systems – are popular in medical. In particular, therapies to treat dry AMD with geographic atrophy (GA) – a condition with no current cure – are in style. “It looks like there are new meds on the horizon to treat dry AMD with geographic atrophy that may actually increase visual acuity – not just slow progression,” said Dr. Foxman.
enerally speaking, ophthalmology isn’t usually associated with fashion. However, at PIE Magazine, we’ve always interwoven the two. Over the years, we’ve worn watermelon suits, dressed as flight attendants, retina monsters, bakers and race car drivers – and these costumes tie directly to the theme of each posterior segment magazine. So, now that we’re at EURETINA in Paris, it’s natural that we embrace our inner fashionistas, and present you with ‘Haute Couture’. Below, some of our catwalk-ready models reveal their favorite fashions and trends.
Hannah Nguyen, Production & Circulation Manager (PIE and CAKE Magazines), COO & CFO (Media MICE).
As an avid jet-setter herself, Ms. Nguyen’s favorite congress fashion harks back to Hawaii (also her favorite conference destination), where she flew the friendly ophthalmic circuit in a flight attendant costume. When she’s not pointing out the nearest exit, you’ll find her behind the camera, computer or smart phone, keeping Team Media MICE flying along at mach speed.
COVER STORY One such therapy noted by Dr. Foxman – and fresh from the OIS and the American Society of Retina Specialists (ASRS) runway – is elamipretide, which targets mitochondrial dysfunction. Results from a recent study1 – which assessed the safety, tolerability and efficacy of elamipretide in dry AMD – were displayed fashionable in a poster at ASRS 2019. Specifically, the investigators studied the effects of the elamipretide on leakage-independent vision loss in fellow, non-study eyes with neovascular age-related macular degeneration (nAMD) in the ReCLAIM study. They found that that the mean change in standard BCVA in fellow eyes with nAMD was +6.3 ± 5.0 letters (p<0.001) – resulting in a ≥6-letter BCVA gain in 54% of fellow eyes, and a ≥10-letter BCVA gain in 31%. Meanwhile, the mean change in LLVA (low luminance visual acuity) in fellow eyes with nAMD was +6.4 ± 4.8 letters (p<0.001) – also resulting in a ≥6-letter LLVA gain in 54%, and ≥10-letter LLVA gain in 31%. They concluded that subcutaneous administration of elamipretide for dry
Another trend in surgery is not new . . . away from scleral buckles and toward vitrectomy. I agree with the trend, but it’s led to less buckle experience with newer surgeons.
– Dr. Brett Foxman AMD was associated with improved vision in fellow, non-study eyes with nAMD. Another promising drug is APL-2, a complement factor 3 inhibitor, which has shown to reduce GA growth in a phase 2 trial (Filly).2 Dr. Foxman says: “[APL-2] is a new type of molecule for use in the eye to inhibit a pathway (that has not yet been treated by intravitreal injection) for a condition that, so far, we don’t have a treatment for.” The Filly trial enrolled 246 patients with GA at more than 40 clinical sites in the U.S., Australia and New Zealand. Patients received monthly or every other month (EOM) intravitreal injections of APL-2 for the first 12
Matt Young, CEO & Publisher. Mr. Young
doesn’t need a reason to dress up – and in fact, it’s his unique sense of style that started it all. That said, his favorite congress attire goes back to the basics – when PIE was just starting, and the trend of orange, banana and watermelon suits were taking Southeast Asia by storm. When he’s not working the conference circuit, Matt spends his spare time dreaming up new costumes and internally debating a career in fashion design.
months and then received no treatment up to month 18. At 12 months, patients with monthly injections had a 29% reduced GA growth rate, while those on EOM treatment were reduced by 20%, compared to sham. From 12-18 months, patients received follow-up, but no treatment – and during this period, GA lesions in both treated groups grew at a rate similar to the sham group: Patients previously receiving monthly treatment showed only a 12% reduction, while those in the EOM group decreased to 9%.3 Additional phase 3 trials are scheduled, with results in the next few years. Dr. Foxman also mentioned two up-and-coming drugs for targeting
nAMD: brolucizumab and faricimab, noting the HAWK and HARRIER, and STAIRWAY trials, respectively. HAWK and HARRIER were similarly designed phase 3 trials that compared brolucizumab with aflibercept to treat active choroidal neovascularization due to nAMD in 1,817 patients. It was found that “brolucizumab was noninferior to aflibercept in visual function at week 48 . . . and while overall safety was similar between the two drugs, anatomic outcomes favored brolucizumab over aflibercept.4 Next on the runway is STAIRWAY5: A 52-week study that assessed two extended dosing regimens of faricimab (6.0mg at every 16- or 12-weeks), compared to ranibizumab (0.5mg every 4 weeks). In the two faricimab groups, the mean improvement from baseline was 11.4 letters in the 16-week group and 10.1 in the 12-week group. The mean improvement for patients in the ranibizumab group was 9.6 letters. The authors found the three treatment regimens were similar in terms of patients gaining, or a avoiding a loss of, more than 15 letters. The safety profile of faricimab was also consistent with other intravitreal anti-VEGF therapies. Of course, there are many fabrics to choose from in fashion. Likewise, there are numerous molecules in the drug development pipeline other than those highlighted here – all with their own distinct pattern of targeting, and thereby treating, sight-threatening conditions like wet and dry AMD . . . making this a trend worth following.
The Needle Performing eye surgery is like a weaving a needle through delicate fabric – for success in both, care and precision must be taken to avoid complications (although a detached retina is much worse than a missed stitch!). And indeed, a tailor without a needle is much like a surgeon without instruments. For the past few years, surgical instruments have been riding the “smaller is better” wave, with 27-gauge (27G) pars plana vitrectomy
Rob Anderson, Director of Media. If you ask Mr.
Anderson, his favorite congress theme – by far – was our racing theme, complete with fire-proof race suits and helmets. His enthusiasm for this particular fashion stems from his love of impersonating race car drivers, watching Talladega Nights (‘shake ‘n bake!’) and pushing his scooter to its limits along the roads in Vietnam.
(PPV) topping the ophthalmic in-style charts. The potential to improve patient outcomes is the driving force behind this 27G trend, and the goal of making successful PPV procedures less invasive and safer, with a quicker recovery. A 2019 study in the Journal of Ophthalmology notes that in the beginning, 27G PPV was considered for less complex cases – however, surgeons have advocated for its use in more complicated procedures recently. That said, 27G vitrectomy also has some potential drawbacks when compared to its earlier versions, 23G
and 25G, including: a reduction in the flow rate (which could influence the efficiency of the procedure), increased instrument flexibility (especially during anterior maneuvers), and the potential to underfill tamponade.6 According to Dr. Foxman, 27G PPV has been a hot trend for a while, and though instrumentation has improved, it hasn’t been revolutionary. To zoom in on the details of this trendy instrument, numerous studies have been conducted on its safety and efficacy. A 2018 study7 by Li et al., evaluated the safety and efficacy profile
Elamipretide is a new drug with the potential to improve vision.
– Dr. Brett Foxman
Travis Plage, Director of Finance. Mr. Plage is a
newer addition to Team Media MICE, and as such, this is his first time rocking the congress runway – and lucky for him, this is our most dapper theme yet. When he’s not managing the company finances, he spends a lot of time lamenting his decision not to wear a belt with his suit and debating (mostly with himself ) if brown shoes match grey pants.
A 2019 article9 found that “there are no reliable data to prove whether SB surgery or vitrectomy is more advantageous, and a standard treatment is still lacking, generally leaving surgical treatment options to be selected according to the experience of the attending doctors”. Dr. Foxman says that he agrees with the trend, but that it’s led to less buckle experience with newer surgeons. Dr. Banker has also noted the popularity of vitrectomy machines, along with newer vitreous substitutes and technology cutters. Innovations in surgical technology, like in PPV, have certainly provided more options for both patients and doctors – and time will tell which trends stick. Plus, instrumentation aside, a new trend in surgical viewing systems may also thread together additional benefits . . .
The Thread of 27G pars plana vitrectomy (PPV) for treating vitreoretinal diseases, including: rhegmatogenous retinal detachment (RRD), full-thickness macular hole, diabetic retinopathy, vitreous hemorrhage, Eales disease, pathological myopia-related vitreous floater and macular epiretinal membrane. The authors found that 27G PPV was safe and effective for the various vitreoretinal diseases but cautioned that “surgeons may encounter a learning curve and should gradually expand surgical indications from easy to pathologically complicated cases”.
Looking at longer-term rates (minimum of 1-year follow-up), another 2018 study8 found that 27G PPV was well tolerated, “with low rates of postoperative complications across varied surgical indications”. Using smaller instrumentation for vitrectomy has helped usher in another trend: The shif t from scleral buckling (SB) and toward PPV in cases of RRD. In the community, opinions vary widely on the advantages and disadvantages of each.
In imagining, automated wide-angle imaging, combining color, FFA, ICG and OCT in one machine, is trending. – Dr. Alay Banker
Thread is a vital component to creating clothing, just as imaging and visualization systems are crucial for diagnosis, as well as pre-, intra- and postoperative disease and patient management – and the latest iterations have been getting some attention. In fact, the ASRS 2019 Global Trends in Retina Survey10 included topics like the use of 3-D visualization, intraoperative OCT (iOCT), OCT angiography (OCTA) and swept source OCT (SS-OCT) in its questionnaire. [Ed note: See infographic on page 22 to see how these four fashionable systems rank around the world.] Dr. Foxman has also noticed this focus on innovation: “There’s a trend toward digital surgical viewing systems, like Alcon’s NGENUITY, as well as intraoperative OCT,” he said. “However, these will be slow to reach the typical community retinal surgeon’s operating room due to cost and uncertain increased value in a very cost-conscious era.” According to Dr. Banker, threedimensional heads-up microscopes (3DM) are trending in the operating
room. That’s because PPV with 3DM is more comfortable for surgeons – plus, they don’t pose a greater risk of complications. In addition, 3DM surgery helps to significantly improve both the teaching and the learning of intraoperative surgical procedures.11 In imaging, Dr. Foxman says that there’s been a strong trend toward ultra-widefield photography. But with a caveat: “The cost is high . . . to the degree that a small practice will probably not recoup the increased cost over a standard fundus camera,” he said, adding that however, it does appear to have value and many retina docs have decided it’s worth the cost. The use of OCTA – and its value – is another trending topic. “OCT angiography is also a trend, but its value is not really clear . . . it’s one of those items that you like if you have it, but you may not go out and buy this feature outright,” explained Dr. Foxman. He said that in his practice it just happened: Several of the older OCTs needed replacement, so when forced to upgrade, they chose to add OCTA to two of the three new machines. As far as imaging, Dr. Banker adds that OCT machines combining indocyanine green with angiography (ICG), automated wide-angle imaging and fundus fluorescein angiography (FFA), are also gaining attention. Meanwhile, emerging technology in the autointegration of artificial intelligence (AI) systems and less expensive phone-based imaging devise (using applications with AI) are garnering enthusiasm and are definitely ‘looks’ worth watching in the upcoming season’s shows.
The Final Garment At the EURETINA 2019 Congress in Paris, we expect all of these trends to walk down the metaphorical catwalk: From the fabrics of disease-targeting agents, to the needle of surgical instruments and new techniques, sown together by the threads that create visualization pre-, intra- and postoperatively.
And through research, study and practice, surgeons will continue to design ‘haute couture’ procedures, using the latest (and trending) innovations to continue improving patient outcomes for posterior segment conditions.
References: Mettu PS, Allingham MJ, Cousins SW. “Effects of the Mitochondria-Targeted Drug Elamipretide on Leakage-Independent Vision Loss in Fellow Eyes with Neovascular AMD in the ReCLAIM Study. Poster at the 2019 American Society of Retina Specialists; 2019 July 26-30; Chicago, United States. 2 Kassa E, Ciulla TA, Hussain RM, Dugel PU. Complement inhibition as a therapeutic strategy in retinal disorders. Expert Opin Biol Ther. 2019;19(4):335-342. 3 Nebbioso M, Lambiase A, Cerini A, et al. Therapeutic Approaches with Intravitreal Injections in Geographic Atrophy Secondary to Age-Related Macular Degeneration: Current Drugs and Potential Molecules. Int J Mol Sci. 2019; 20(7):1693. 4 Dugel PU, Koh A, Ogura Y, et al. HAWK and HARRIER: Phase 3, Multicenter, Randomized, Double-Masked Trials of Brolucizumab for Neovascular Age-Related Macular Degeneration. Ophthalmology. 2019;pii: S0161-6420(18)33018-5. 5 Khanani AM, et al. Simultaneous Inhibition of VEGF and Ang-2 with Faricimab in Neovascular AMD: STAIRWAY Phase 2 Results. Presented at the 2018 American Academy of Ophthalmology (AAO) Annual Meeting; 2018 Oct 26; Chicago, United States. 6 Veritti D, Sarao V, Lanzetta P. A Propensity-Score Matching Comparison between 27-Gauge and 25-Gauge Vitrectomy Systems for the Repair of Primary Rhegmatogenous Retinal Detachment. J Ophthalmol. 2019;2019: 3120960. 7 Li J, Liu SM, Dong WT, et al. Outcomes of transconjunctival sutureless 27-gauge vitrectomy for vitreoretinal diseases. Int J Ophthalmol. 2018;11(3):408-415. 8 Khan MA, Kuley A, Riemann CD, et a;. Long-Term Visual Outcomes and Safety Profile of 27-Gauge Pars Plana Vitrectomy for Posterior Segment Disease. Ophthalmology. 2018;125(3):423-431. 9 Li Liao, Xiao-Hua Zhu. Advances in the treatment of rhegmatogenous retinal detachment. Int J Ophthalmol. 2019; 12(4): 660–667. 10 Singh RP, Stone TW, Hahn P, eds. 2019 Global Trends in Retina Survey: Chicago, IL. American Society of Retina Specialists; 2019. 11 Romano MR, Cennamo G, Comune C, et al. Evaluation of 3D heads-up vitrectomy: outcomes of psychometric skills testing and surgeon satisfaction. Eye (Lond). 2018;32(6):1093-1098. 1
About the Contributing Doctors Dr. Brett Foxman has been the chief of the Division of Ophthalmology at Shore Medical Center in New Jersey, USA, since 2008 and a retina specialist at Retinal and Ophthalmic Consultants, P.C. since 1992. He completed his ophthalmology residency and retina fellowship at the University of California, Los Angeles (UCLA), Jules Eye Institute. Dr. Foxman is active in various societies and has served on the board of the American Society of Retina Specialists (ASRS) and the American Retina Foundation. He’s given numerous lectures and published papers, and is actively involved in research, with interests in therapies for posterior segment conditions like dry AMD. In 2019, he received a United States patent for a scleral depressor which makes small changes, but advances to retinal surgery. [Email: email@example.com] Dr. Alay S. Banker is the director of Banker’s Retina Clinic, Ahmedabad, Gujarat and chief of Gujarat Telemedicine ROP Project (Honorary Services). After completing MS from Gujarat University, he completed a vitreoretinal fellowship at Medical Research Foundation, Sankara Nethralaya, Chennai. Following that, he was a clinical instructor and fellow of vitreoretina and uveitis at University of California, San Diego, USA. He has won awards from societies including the American Academy of Ophthalmology (AAO), the American Society of Retina Specialists (ASRS), and the AsiaPacific Academy of Ophthalmology (APAO). Dr. Banker is a member of the International Uveitis Society Group (IUSG) and the Chief Liaison leader for Asia-Pacific Region to the International Affairs Committee of ASRS. He has published 48 papers in international and national peer-reviewed journals and has written eight book chapters. He has given more than 500 guest speaker presentations and over 100 instruction courses at national and international conferences. [Email: firstname.lastname@example.org]
HAUTE TRENDS In Imaging & Visualization An excerpt from the ASRS Global Trends Survey 2019
Do you have access to OCT-A? Yes, and find it useful in clinical practice
No, I do not have access
Do you have access to SS-OCT? Yes, and find it useful in clinical practice
No, but plan to have access soon
No, and do not plan to have access soon
What is your experience with, and assessment of, 3-D heads-up visualization systems? Have not used 3-D in the OR, but plan to Have used 3-D in the OR and do not think it is helpful Have used 3-D in the OR and it has been helpful
What is your opinion of intraoperative OCT? Have not used intraoperative OCT
United States Europe
69.3% Singh RP, Stone TW, Hahn P, eds. 2019 Global Trends in Retina Survey: Chicago, IL. American Society of Retina Specialists; 2019.
INNOVATION ROP SURGERY
Surgical Treatment of
Advanced Retinopathy of Prematurity When Less is More
Take a bite out of ROP with MIVS.
by Olawale Salami
Microincision vitrectomy surgery (MIVS) along with wide angle viewing systems allow surgeons to effectively manage ROP surgeries while at the same time reducing complication rates in infantsâ€™ eyes.
etinopathy of prematurity (ROP) is one of the most common causes of visual loss in infancy and can lead to lifelong vision impairment and blindness. It primarily affects newborn babies who weigh 1,250 grams or less, or are born before 31 weeks of gestation.
Landmark trials such as CRYOROP and ETROP (Early Treatment Retinopathy of Prematurity) have provided deeper understanding of the natural history of the disease and established management guidelines. Currently, in developing countries like India, there are several important barriers to early treatment initiation in extremely premature infants with ROP. These include lack of awareness, lack of availability of specialized care, and low access to timely screening service in the immediate post-natal period. An important complication of ROP is tractional retinal detachment (TRD) and once that occurs, surgical intervention in the form of vitrectomy is necessary. Vitrectomy relieves the traction, eliminates the scaffold for
further fibro vascular growth and can remove the excessive levels of vascular endothelial growth factors (VEGF). Micro-incision vitrectomy surgery (MIVS) has the advantage of minimal ocular surface disruption. It increases the surgeonâ€™s ability to access between tight retinal folds and reduces surgical trauma, resulting in faster and better postoperative recovery. MIVS is used almost universally for most vitreoretinal procedures. In a paper titled, Surgical outcomes of microincision vitrectomy surgery in eyes with retinal detachment secondary to retinopathy of prematurity in Indian population*, Dr. Parveen Sen and colleagues from the Department of Vitreoretinal Services, Shri Bhagwan Mahavir Vitreoretinal Services, Sankara
INNOVATION ROP SURGERY Nethralaya, Chennai, reported anatomical outcomes of MIVS for Stage 4 and 5 ROP in Indian Infants. Their findings were published in the June 2019 edition of the Indian Journal of Ophthalmology. Between January 2012 and April 2015, Dr. Sen and colleagues reviewed medical records of 202 eyes of 129 premature children undergoing MIVS for Stage 4 or 5 ROP. The primary outcome measure was the proportion of eyes with anatomical success (defined as attached retina at the posterior pole at last follow-up). Furthermore, complications associated with MIVS were noted and an analysis of risk factors associated with poor anatomical outcomes was performed. The infants were monitored for an average period of 32 weeks. At the end of follow-up, Dr. Sen and colleagues observed that 102 eyes (50.5%) had achieved anatomical success, including 74% eyes in Stage 4a and 4b, and 33% in Stage 5. Complications were documented in some infants, including intraoperative break formation in 19% of infants, postoperative vitreous hemorrhage in 28%, raised intraocular pressure in 12.7%, and cataract progression in 2.4% of infants. Based on the study results, the authors concluded that “MIVS along with wide-angle viewing systems allow surgeons to effectively manage ROP surgeries, while at the same time reducing the complication rate in these eyes, which have complex pathoanatomy and otherwise grim prognosis”. Dr. Sen provided a narrative of some of the key challenges faced today by surgeons in the management of advanced ROP. She explained that “ROP is largely a preventable cause of childhood blindness. If premature babies are screened within the first four weeks of birth and treated appropriately, surgical intervention can be prevented in most cases”. “Once the child needs surgical intervention, a highly competent and experienced team comprising a
ROP is largely a preventable cause of childhood blindness. If premature babies are screened within the first four weeks of birth and treated appropriately, surgical intervention can be prevented in most cases. – Dr. Parveen Sen pediatric retina specialist, pediatric anesthesiologist and a pediatrician is necessary to handle the baby during surgery and provide the essential postoperative care. Such a team very often may be available only in tertiary care centers,” she added. According to Dr. Sen, surgery itself for ROP is a typical example where less is more. “Astute preoperative planning and precise execution are the keys to success,” she emphasized. For stage 4 ROP surgery, a vitrectomy through the pars plicata (since pars plana is not well developed in very small babies) with MIVS is the most widely accepted surgical approach at present. In addition, the limbal approach, which avoids the pars plicata is the popular approach in cases of stage 5 ROP. “It allows adequate surgical maneuvering as well as decreases the rate of complications associated with this surgery. Regular follow-up of these babies is a must for adequate visual rehabilitation,” explained Dr. Sen.
On surgical outcomes, Dr. Sen clarified that “surgery itself is extremely demanding and unforgiving, needing high degree of precision and accuracy. In spite of best efforts, the success rate of surgery in the most advanced stage (stage 5) of ROP may be about 30 percent due to the complex nature of these retinal detachments”. Furthermore, Dr. Sen gave important advice on the best ways to prevent ROP: “Prevention by timely screening and treatment is the best approach. To meet the challenge of preventing visual loss from ROP and screening all premature babies (about 3.5 million premature babies are born annually in India), ophthalmologists, neonatologists, gynecologists and government institutions must take collaborative efforts.” * Sen P, Bhende P, Sharma T, et al. Surgical outcomes of microincision vitrectomy surgery in eyes with retinal detachment secondary to retinopathy of prematurity in Indian population. Indian J Ophthalmol. 2019;67(6):889-895.
About the Contributing Doctor Dr. Parveen Sen was born in 1971 in India. She is a trained vitreoretinal surgeon and did her fellowship at Sankara Nethralaya in 2000. Since then she has worked as a vitreoretinal surgeon at the Department of Vitreoretina at Sankara Nethralaya, a tertiary care ophthalmic center in Chennai, India. She has been practicing for the last 19 years and is an experienced surgeon with large number of complicated vitreoretinal surgeries to her name. She heads the Retinal Electrodiagnostics Services at Sankara Nethralaya. Her special areas of interest are pediatric retinal Imaging, pediatric retinal surgery, especially surgery for retinopathy of prematurity, as well as other pediatric retinal detachments (PFV, FEVR, Coats and Trauma), velectrophysiology, genetic disorders of the retina, AMD, polypoidal choroidal vasculopathy and retinal imaging. Dr. Sen has more than 72 publications in the peerreviewed indexed journals and has made many presentations at national and international conferences. She has been actively involved in the teaching and training of vitreoretinal fellows and guided them through their research work. She has co-authored three books and has written several book chapters. Dr. Sen is also a reviewer for several national and international journals. [Email: email@example.com]
ENLIGHTENMENT EYE RESEARCH
Out of the Blue The Zebrafish Animal Model for Ocular Research by Gerardo Sison
isual impairment and blindness affects millions of people worldwide each year. And, as the general age of the population increases, rates of vision loss are not getting any better. Despite our knowledge of these visual conditions, there is still a lack of understanding on how these visual problems arise. The question then becomes: How can we better treat them? With such an important question to be answered, there is a growing need for animal models in research. One particular application for zebrafish has evolved in the study of retinal pigment epithelium (RPE) as it relates to prevalent diseases, such as agerelated macular degeneration (AMD). By understanding critical points of pathogenesis, researchers may be one step closer to unlocking new treatment modalities.
Zebrafish as a Model Organism According to Dr. Jeffrey Gross, PhD, director of research at the Department of Ophthalmology, University of Pittsburgh School of Medicine, zebrafish are an ideal model for studying visual developments. “Zebrafish provide a robust system for modeling human diseases,” said Dr. Gross. “Since cell types are similar and the architecture is the same, they are valuable for understanding mechanisms of disease.” Zebrafish are a type of freshwater fish belonging to the minnow family. Native to South Asia, zebrafish have become widely used specimens in research and drug development.
Fish animal models are ‘in’ this season. (Zebrafish not pictured)
Compared to mice, the eyes of zebrafish develop at a faster rate with features that more closely resemble those of human eyes. “Compared to mice which have a rod-rich retina, zebrafish have a conerich retina similar to the human retina,” share Dr. Gross. “The zebrafish retinal structure is arranged in the same way as that in humans, so you’re modeling the same process.” As a useful animal model, zebrafish are easy to care for without incurring high laboratory costs. Because they can produce up to 200 eggs for every mating, zebrafish can provide a large sample size needed for identifying structures of interest and other potential mutant variations. “We can look at 10 to 20 embryos at a time versus a much smaller sample in mice,” said Dr. Gross. “Along with other factors, this makes zebrafish useful for developmental biology, imaging, and genomics.” Zebrafish utilize vision as a defense mechanism against predators. Their resourceful vision system and 360-view allows them to remain alert to predator shapes while also detecting potential food sources. Additionally, because of their regenerative abilities within their ocular systems, zebrafish
have opened many doors for new treatment methods.
Regenerating Zebrafish RPE after Genetic Ablation As a specialized, pigmented monolayer of cells, the RPE separates the retina from the choroid and acts as a critical component of vision. The dysfunction and degeneration of the RPE is believed to play an important role in the pathology of diseases, notably AMD. In AMD, RPE dysfunction and degeneration can result in the loss of cone photoreceptors and eventually, the loss of vision. In one of his recent studies1 published this year, Dr. Gross and his team examined the mechanisms of RPE regeneration in zebrafish. They studied this mechanism by developing a transgenic model that implemented ablation of mature RPE. Using this model, they found for the first time, that stimulating endogenous RPE regeneration may provide a possibility for treating RPE degenerative diseases in humans. “We sought to understand how the RPE regenerates in order to see how regeneration may be stimulated
ENLIGHTENMENT EYE RESEARCH
Compared to mice which have a rod-rich retina, zebrafish have a cone-rich retina similar to the human retina. The zebrafish retinal structure is arranged in the same way as that in humans, so you’re modeling the same process.
– Dr. Jeffrey Gross in a human eye,” explained Dr. Gross. “We want to see whether the strategies it employs could be used to keep RPE functioning in diseased eyes to retain vision longer. We could then identify genes, pathways and potential compounds which could help preserve and restore vision.” Interestingly, compared to other models for RPE regeneration, their zebrafish model more closely resembles the degeneration and loss of visual function seen in late-stage AMD. Other models use non cell-specific injury methods such as debridement or laser photocoagulation. However, the zebrafish model produces RPE and photoreceptor degeneration which may provide a more applicable clinical picture for evaluating RPE regeneration in mammals.
Making Waves for Research in Ocular Disease Several studies have used zebrafish models to explore the therapeutic potential of new drugs for pathological conditions from cardiovascular disease to infectious diseases. In recent years, studies in ocular diseases have shown an even stronger potential with zebrafish. Similar disease phenotypes have been replicated in zebrafish, mirroring several human vision conditions such as glaucoma, cataracts and diabetic retinopathy. One study in the Human Genetics
and Human Mutation journal found a crystalline gene mutation using zebrafish animal models.2 The protein crystalline, is known to influence refractive power by regulating lens and cornea transparency. Mutations of the CRYBA2 and CRYGC gene were ultimately found to be linked to the formation of cataracts in humans. Other studies, such as the one found in Human Molecular Genetics, examined the genetics of glaucoma. Experts later found a link between a FOXC1 gene mutation and increased intraocular pressure in zebrafish. Anterior segment defects and severe myopia were also exhibited due to mutations in the FOXx1 gene, predominantly expressed in the periocular mesenchymal cells.3 Lead investigator, Bo Chen, PhD, , an associate professor of Ophthalmology and Director of the Ocular Stem Cell Program at the Icahn School of Medicine at Mount Sinai, found that zebrafish could repair retinal damage within a few days. Dr. Chen and his colleagues explored evidence for vision restoration as a result of Müller glial cell derived regeneration.4 Due in part to Müller glial cells, the freshwater fish can replenish damaged retinal nerve cells
and essentially repair vision. While Müller glial cells do not possess regenerative properties in the human retina, these cells may provide deeper insight for future research in retinal degeneration. Plus, with the additional understanding of RPE regeneration provided by Dr. Gross’s study, the framework behind photoreceptor degeneration may be further laid out.
The Future of Zebrafish Retinal disease is a growing problem that can only be tackled with greater understanding of the underlying mechanisms of disease. With an increased need for adequate studies comes the need for effective animal models. Because of their similar anatomical eye structure to the human eye, zebrafish can provide a new lens into the pathology behind ocular conditions. Zebrafish are easy to maintain, relatively quick to generate and display rapid retinal development. With several studies already replicating human vision disorders in zebrafish, the zebrafish model can only gain more traction moving forward.
References: Hanovice NJ, Leach LL, Slater K, et al. Regeneration of the zebrafish retinal pigment epithelium after widespread genetic ablation. PLoS Genet. 2019; 15(1): e1007939. 2 Reis LM, Tyler RC, Muheisen S, et al. Whole exome sequencing in dominant cataract identifies a new causative factor, CRYBA2, and a variety of novel alleles in known genes. Hum Genet. 2013;132(7):761–770. 3 McMahon C, Semina EV, Link BA. Using zebrafish to study the complex genetics of glaucoma. Comp Biochem Physiol C Toxicol Pharmacol. 2004;138(3):343-350. 4 Yao K, Qiu S, Wang YV, et al. Restoration of vision after de novo genesis of rod photoreceptors in mammalian retinas. Nature. 2018;560(7719):484-488. 1
About the Contributing Doctor Dr. Jeffrey Gross is the E. Ronald Salvitti chair in ophthalmology research in the Department of Ophthalmology, University of Pittsburgh School of Medicine, and the vice chair and director of research. He is also the director of the Louis J. Fox Center for Vision Restoration and of Ocular Development, Disease and Regeneration Laboratory at the University of Pittsburgh School of Medicine. Dr. Gross earned his PhD in biology at Duke University and has served as a professor at the Department of Molecular Biosciences, Institute for Cellular and Molecular Biology & Institute for Neuroscience, University of Texas. Dr. Gross contributes as a member of the Society for Developmental Biology, the Genetics Society of America, the American Association for Vision and Ophthalmology, and the International Society for Eye Research. He is also associate editor of BMC Developmental Biology and editorial board member of Developmental Dynamics. [Email: firstname.lastname@example.org]
Behind-the-Scenes of Media MICEâ€™s Haute Couture Photoshoot
When Fashion Meets Vision by Tan Sher Lynn
Dr. Arun C. Gulani, dubbed “the Da Vinci of Eye Surgery”, talks about how he threads ophthalmology and fashion together. . .
r. Gulani is an ophthalmologist specializing in advanced KeratoLenticulo-Refractive (i.e. the full spectrum cornea and lens-based surgeries), which includes all versions of LASIK, premium cataract surgeries and corneal surgeries, to provide patients with spectacle independence. Originally from India, he completed his postgraduate in ophthalmology and earned the coveted gold medal. While still a junior resident ophthalmologist, he wrote the first textbook on Color
Doppler for eye tumors, which attracted the attention of renowned eye surgeons and universities from all over the world. And at the young age of 25, he was invited to receive the Becton Dickinson Career achievement award in Philadelphia, where most of the competing candidates were in retirement age. “Having received numerous invitations from the U.S., I proceeded with refractive surgery while it was still in its infancy, and was even called ‘Buccaneer Surgery’,” he said. According to Dr. Gulani, he was naturally attracted to ophthalmology when he was exposed to it during surgical rotations in medical school. “Not only was it a combination of surgical artistry at its highest form, it also provided for my desire for
innovation, along with near-immediate gratification from patient’s visual outcomes,” he said. In 2003, he founded the Gulani Vision Institute at the Southpoint area of Jacksonville, Florida, based on his philosophy of a “High-Tech” and “High-Touch” approach to patient care. The institute soon grew into a globally acclaimed ophthalmology center, receiving patients and students from all over world.
An Eye for Fashion Impeccably dressed, even in the slightest details, Dr. Gulani’s love for high fashion is evident in his practice. To him, it is important to be welldressed as it reflects his pride in his work and his desire to impart elegance wherever he can. “Fashion is my parallel passion, just like eyes are. In my practice, my penchant for colors, symmetry, beauty and elegance are always the driving factor to bring out the best in each and every person as I custom-treat each and every eye to fulfill my patients’ best vision potential,” he shared.
In 2017, Dr. Gulani launched his fashion line – Gulani Fashion. “My fashion line is as unique as my practice is. In fact, my tagline for Gulani Fashion is “For Those Who Have Arrived” – for people who aspire to look their very best. Once again, just like my eye surgeries, I don’t offer choices. I will decide what is best for my clients based on each person’s unique characteristics – their background, desires, body type and what I feel should be the colors and cuts that would suit them best, for both men and women. Then, I celebrate their looks just like how I celebrate their vision,” he said. In fact, his artistic sense can be felt and seen in his everyday life. For instance, he uses colors in full range from suits to scrubs to the lighting in his surgery suite and colors of medical instruments. “One surreal observation is that somehow (without knowing it), I always seem to be wearing the color that coincides with the color of the theme of the conference at which I am speaking,” he noted.
A Fulfilling Life Dr. Gulani believes that each one of us is born with our internal GPS, and it is this GPS which he has allowed to unfold throughout his life, creating beautiful, unique outcomes that the world is able to regale in today. Even though he has received numerous national and international awards and recognition, to him, his best achievement is his family and the fact that he was able to help so many patients around the world. “My proudest achievements are my family and the blessing that I have gathered from so many patients from all over the world for nearly three decades, and from having mentored so many to achieve the best of their potential. My passion for eyes and fashion has never allowed me to feel that I am working at all, and when my patients celebrate their outcomes with me there is nothing higher or greater that I can look forward to,” he said.
Fashion is my parallel passion, just like eyes are. In my practice, my penchant for colors, symmetry, beauty and elegance are always the driving factor to bring out the best in each and every person as I custom-treat each and every eye to fulfill my patients’ best vision potential.
– Dr. Arun C. Gulani When he is not busy with fixing eyes or designing clothes, Dr. Gulani loves to spend time with his family, and indulge in his other passions, namely modeling, sports, travel, Porsche-racing, as well as eating ice-cream and candies. As a sought-after mentor and speaker, he constantly encourages eye surgeons to stop talking about technology and in-the-box thinking, but to rise beyond and accept the artistry of eye surgery in delivering vision beyond 20/20 in every patient. “It is a constant pleasure to share my work with colleagues worldwide,
and despite how exciting our progress in the eye care industry may be, I am dedicated to change the mindset of eye care providers to believe that no patient should be wearing glasses or contact lenses, as they are a mark of disability whose time of extinction has already passed,” he said. “They say imitation is the best form of flattery and I must say I am gratified to see lately, doctors dressing up, allowing pictures with patients and even using my ‘thumbs up’ sign tradition, which I introduced nearly three decades ago,” he quipped.
About the Contributing Doctor Dr. Arun C. Gulani is a world-renowned LASIK cataract, and corneal surgeon and performs the entire spectrum of advanced vision surgeries to reduce dependence on glasses and contacts, customising vision correction surgery to meet each patient’s unique goals. He has extensive experience in a wide variety of eye surgery techniques and technology. He was formerly the Chief of Cornea and Assistant Professor of Ophthalmology in the University of Florida’s School of Medicine before founding the Gulani Vision Institute in 2003, where he receives a global clientele and acts as a consultant to eye surgeons and the eye care industry as well. With an eye of an artist, his passion is to make people see and with his no-hype, one-on-one personalized care, he has turned Jacksonville, Florida into a vision destination for the world.[Email: email@example.com]
Strutting down the Runway of
EURETINA 2019 in Paris
THE WORLDâ€™S SECOND FUNKY OPHTHALMOLOGY MAGAZINE
The Haute Couture Issue CAKE/PIE Crossover edition September/October 2019 www.cakemagazine.org
Top 10 Trends Cover Story
Anterior Segment for
Fall 2019 Page 10
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MIGS Rising: Uncovering the benefits of a new cutting-edge instrument
Production & Circulation Manager
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SIGHT COUTURE: Top 10 Trends in Anterior Segment for Fall 2019
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Enlightenment What Europe Can Learn from India
• Can Biomarkers in the Aqueous Humor now be used in the Diagnosis, Prognosis or Management of Retinoblastoma? • Game Changer: OD-OS Scores with Navilas® Microsecond Laser Platform • In Fashion: Posterior Segment Trends for Fall 2019
posterior segment • innovation • enlightenment
Asia-Pacific Academy of Ophthalmology
in this special cross-over issue on the reverse side of this publication!
• Surgical Treatment of Advanced Retinopathy of Prematurity: When Less is More • Out of the Blue: The Zebrafish Animal Model for Ocular Research • When Fashion Meets Vision
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CAKE MAGAZINE Letter to Readers
A Sartorial Vision “I blame Kylie Minogue.” I do a double-take. “What?”, I asked, blinking.
here I was, amongst a group of refractive surgeons. One is holding court, attributing some of the blame for the downturn in laser-assisted in situ keratomileusis (LASIK) numbers over the last decade to the five-foot Australian pop minstrel. There was a bit of a low commotion in the group after he said that, but he went on: “She wore glasses in her pop videos, looked good, and this was making Millennials think that glasses look cool”. I do have a pair of glasses, but not because I’m not cool (I should be so lucky!), but because I’m very mildly hyperopic. I also can say, hand on my heart, that I never, ever wear them. Less “Can’t get you out of my head”, more “Can’t find them to put on my head”. Let’s step back in time and look at what the fashion has been in terms of cataract and refractive surgery. If we ignore the cosmetic aspect (which is subject to the whims of popular culture), then the drive is to have tailored solutions to people’s vision disorders. The elective refractive surgery market exists for a reason — there’s still a big demand for it. To be fair, there’s never been a better time to undergo refractive surgery. Thanks to improvements in ocular biometry and laser technology, procedures like LASIK, photorefractive keratectomy (PRK), and small incision lenticule extraction (SMILE) have never been safer or more effective. And while the laser is the tailor’s scissors (which have got faster, sharper and safer over time), it’s the measuring tape of the diagnostic instruments that have enabled the final fit to be as good as it is, with far fewer wardrobe malfunctions than ever before. But if laser surgery is the leather jacket, then allogenic inlays are sports-casual blazers. (Which goes best with jeans?) Again, these refractive corneal implants are being tailored to each patient’s eye, be it by blade or by laser. Whether this approach comes to dominate the market is beyond my predictive abilities. But what I do notice is that multiple groups are working on this approach, and dare I say it: It’s currently in fashion. But let’s look at intraocular lenses (IOLs). Ridley’s first patient had a refractive surprise of 20 D, but the work of Fyodorov and others in the 1960s and 1970s brought about the combination of ocular biometers and IOL power calculations that enabled surgeons to pick an IOL that aimed for emmetropia. Today’s off-the-peg cataract surgery involved the implantation of a monofocal lens — usually to give the patient clear distance vision.
And if you’re of an age where cataract surgery is required, you’re not considering glasses because Kylie rocks a pair like no other: You need them to read, to shower, to drive . . . as does everybody else with them. Plus, everyone else your age is wearing them, too! But now we have multifocal and extended depth of focus (EDOF) IOLs. They’re not the best choice for everyone, and they tend to give two or three distances with sharp vision, with gaps in between, but for some, this (relatively) off-the-peg can be a great premium option (more Versace than Levi’s), dramatically reducing or even eliminating the need to wear glasses. But even here, better tailoring can occur. It’s clear that a comprehensive understanding of a patient’s visual needs is key to selecting the right multifocal IOL for them, but this takes a lot of “chair time” and requires the patient to remember all of their use cases. Forgetting that they like to embroider in low light next to the coal fire might be trivial to them, but it can make a big difference to which distances are required by the patient most, and therefore the IOL selected for implantation. So, I like the concept of the spectacle-mounted infrared distance sensing devices that record what the patient does and spits out suggestion list of IOLs that would serve the patient best. I like the idea of glasses that can be programmed to simulate any given multifocal IOLs that patients can wear to test-drive their post-surgical vision — this is like trying on an outfit in a changing room before deciding to buy it. But really, what’s to stop people from having tailored IOLs? As far as I’m aware, 3D printing isn’t at a point where an IOL can be custom-printed in the office for each patient. But I don’t think it’s too far beyond the capabilities of IOL manufacturers today to custom program a lathe to produce a unique IOL for each patient based on their biometry and use-case scenarios. The ultimate arbiter of visual quality is the retina, and there’s very little that can be done to enhance the quality of vision there (in a healthy retina, at least). But in terms of the light-refracting structures in front of it, it’s incredible how much power surgeons have to fine-tune and sculpt vision. This power is only going to get better and better. So, I may not be cool (with or without spectacles) – but what’s happening in cataract and refractive surgery certainly is.
Dr. Mark Hillen Director of Communications ELZA Institute, Zurich, Switzerland Editor-At-Large CAKE Magazine
CAKE MAGAZINE Advisory Board Members Dr. Jodhbir Singh Mehta, B.Sc. (Hons.), M.B.B.S., PhD, FRCOphth, FRCS(Ed), FAMS Dr. Mehta is head of Cornea External Disease and senior consultant in the Refractive Service at Singapore National Eye Centre (SNEC), deputy executive director at Singapore Eye Research Institute (SERI), as well as a professor at Duke-National University of Singapore. With a main interest in corneal transplantation, he completed a corneal external disease and refractive fellowship at Moorfields Eye Hospital in London and at SNEC. He has co-authored nearly 20 textbooks and 333 citations, and holds 16 patents, six of which have been licensed. A seasoned committee organizer, Dr. Mehta will be part of the World Corneal Organizing Committee in 2020, as well as the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS), Singapore, in the same year. He has won several awards from the American Academy of Ophthalmology (AAO) and the Association for Research in Vision and Ophthalmology (ARVO), among others, the latest of which was from the American Society of Cataract and Refractive Surgeon (ASCRS) in 2018. Dr. Mehta is also a favorite keynote speaker and presenter in several international conferences. [Email: email@example.com]
Dr. William B. Trattler, M.D. Dr. Trattler is a refractive, corneal and cataract eye surgeon at the Center For Excellence In Eye Care in Miami, Florida, USA. He performs a wide variety of cataract and refractive surgeries, including PRK; all laser LASIK; no injection, suture-less cataract surgery; as well as laser cataract surgery. He has been an investigator for next generation technologies (like the Tetraflex accommodating intraocular lens) and procedures like corneal collagen crosslinking (CXL). His involvement in the FDA-approval study for CXL led to its approval in 2016. In addition to his private practice, Dr. Trattler is on the Volunteer Faculty at the Florida International University Wertheim College of Medicine, as well as the University of Miami’s Bascom Palmer Eye Institute. He is board certified by the American Board of Ophthalmology and has been an author of several articles and abstracts. In 2016, Dr. Trattler received the Catalyst Award in Advancing Diversity in Leadership from the Ophthalmic World Leaders (OWL), an association of interdisciplinary ophthalmic professionals dedicated to driving innovation and patient care by advancing diversity in leadership. [Email: firstname.lastname@example.org]
Dr. Chelvin Cheryl Agnes Sng, B.A., MBBChir, M.A., MRCSEd, MMed Dr. Sng is a consultant at the National University Hospital (NUH) and assistant professor at National University of Singapore (NUS). She is also an honorary consultant at Moorfields Eye Hospital, London, and adjunct clinic investigator at SERI. A pioneer of minimally invasive glaucoma surgery (MIGS), Dr. Sng was the first surgeon in Asia to perform XEN, InnFocus Microshunt and iStent Inject implantation. A coauthor of “The Ophthalmology Examinations Review”, Dr. Sng has also written several book chapters and publications in various international journals. She has received international grants and awards for her research accomplishments from the American Academy of Ophthalmology and the Australian and New Zealand Glaucoma Interest Group. Proficient in conventional glaucoma surgery and trained in complex cataract surgery, Dr. Sng co-invented a new glaucoma drainage device, which was patented in 2015. She has been invited as a reviewer for several international ophthalmic publications, and as a speaker in various international lectures and conventions. When not working, Dr. Sng can be found volunteering in medical missions in India and across Southeast Asia. [Email: email@example.com]
Dr. Harvey Siy Uy, M.D. Dr. Uy currently serves as associate clinical professor at the University of the Philippines-Philippine General Hospital, consultant for Retina and Uveitis Services at St. Luke’s Medical Center, as well as medical director at Peregrine Eye and Laser Institute in the Philippines. Previously, he was a clinical fellow in Medical and Surgical Retina at St. Luke’s Medical Center, Philippines, and in Ocular Immunology and Uveitis at the Massachusetts Eye and Ear Infirmary at Harvard Medical School. In 2015, he co-invented the Modular Intraocular Lens Designs, Tools and Methods, which was patented with the United States Patent Office. Dr. Uy is a recipient of numerous awards and honors, including the Immunology Award, presented by the Ocular Immunology Service from the Massachusetts Eye and Ear Infirmary, Harvard Medical School (1998), and the Senior Achievement Award from the Asia-Pacific Academy of Ophthalmology (2017). He has also published more than 32 international peer-reviewed journals and 30 book chapters, and is a prominent speaker, presenting in various national and international conferences. [Email: firstname.lastname@example.org]
Cataract NTERIOR SEGMENT MIGS It’s the dawn of a new day – or era – in MIGS procedures.
Uncovering the benefits of a new cutting-edge instrument by Brooke Herron
o treat glaucoma, surgical intervention is often required to lower intraocular pressure (IOP) when therapies, like topical eye drops, do not produce the desired results. However, the standard surgeries for treating glaucoma, such as trabeculectomy and tube shunt implantation, are major and invasive procedures. And while they are effective, they can also result in serious complications.
Therefore, when it comes to ophthalmic surgical procedures, the less invasive, the less chance of sightthreatening adverse events. In recent years, micro-invasive glaucoma surgeries – or MIGS – are gaining popularity in the treatment of patients suffering from open-angle glaucoma (OAG). These procedures generally provide improved safety and mild-to-moderate IOP reduction and help fill the gap between topical medications and aggressive surgery. Below, we take a deeper look at one MIGS procedure: goniotomy using the Kahook Dual Blade (KDB) from New World Medical (Rancho Cucamonga, California, USA).
Dual blades for twice the precision An ab-interno Schlemm’s canal surgery, the KDB is used during goniotomy to enhance fluid outflow using the eye’s inherent drainage system. The single-use, ophthalmic knife removes the trabecular meshwork (TM) in a more complete fashion, with minimal residual TM leaflets and less collateral damage. During the procedure, the KDB’s distal tip pierces the TM and enters Schlemm’s canal. As the instrument is advanced along Schlemm’s canal, the TM is elevated on the KDB ramp and guided toward two parallel blades. Unlike a standard goniotomy knife that simply incises the TM (leaving contiguous anterior and posterior flaps), the KDB excises a strip of TM – which leaves a direct opening for aqueous to pass from the anterior chamber into Schlemm’s canal. Thus, goniotomy with KDB removes diseased tissue at the site of aqueous outflow obstruction, restoring the natural aqueous outflow pathway without the formation of a filtering bleb.1
Dr. Syril Dorairaj, a professor of ophthalmology and consultant in glaucoma and cataract surgery at Mayo Clinic, Jacksonville, USA, said the major benefit of the KDB is its precision. “The Kahook Dual Blade, by design, has the distinct advantage of a cleaner and more precise ab-interno trabeculectomy. The basic design of the device allows precise excision of the diseased trabecular meshwork, while minimizing damage to the surrounding tissues, thereby reducing complications and ensuring a faster recovery,” he explained. “There are published comparative data which shows that KDB reduced IOP significantly with fewer adverse events.” Additionally, the unique design of the blade allows surgeons to perform goniotomy as a stand-alone procedure, during cataract surgery, or on pseudophakic patients. And as with any procedure, patient selection is crucial for positive outcomes. “Published data shows that KDB has a distinct advantage in both open angle and closed angle glaucoma of varying severity,” said Dr. Dorairaj.
Cataract and glaucoma: when comorbidities collide Frequently, cataract and glaucoma coexist – and as the population ages, these comorbidities are expected to rise. As a result, the combination of phacoemulsification and MIGS is becoming increasingly used in glaucoma management. In 2018, a paper published in Advances in Therapy1 by Dr. Dorairaj and colleagues, described the 12-month efficacy and safety of goniotomy performed using the KDB
in combination with cataract surgery in eyes with medically treated OAG. During the prospective, interventional case series, 52 eyes (with medically treated OAG and visually significant cataract) underwent phacoemulsification combined with goniotomy using the KDB to reduce both IOP and use of IOP-lowering medications. From baseline to month 12, investigators found that mean IOP was reduced by 26.2% (16.8 ± 0.6 mmHg to 12.4 ± 0.3 mmHg (P < 0.001)), with mean IOP across time points ranging from 12.4–13.3 mmHg during follow-up. The mean number of topical IOP-lowering medications was reduced by 50.0% from baseline to month 12 (from 1.6 ± 0.2 to 0.8 ± 0.1 (P < 0.05)). Meanwhile, at month 12, 57.7% of eyes had IOP reduction ≥ 20% from baseline, and 63.5% were on ≥ 1 fewer IOP-lowering medications. The authors reported that in a subgroup analysis, 84.6% of eyes with lower mean baseline IOP were using ≥ 1 fewer medications at month 12, and 100% of eyes with higher mean baseline IOP had IOP reductions ≥ 20%. They found that the most common postoperative adverse events were pain/irritation (n = 4), opacification of the posterior lens capsule (n = 2) and IOP spike > 10 mmHg (n = 2). These events were not sight threatening and typically resolved spontaneously. This led the investigators to conclude that phacoemulsification with goniotomy using the KDB significantly lowers both IOP and dependence on IOP-lowering medications in eyes with OAG – and these results compare favorably with other MIGS procedures.
The Kahook Dual Blade is used during goniotomy to enhance ﬂuid outflow.
Another study published in 2019 in Clinical Ophthalmology2, described the six-month rates of achieving target IOP (without requiring additional glaucoma surgery) after excisional goniotomy using the KDB combined with phacoemulsification (phaco-KDB) in patients with severe-stage glaucoma. This retrospective review included 42 eyes with severe glaucoma, including primary and secondary open-angle, as well as combined-mechanism glaucoma. The primary outcome was the proportion of patients achieving IOP ≤15 mmHg without additional glaucoma procedures, while secondary outcomes were mean change in IOP, reduction of glaucoma medications, additional glaucoma procedures needed and adverse events. The investigators reported that preoperative baseline mean IOP was 17.1±4.8 mmHg (mean ± SD) and number of medications was 2.4±1.3. At six months, they found that 64.3% (27/42) of eyes had achieved IOP ≤15 mmHg without additional glaucoma procedures, 45.2% (19/42) reached this target IOP on fewer medications, and 31.0% (13/42) on no medications. Overall, the mean IOP reduction was 2.1 ± 4.67 mmHg (P=0.022), and the mean medication reduction was 1.2 ± 1.4 (P≤0.001). Complications and the need for additional procedures were rare, with three eyes experiencing visually significant complications and requiring additional IOP-lowering procedures within six months of surgery. The authors concluded that patients with severe-stage open-angle glaucoma achieved significant IOP and medication reductions following phacoKDB – and notably, about two-thirds of eyes achieved an IOP of ≤15 mmHg at six months without additional glaucoma procedures. Overall, they found that “phaco-KDB may be an effective and safe alternative to more invasive filtering surgery in many patients with severe glaucoma”.
Cataract NTERIOR SEGMENT MIGS Goniotomy with KDB: A beginner’s guide For doctors in the early stages of performing KDB goniotomy with phaco, Dr. Dorairaj has a few tips. According to him, one of the major guidelines is to perform a gonioscopic evaluation on all patients to understand the anatomy of the angle structures in the preoperative evaluation. Next, he said, is to practice direct gonioscopy to visualize the structures preoperatively, and to be comfortable with hand movements and also the patient’s head and eye movements.
“Additionally, inform all patients on what to expect during surgery and postoperatively,” he continued. “Most cases of postoperative hyphemia will resolve in less than a week without any additional interventions.” MIGS innovations in treating glaucoma, like the KDB, have not only translated to faster recovery times, but they’ve also opened doors for comprehensive ophthalmologists to treat mild to severe glaucoma surgically.
“However, the outcomes of these surgeries are entirely dependent on the precision of the surgery. To ensure success, it is important to understand the anatomy of the angle and to perform a thorough postoperative exam by gonioscopy and imaging in cases of bad outcomes,” Dr. Dorairaj concluded, adding that the long-term safety and efficacy of these procedures remain to be validated.
About the Contributing Doctor References 1
Dr. Syril Dorairaj is a professor of ophthalmology and consultant in glaucoma and cataract surgery at Mayo Clinic, Jacksonville, USA. He is one of the pioneers in minimally invasive glaucoma surgeries and has done extensive research on understanding the biomechanical aspects of glaucoma especially angle closure. A graduate of Bangalore Medical College, India, Dr. Dorairaj did his residency at the New York Eye and Ear Infirmary of Mount Sinai, New York, and glaucoma fellowships at the New York Eye and Infirmary and University of California, San Diego. He has presented over 100 instructional courses and over 300 lectures worldwide, and has been an invited speaker and chaired sessions at national and international conferences. He has co-authored over 200 peer-reviewed publications and abstracts, over 50 book chapters and editorials, and a book on glaucoma management. He has mentored over 25 fellows and residents. Dr. Dorairaj is a recipient of achievement awards from the American Academy of Ophthalmology and Asia-Pacific Academy of Ophthalmology. [Email: email@example.com]
Dorairaj SK, Seibold LK, Radcliffe NM, et al. 12-Month Outcomes of Goniotomy Performed Using the Kahook Dual Blade Combined with Cataract Surgery in Eyes with Medically Treated Glaucoma. Adv Ther. 2018;35(9):1460-1469.
Hirabayashi MT, King JT, Lee D, An JA. Outcome of phacoemulsification combined with excisional goniotomy using the Kahook Dual Blade in severe glaucoma patients at 6 months. Clin Ophthalmol. 2019;13:715-721.
A ‘Wiser’ Way to Analyze Data with Schwind’s WiseNET
etter patient outcomes could be on the horizon, thanks to WiseNET, a new development from Schwind eye-tech-solutions (Kleinostheim, Germany). WiseNET is a web-based database that captures refractive data quickly and precisely to ensure and optimize treatment outcomes. This data is then presented graphically – diagrams show visual acuity, refraction (including astigmatism), and follow-up periods, so outcomes can be monitored and improved. This database is not only useful in individual analysis and in single
practices, but in large eye clinics as well. WiseNET also meets the requirements for peer-reviewed publications. It helps to meet regulatory requirements for the long-term documentation of treatment outcomes – and therefore, can be used in scientific studies and presentations at congresses. The user can access data gathered previously, analyze it systematically by topic, and present it visually. In addition, using the Schwind Cloud Community, treatment results can be shared and compared with other members using the company’s products. Patient data is anonymized,
and the user can select which data is shared and with whom – whether it’s a study group, private group or the wider Schwind group (available to all WiseNET users). And data can be accessed at any time, from any internet-capable device with a sufficiently large display. Schwind produces and markets a comprehensive product portfolio for the treatment of vision defects and corneal diseases, including excimer laser systems, diagnostic systems and treatment planning tools for a wide scope of applications. For more information, visit www.eye-tech-solutions.com.
Top 10 Trends in Anterior Segment by Brooke Herron
h, Paris. The city of love, fabulous food and wine, and haute couture. As the city gears up for the much-anticipated Paris Fashion Week in September, so do we at CAKE Magazine for our first-ever Top 10 list of anterior segment trends. While fashion might not be top-of-mind for many physicians – we haven’t necessarily seen any ophthalmologists strutting down a catwalk (yet!) – trends backed by research and data certainly are. That’s because these new(er) procedures, instruments and innovations have one end goal: improving patient outcomes. To learn what’s ‘hot’ (and also what’s ‘not’), we spoke with some of the most stylish ophthalmologists lighting up the anterior segment. Below, they reveal their opinions on what’s trending in refractive, glaucoma, and cataract surgery.
SMILE is Looking Dapper
According to Prof. Dr. Gerd Auffarth, chairman of the Department of Ophthalmology at the University of Heidelberg, Germany, a lot of changing trends can be seen in refractive surgery today. “Treating myopia, especially in younger patients, has become the standard in ophthalmology,” he said. For treating myopia, LASIK has ruled the refractive runway for quite a while. However, a new contender is causing quite a stir: SMILE or small incision lenticule extraction. SMILE is designed to treat refractive errors like myopia, hyperopia, presbyopia and astigmatism. And while LASIK uses an excimer laser to create a flap, SMILE uses the VisuMax femtosecond laser (Carl Zeiss Meditec, Jena, Germany) to create a corneal lenticule, which is then extracted through a small incision. Data shows SMILE has similar efficacy and safety to LASIK, with potential advantages in biomechanical stability and postoperative outcomes. So, this begs the question: Is SMILE the new ‘black’?
According to Dr. Gaurav Luthra, director of cataract & refractive surgery at Drishti Eye Institute, Dehradun, India, SMILE is currently the trend in refractive surgery. “With better understanding of the key strengths and the limitations of the procedure, and the confidence of numbers – with more than two million SMILE procedures performed worldwide – there is better acceptance of the procedure by refractive surgeons.” “There is now some competition between the SMILE procedure and classical Femto LASIK,” said Prof. Auffarth. “SMILE gets a lot of attention especially at international meetings – however, Femto LASIK is still performed in higher numbers than SMILE.” A 2016 study1 by Shen Z. et al., compared results from SMILE with Femto LASIK (FS-LASIK) for treating myopia in 1,076 eyes. At 6 months postop, there were no significant differences between the two groups with regard to the following: a loss of one or more lines in the best corrected spectacle visual acuity (BSCVA); uncorrected visual acuity (UCVA) of 20/20 or better; logMAR
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UCVA; postoperative refractive spherical equivalent or postoperative refraction within ±1.0 D of the target refraction. However, they did find that the FS-LASIK group suffered more severely from dry eye symptoms and lower corneal sensitivity at 6 months. The authors concluded that “both FS-LASIK and SMILE are safe, effective and predictable surgical options for treating myopia. However, dry eye symptoms and loss of corneal sensitivity may occur less frequently after SMILE than after FS-LASIK”. “With visual results of SMILE appearing at least on par, if not better than LASIK, the benefits of a flapless procedure including better corneal biomechanics (and lesser risk of ectasia) and minimizing flap complications will be too appealing to any surgeon, and ultimately the patient, to ignore,” said Dr. Luthra. “Moreover, with pure astigmatic corrections becoming commercially available and good outcomes reported in ongoing hypermetropia SMILE trials, the indications continue to expand.”
ith ESCRS in Paris, ‘Congress Couture’
is ‘haute’ this season. To look your most dapper during scientific sessions, CAKE Magazine has compiled four simple tips on the hottest trends hitting the ophthalmic conference catwalk.
All about Attitude This is less about being fashionable, and more about being ‘fierce.’ Whether speaking at a symposium or networking with peers, confidence is key – making this CAKE Magazine’s #1 ‘Congress Couture’ trend for 2019. Model: CAKE Magazine Production & Circulation Manager and Media MICE CFO & COO Hannah Nguyen
Hot On Its Heels: Topography-Guided Refractive Surgery
Dr. George Beiko, a cataract, anterior segment and refractive surgeon practicing in St. Catharines, Ontario, Canada, says: “My impression is that corneal lenticule directed and corneal surface procedures involving topography guided approaches seem to be the trends in refractive surgery.” Topography-guided laser refractive surgery corrects vision by altering the surface of the eye. The procedure has been found to be uniquely effective in eyes with corneal irregularities or in highly aberrated corneas, where wavefront aberrometry is often not possible2-3. Holland S. et al., published a review3 of topography-guided ablations in normal corneas and highly aberrated corneas and found that “topography-guided laser ablation is increasingly used with good efficacy and safety outcomes in highly aberrated corneas with irregular astigmatism.” These include eyes with refractive surgery complications including post-LASIK ectasia, decentered ablation, small optical zones, asymmetrical astigmatism, and postradial keratectomy astigmatism. “Topography-guided laser refractive surgery is proving to be effective and well-tolerated in the visual rehabilitation of highly aberrated eyes, with increasing predictability based on the recent research,” Holland concluded. “The expected future trend in refractive surgery procedures is likely to see a growth in SMILE procedures, phakic lenses with photorefractive keratectomy (PRK) and advanced surface ablation (ASA) holding fort, and LASIK numbers gradually declining, to remain limited to customized treatments not possible yet with SMILE,” added Dr. Luthra.
RLE is All the Rage
Another trend noted by Dr. Beiko and Prof. Auffarth is the refractive lens exchange (RLE), which rides the wave between refractive and cataract surgery. The procedure is identical to cataract surgery, except rather than a cloudy lens, a clear lens is replaced to correct presbyopia. “It seems that lens-based refractive surgery is also on the rise,” said Dr. Beiko. In fact, improved outcomes in cataract surgery have organically led to the use of lens surgery as a refractive modality. It offers distinct advantages over corneal refractive surgery in selected cases, while simultaneously eliminating the need for cataract surgery in the future. According to Alio et al., RLE is an elective intraocular surgery that needs to be minimally invasive and performed with precision and high accuracy. The authors said: “The indication of this surgery is the presence of high refractive error in the absence of cataract and requires an approach with the risk–benefit ratio in mind depending on the age, refractive condition and pre-operative condition,” adding that in general, RLE should be performed only in presbyopic eyes and the main challenge involved is to reach emmetropia.4 Prof. Auffarth has also taken notice of RLE, including presbyopic clear lens extraction, up to premium lens application in cataract patients. “The more sophisticated the implant, the more advanced and the more comprehensive the preoperative evaluation should be, as well as having high standards for the intraoperative procedures.” On the flip side, Dr. Beiko provided a word of caution regarding these procedures: “Surgical intervention for presbyopia with clear lens extraction needs to be critically reviewed. Long-term follow-up of uncomplicated lens extraction reveals optical quality to be inferior to the native lens, retinal detachment rates and in-the-bag lens dislocation both increase with time, opacification of intraocular lens optic may be an issue with some materials, and with only partial resolution of the presbyopia – all to be of grave concern.”
Tailored Suits If ‘the suit makes the man’, then it makes sense that it should actually fit the man. Cheekiness aside, the Media MICE fashion line was created in Hoi An, Vietnam . . . the tailored clothing promised land. This season, fine lines, colorful shirts and jacket linings are trending in ophthalmic Congress Couture. Model: Media MICE Director of Finance Travis Plage
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The Sophistication of Astigmatism Management
Cataract surgery is one of the most common procedures to treat preventable blindness around the world. So, what is trending in cataract today? According to Dr. Beiko, management of astigmatism is a very hot topic, specifically as it applies to the posterior corneal surface. More than 50% of patients undergoing cataract surgery have corneal astigmatism ≥0.75D, which may significantly limit visual outcomes if left uncorrected. Generally, with astigmatism, the main consideration is related to the anterior cornea. However, it’s been revealed that the posterior surface exhibits more toricity than the anterior surface – and ignoring posterior corneal astigmatism (PCA) could be a significant factor with regard to postoperative refractive astigmatism after toric intraocular lens (IOL) implantation.5 “Our understanding of the role of the posterior corneal surface is extensive, but our ability to measure it directly is limited,” explained Dr. Beiko. “Devices recently made available which measure the total keratometry and incorporate the Barrett formulas, which have been developed for this measurement, have been very effective in my hands.” The Barrett formula uses the Universal II formula to predict the required spherical equivalent IOL power; and the calculator derives the posterior corneal curvature based on a theoretical model proposed to explain the behavior of the posterior cornea.5 These lens power calculations, based on predicted, rather than measured posterior corneal curvature have yielded the best results thus far.6 “More surgeons now rely on these newer formulas, including Barrett and Hill-RBF methods, for more predictable outcomes,” said Dr. Luthra. A 2019 study6 by Skrzypecki et al. compared refractive predictions of the Barrett Toric Calculator, based on IOL Master 700 biometry (Carl Zeiss Meditec), with and without measurements of posterior corneal curvature. The authors found that astigmatism prediction errors, with and without measured posterior corneal curvature, were similar. “The updated Barrett Toric Calculator is the first formula to provide non-inferior and reliable predictions based on measurement of posterior corneal curvature,” the authors concluded. According to Dr. Luthra, the increased use of toric IOLs can be attributed to a better understanding of posterior corneal astigmatism, along with better calculators, that incorporate the same. “Most surgeons have lower thresholds for switching to a toric IOL than ever before,” he said, adding that image-guided cataract surgery, like with Zeiss Callisto and the Alcon Verion, has gained popularity with surgeons, especially for toric IOL planning and surgery.
OCT in the Spotlight
Dr. Beiko mentioned that another ‘hot’ topic is the integration of intraoperative optical coherence tomography (iOCT) into the microscope, which allows for enhanced visualization of the anterior segment. Intraoperative OCT aids in decision-making in various anterior segment surgeries and has the potential to decrease surgical time as well as postoperative complications.7 According to Titiyal et al., iOCT is also useful in assessing the posterior capsule during cataract surgery.7 The authors noted: “In cases with posterior polar cataract, it may help detect cases with a true posterior capsular defect, and this may allow the surgeon to exercise extra caution in such cases, thus reducing the incidence of complications.”
OCT, Upgraded in Style
In addition to iOCT, the use of OCT for pre- and postoperative patient management has been in style for a while. However, new upgrades are further enhancing its capabilities in anterior segment procedures. “For premium lens patients, OCT diagnostics for the macula is almost mandatory to rule out epiretinal membranes or other pathologies,” added Prof. Auffarth. “New machines, for example the Oculus Pentacam AXL or Pentacam AXL Wave (Wetzlar, Germany), and similar machines from different other companies, offer the possibility to assemble a lot of parameters on one machine – which is necessary for finding the right lens or excluding the patient due to some pathology.” “With the availability of reliable high-resolution epithelial thickness mapping on OCT, it has become a valuable tool for better evaluating, planning and following up patients with suspect corneas, as well as candidates for refractive surgery, including monitoring postoperative outcomes and surprises,” explained Dr. Luthra. “Epithelial thickness mapping is likely to become an indispensable aid to the cornea and refractive surgeon with time.” Dr. Luthra adds that now, surgeons also increasingly depend upon aberrometry devices like the iTrace to plan premium IOLs, and for dealing with dissatisfied cases. The iTrace (Tracey Technologies, Houston, Texas, USA) is a raytracing, wavefront and corneal topography combination device.
Any CAKE Magazine Congress Couture ‘haute’ list must include shoes – and this season, the ‘funkier’ the better. On the ophthalmic runway, shoes are certainly one area where you can show your own style, or quirkiness... just make sure they’re comfortable! Model: Media MICE CEO & Publisher Matt Young
The ‘Perfect’ Capsulotomy
One of the most important steps to ensure optimal visual outcomes in cataract surgery is the anterior capsulotomy. Recently, femtosecond lasers have allowed surgeons to create a perfectly sized and perfectly circular anterior capsulotomy. However, an increased rate of anterior capsule tears following femtosecond laser has been reported8, which remains an important concern.This has led to the development of alternative approaches. “In regard to femtosecond laser technology in the cataract segment, demand for a perfect circular capsulotomy has become much bigger, and alternative applications have been developed,” shared Prof. Auffarth. “Devices such as CAPSUlaser (Excel-Lens, Livermore, CA, USA) or Zepto (Mynosys Cellular Devices, Fremont, CA, USA) can create a capsulotomy like a femtosecond laser. However, in contrast to femtosecond laser, they cannot perform a fragmentation of the lens and also cannot create corneal incisions.” The CAPSULaser is a thermal laser, and unlike the femtosecond laser it acts in a continuous manner to create the capsulotomy – plus, it’s small and attaches to the underneath of an operating microscope, which doesn’t interfere with the operating flow. Meanwhile, Zepto is a singleuse device which consists of a suction ring containing a wire made of nitinol. The device is pushed into the eye through the phaco wound, then placed on the anterior capsule. Once it has been centered by the surgeon, suction is applied to attach the device to the capsule. A short electric charge is activated to cut the capsule.9
IOLs: In or Out?
Another trend under speculation are multifocal IOLs – with some opinions in favor, and other not. “Intraocular lenses which increase depth of focus have been disappointing in their outcomes, despite the initial promises,” said Dr. Beiko. So, will they stay or will they go? That is yet to be determined. A 2017 paper10 reported that “the patient’s satisfaction depends on careful and individualized selection based on the preexisting conditions, visual needs and realistic expectations, as well as on the knowledge of the different optical designs and visual performances of the multifocal IOLs, and the proper surgical technique and eventual complications management. The main reasons for patient dissatisfaction following a multifocal intraocular lens implantation are residual ametropia, posterior capsule opacification (PCO), dry eye, IOL decentration, inadequate pupil size, and wavefront abnormalities”. It’s also suggested that trifocal models are better for those patients who require a good intermediate vision. “Trifocal lenses are gaining increased popularity for managing near vision performance in cataract surgery, but they are far from being the mainstay in daily practice,” said Dr. Beiko. “Trifocal IOLs, which offer good acuity at near, intermediate and distance, with lesser complaints of glare and haloes, have taken over from the bifocals and to an extent from the extended depth of focus (EDOF) lenses in many practices,” added Dr. Luthra. “Trifocals are likely to gradually replace the bifocal IOLs completely as surgeon confidence grows.”
Stylish Accessories Completing the 2019 Congress Couture trends this season are accessories – and in Paris, especially, scarves are always in. ‘Haute’ right now are long, flowing scarves ... a dapper final addition for runway-ready conference style. Model: Media MICE Director of Media Rob Anderson
MIGS is a Runway Hit
When topical drops fail to manage intraocular pressure (IOP), and with the complications posed by more invasive surgeries to treat glaucoma, micro-invasive glaucoma surgery (or MIGS) has certainly been ‘in’ lately. Currently, there are numerous MIGS devices and procedures – and to list them all would require more space than this short runway. Dr. Beiko helped to narrow down the list to one: The ab externo approach and placement of the XEN GEL Implant (Allergan Inc., CA, USA). It decreases IOP by creating a permanent drainage shunt from the anterior chamber to the subconjunctival space through a scleral channel.11 “This technique offers the opportunity for some surgeons to perform it at the slit lamp, negating the necessity of going to the operating theatre,” said Dr. Beiko. A 2019 review12 by Chatzara et al., summarized the current knowledge on XEN implant for the treatment of glaucoma. They found that there was a significant reduction in IOP, as well as in the number of medications needed, both in patients treated with XEN implant alone or combined with cataract surgery. The authors concluded that “XEN implant devices have been developed as a surgical alternative for glaucomatous patients and are expected to play an important role in the management of glaucoma in the future”. “I believe that devices which increase flow through the trabecular meshwork remain the mainstay of modalities employed surgically to manage glaucoma,” Dr. Beiko concluded.
Ocular Fads: Hot or Not?
While fads in fashion can result in embarrassing photos, ‘fads’ in ophthalmology can have more devastating consequences, like permanent ocular damage (sounds fun!). And ironically enough, some of these ocular ‘fads’ can have quite a bit to do with actual fashion – no metaphor needed! Prof. Auffarth said that one anterior segment procedure that may fall under this category is the elective changing of iris color by femto-laser or other laser applications – or keratopigmentation (KTP). “In the last three to four years, it came several times up as a lifestyle procedure and there has been some investment in new companies changing a dark or brown iris to a blue one,” he said. In 2018, Alio et al., published a study13 which reported complications observed in 234 eyes of 204 patients treated with KTP for both therapeutic and cosmetic reasons. Different KTP techniques and three generations of pigments (GP) were used. Of those, 50 eyes of 29 patients suffered complications (12.82%). They found that 49% of patients complained of light sensitivity, then color fading and change in color (19%). Neovascularization, visual field limitations and magnetic resonance imaging (MRI) complications constituted 7%, 4% and 2%, respectively. Although light sensitivity remained with the corneal-specific pigments, it gradually disappeared in most of the patients (81.81%) 6 months postoperatively. Organic complications were observed with the previous GP, but resolved with the latest and third GP. “It seems to be for some patients or some societies or professions as something very important – however, the complications can be quite dangerous. I think this is ‘fad’ in the category of anterior segment,” concluded Prof. Auffarth. Be sure to catch up with the CAKE team at the European Society of Corneal and Refractive Surgeons (ESCRS) annual meeting in Paris. We will be wearing our finest haute couture while we continue our search for all things ‘hot’ in ophthalmology.
Shen Z, Shi K, Yu Y, Yu X, Lin Y, Yao K. Small Incision Lenticule Extraction (SMILE) versus Femtosecond Laser-Assisted In Situ Keratomileusis (FS-LASIK) for Myopia: A Systematic Review and Meta-Analysis. PLoS One. 2016;11(7):e0158176. 2 Pasquali T, Krueger R. Topography-guided laser refractive surgery. Curr Opin Ophthalmol. 2012;23(4):264-8. 3 Holland S, Lin DT, Tan JC. Topography-guided laser refractive surgery. Curr Opin Ophthalmol. 2013;24(4):302-9. 4 Alió JL, Grzybowski A, Romaniuk D. Refractive lens exchange in modern practice: when and when not to do it? Eye Vis (Lond). 2014;1:10. 5 Yogi MS, Ventura BV, Nakano EM. Posterior Astigmatism: Considerations for Cataract Refractive Surgery Planning.Vision Pan-America XVII. N. 1. Jan-Mar 2018. 6 Skrzypecki J, Sanghvi Patel M, Suh LH. Performance of the Barrett Toric Calculator with and without measurements of posterior corneal curvature. Eye (Lond). doi: 10.1038/s41433-0190489-9. [Epub ahead of print] 7 Titiyal JS, Kaur M, Falera R. Intraoperative optical coherence tomography in anterior segment surgeries. Indian J Ophthalmol. 2017;65(2):116-121. 8 Sharma B, Abell RG, Arora T, Antony T, Vajpayee RB. Techniques of anterior capsulotomy in cataract surgery. Indian J Ophthalmol. 2019;67(4):450-460. 9 Wygle˛dowska-Promieńska D, Jaworski M, Kozieł K, Packard R. The evolution of the anterior capsulotomy. Wideochir Inne Tech Maloinwazyjne. 2019;14(1):12-18. 10 Salerno LC, Tiveron Jr. MC, Alió JL. Multifocal intraocular lenses: Types, outcomes, complications and how to solve them. Taiwan J Ophthalmol. 2017;7(4):179-184. 11 De Gregorio A, Pedrotti E, Stevan G, Bertoncello A, Morselli S. XEN glaucoma treatment system in the management of refractory glaucomas: a short review on trial data and potential role in clinical practice. Clin Ophthalmol. 2018;12:773-782. 12 Chatzara A, Chronopoulou I, Theodossiadis G, Theodossiadis P, Chatziralli I. XEN Implant for Glaucoma Treatment: A Review of the Literature. Semin Ophthalmol. 2019;34(2):93-97. 13 Alio JL, Al-Shymali O, Amesty MA, Rodriguez AE. Keratopigmentation with micronised mineral pigments: complications and outcomes in a series of 234 eyes. Br J Ophthalmol. 2018;102(6):742-747. 1
About the Contributing Doctors George H.H. Beiko, BM, BCh, FRCS(C) is a medical graduate of Oxford University and completed his ophthalmology specialty training at Queens University in Canada. After completing his residency, he worked for one year at the St. John Ophthalmic Hospital in Jerusalem. He is currently a cataract, anterior segment and refractive surgeon practicing in St. Catharines, Ontario, Canada. His research interests include development of advanced cataract techniques and new intraocular implants. He has also done extensive work investigating multifocal, accommodating and aspheric IOLs. He is a founding member of the International Society for Intraocular Lens Safety and is an Associate Clinical Professor at McMaster University and a Lecturer at the University of Toronto. He has published over 30 peer-reviewed articles and authored twelve book chapters, and has given over 700 scientific presentations at meetings throughout the world. [Email: firstname.lastname@example.org] Gerd U. Auffarth, MD, PhD, FEBO of Heidelberg, Germany, is professor and chairman of the Department of Ophthalmology, University of Heidelberg, Germany. He is also a director of the International Vision Correction Research Centre (IVCRC) and the David J. Apple International Laboratory for Ocular Pathology, board member and secretary general of the German Society for Cataract and Refractive Surgery (DGII), honorary member of the Hungarian Society for IOL implantation, and board member of the European Society for Cataract and Refractive Surgeons (ESCRS). His surgical expertise includes cataract and refractive, as well as cornea and glaucoma surgery. He was the first surgeon worldwide to implant a toric, aspheric, multifocal IOLs. In 2018, he was ranked number two of the most influential individuals in ophthalmology worldwide. [Email: email@example.com] Dr. Gaurav Luthra is an alumnus of Maulana Azad Medical College, New Delhi, India. Presently, he is the director and chief of Cataract & Refractive Surgery at Drishti Eye Institute, Dehradun, Uttarakhand, since 1998. His areas of interest are refractive surgery, pediatric & challenging cataract surgery, premium IOLs and keratoconus. A past president of Intraocular Implant & Refractive Society of India (IIRSI), he is currently the chairman, Academics & Research, IIRSI and a Member, Scientific Committee, All India Ophthalmological Society (AIOS), besides being the Honorary General Secretary of UKSOS. Dr. Luthra is regularly invited as a faculty at most international meetings including ASCRS, ESCRS, American Academy, APAO, APACRS, and World Ophthalmology Congress. He has successfully performed over 120 live surgery workshops, demonstrating latest cataract and refractive surgical techniques around the world and has presented over 135 papers/lectures in international conferences and over 200 papers/courses in national conferences. [Email: firstname.lastname@example.org]
Keeping Children’s Eyes Healthy in A Digital World, One Book at a Time by Tan Sher Lynn
Kudos to Assoc. Prof. Mo Dirani for his tireless crusade against myopia in children. His recent projects include a book series, called The Plano Adventures, which aims to educate children on the environmental risk factors that contribute to the development of myopia.
obile device dependency, gaming addiction, cyberbullying, and lack of outdoor activity are all common and growing problems in children worldwide. Often, these are the results of excessive device usage, which often leads to vision conditions, particularly myopia or nearsightedness. To address this issue, academic and global myopia authority Associate Professor Mohamed (Mo) Dirani collaborated with Singapore’s awardwinning creatives, Hwee Goh and David Liew, to produce an engaging book series for children, called “The Plano Adventures”. We talked to Prof. Mo to find out more about the books and get his take on myopia.
CAKE: What is The Plano Adventures about?
Prof. Mo: The Plano Adventures is a series of books that aims to educate children on the environmental risk factors that contribute to the development of myopia, including excessive near work and lack of outdoor activity. The five books in the series address global issues on the link between excessive device use and adverse health outcomes, with a focus on myopia (first two books), gaming addiction, cyberbullying and device dependency. The underlying call to action in each book in the series is for children to remember and adopt Professor Plano’s “Clear Vision Recipe”, which consists of recommendations on healthy device use and eye care habits, developed using the latest scientific literature.
CAKE: What inspired you to publish the series?
Prof. Mo: I knew that it was important to empower the next generation with the required knowledge to avoid the pitfalls of excessive device usage and establish healthy relationships with emerging technology. The challenge was finding a way to go about educating children
in an engaging manner. Through this publication, we have truly managed to deliver science in a fun and engaging narrative that all children will enjoy.
CAKE: Please share your experience in producing the books. Prof. Mo: As an eye scientist focused on writing scientific manuscripts, it was a huge opportunity for me to collaborate with author and renowned children’s book writer Hwee Goh and celebrated illustrator David Liew to relay our scientific findings to the public and educate children on vision care and the perils of excessive device use in a creative and engaging way.. It was very special how the stories came together, from the initial pitch, to the draft storylines, sketches, scientific reviews and finally, the official publication by Marshall Cavendish, without whom this book series would not have been possible. We engage readers through each of our social media platforms, print and media publications, as well as live book readings. These have been very well received by both parents and children, and we are incredibly humbled to have their continued support ever since we embarked on this journey together.
CAKE: Will there be more Plano Adventure books in the pipeline? What are you currently working on?
Prof. Mo: Goh, Liew and I are developing The Plano Adventures sequel and picture books, and we have also developed a 24-week video series called The Plano Diaries at the request of many parents. The episodes are released every Friday and are available on the Plano App social media platforms. Each episode in the video series offers a deeper look into the backstory of each of the characters.
CAKE: Please tell us more about the Plano App.
Prof. Mo: My team at Plano Pte. Ltd. has developed the Plano App to address the rising issue of unhealthy smart device use in children and to assist parents in cultivating healthy eye care habits in children. The app provides various child safety functions, while using science-based features that help modify behavior in children to reduce myopia-related risk factors. We are also working on launching a major update to our in-app optometry referral platform, where the Plano App uses smart algorithms to remind parents when to take their children for comprehensive eye examinations according to recommended national guidelines. Parents can then easily locate and book their childrenâ€™s next eye examination within the platform itself. Through this platform, we hope to make the process of getting children into eye care early and in a regular and timely manner, which is pivotal in addressing the growing issue of myopia in Singapore and around the world.
CAKE: After the books, whatâ€™s next for Plano?
Prof. Mo: Beyond these current efforts, we are looking into partnering with major players in the publication and film industries to create a film adaptation of the series. We also hope to get The Plano Adventures integrated into the school curriculum across the globe to ensure that children as young as five years old can have the knowledge at hand to better understand the role of smart devices in their life.
Professor Plano’s ‘Clear Vision Recipe’ [and the research findings that support it!] 1. Scoops of Good Distance – We should use smart devices at a distance of at least 30 cm from our eyes. Bababekova Y, Rosenfield M, Hue JE, Huang RR. Font size and viewing distance of handheld smart phones. Optom Vis Sci. 2011;88(7):795-797.
CAKE: What is your take on myopia? How do you foresee the condition in the future? Prof. Mo: Myopia is one of the most common health problems, affecting an estimated two billion people worldwide. The number of people with myopia is expected to increase to five billion by 2050, which will be half of the world’s population. Studies have attributed the increasing prevalence of myopia to the rising trend of smart device use in children. The unfortunate reality is that 90 percent of all cases develop during childhood years. Unless we address this immediately, we will be seeing our clinics and hospitals filled with patients with sight-threatening high myopia. Our collective efforts are necessary in alleviating this public health and economic crisis. When it comes to myopia, early detection and ongoing management is important. The sooner we educate children on how to develop responsible device use and increase outdoor activity, the better the chances of reducing the risk of device dependency and myopia.
2. Dashes of Eye Breaks – We are recommended to take eye breaks after 30 minutes of using smart devices. Huang L, Kawasaki H, Liu Y, Wang Z. The prevalence of myopia and the factors associated with it among university students in Nanjing: A cross-sectional study. Medicine (Baltimore). 2019;98(10):e14777. 3. Heaps of Time Outdoors – We should spend at least two to three hours every day outdoors. i. Foreman J, Dirani M. Keeping an eye on smart device use. Singapore, 2018. https://www.plano.co/vision-smart/ ii. Huang L, Kawasaki H, Liu Y, Wang Z. The prevalence of myopia and the factors associated with it among university students in Nanjing: A cross-sectional study. Medicine (Baltimore) 2019;98(10):e14777. iii. Dirani M, Tong L, Gazzard G, et. al. Outdoor activity and myopia in Singapore teenage children. Br J Ophthalmol. 2009;93(8):997-1000. iv. Xiong S, Sankaridurg P, Naduvilath T, et al. Time spent in outdoor activities in relation to myopia prevention and control: a meta-analysis and systematic review. Acta Ophthalmol. 2017;95(6):551-566. v. Deng L, Pang Y. Effect of Outdoor Activities in Myopia Control: Meta-analysis of Clinical Studies. Optom Vis Sci. 2019;96(4):276-282.
CAKE: What advice would you give to parents to help them reduce and manage myopia-related risk factors in their children?
Prof. Mo: Parents should be empowered to manage the time their children spend on smart devices better and help modify their children’s behavior to reduce myopiarelated risk factors. By modifying particular risk factors, such as the amount of time their children spend on devices and the lack of outdoor activity, they can help slow down the progression of myopia or even in some cases, delay the onset of myopia, which reduces the chances of developing sight-threatening high myopia. We have published a report for parents and teachers on how to manage smart device use and myopia in children, which is available to download for free from our website, www.plano.co.
Editor’s Note: The Plano Series is currently sold in all major bookstores in the United Kingdom, the United States, Australia and Singapore. It is also available for online orders in Singapore on The Plano Shop (www.plano.co/ plano-shop/), and worldwide on websites for Amazon, Book Depository, and Marshall Cavendish.
4. MyPower – We should remember and adopt the recommendations every day.
About the Contributing Doctor Associate Professor Mohamed (Mo) Dirani is the founding managing director of Plano Pte. Ltd., adjunct associate professor at the Duke-NUS Medical School, and honorary principal investigator at the Singapore Eye Research Institute (SERI) and the Centre for Eye Research Australia (CERA). He completed his PhD at the age of 26 in 2006, during which he established the world’s largest twin study to investigate the genetic and environmental risk factors of myopia. In 2008, Prof. Mo undertook a post-doctoral appointment at the National University of Singapore (NUS), in which he coled a study that produced one of the first and most cited scientific papers that provided novel insights into the protective nature of outdoor activity in the development of myopia. Since completing his PhD, Prof. Mo has published over 120 peer-reviewed manuscripts in prestigious medical journals, has been an invited speaker across the globe as an expert in myopia, published several government-commissioned reports, and has received several competitive scholarships, fellowships, and scientific awards. [Email: email@example.com]
NLIGHTENMENT East Meets West
by Brooke Herron
ith more than 1 billion people, India has the second largest population in the world. In a region where access to healthcare services can be limited in most rural and underserved areas, more people means more potential patients. This is especially true for cataract, which is the most significant cause of blindness and is responsible for 50% to 80% of bilateral blindness in India.1 It is well known that India experienced a severe cataract backlog in the past, but through government and non-government organization (NGO)-sponsored programs, that number has decreased tremendously. Through the sheer volume of surgeries performed, Indian ophthalmologists have refined their surgical technique for efficacy and
efficiency, with an emphasis on safety. To learn more, CAKE Magazine caught up with Prof. Dr. S. Natarajan, the All Indian Ophthalmological Society (AIOS) president, and head and consultant of Vitreo-Retinal Surgery at Aditya Jyot Eye Hospital in Mumbai, India, at the 2019 Annual Meeting of the American Society for Retina Specialists (ASRS) in Chicago. There, he discussed India’s past and present – and how European ophthalmologists can learn from their Indian counterparts.
A look back: India’s cataract backlog In the 1970s, increasing rates of treatable blindness due to cataract caught the Indian government’s
attention. And in 1976, the National Programme for Control of Blindness and Visual Impairment (NPCB&VI) was launched. At that time, the NPCB&VI was 100% government-sponsored, with the goal of reducing the prevalence of blindness to 0.3% by 2020. “They did a lot of camps to identify cataract in the small places like schools,” said Dr. Natarajan, adding that now the camps are done in hospitals. “This started in the early 1960s and then it picked up in the 1970s. In the ‘60s, they were doing intracapsular cataract extraction (ICCE).” During this time, Dr. Natarajan said they increased the number of cataract surgeons to help handle the backlog. Government incentives also created an initiative for surgeons to
NLIGHTENMENT East Meets West
European doctors can come to India “ and learn how to refine the technique, then
implement that into their practice at home.
- Prof. Dr. S. Natarajan, Head and consultant of Vitreo-Retinal Surgery, Aditya Jyot Eye Hospital, Mumbai, India
take up the cause. “For example, if you registered with the government or the National Programme for the Control of Blindness, and you are doing the surgery for free, they would reimburse the surgeon 750 rupees or about $100 for the cataract surgery,” he explained. “This encouraged the other surgeons to do it. It doesn’t cover the whole thing, but instead of a total loss you have something to cover the surgery. And when bigger hospitals did it, and because of the sheer numbers, they could manage the expenses.” Further, he said that every state and region [in India] has a premier institute of ophthalmology. “Their main thing is to prevent blindness for the needless blind, like cataract and glaucoma – and cataract is the primary one.” To show the increase in cataract surgeries in India, there were roughly 1.2 million cataract surgeries per year in the 1980s, and the cataract surgical output increased to 3.9 million per year by 2003.1 Fast forward to 2016-2017, over 6.48 million of cataract surgeries have been performed in India.2
A lesson in refining techniques for efficiency Dr. Natarajan said that in all the government hospitals today, everyone is an expert in cataract. “Every day, everywhere, cataract surgery is being done.” So, how did the rate of cataract surgeries increase from 1.2 to 6.48
million annually over the last few decades? By refining their technique to make surgeries more efficient. “I went to Brazil last month, and they were admiring the amount of cataract surgery done in India,” he shared. “I think they would like to do something like that.” Dr. Natarajan explained that there is a system in place for European ophthalmologists who would like to come to India to train and become quicker and more efficient in cataract surgery. Ophthalmologists from outside of India need to be licensed and registered through the proper Indian channels. “They can come to India and learn how to refine the technique, then implement that into their practice at home,” he said. “The main goal should be ‘patient first’ – it should be refining the technique in every case, so the patient benefits from the best surgery with the best surgical skills,” said Dr. Natarajan, noting that approximately 1,000 cataract surgeries are performed daily in the bigger hospitals in India. In the camps, about 100 are completed per day – all to combat the backlog. “I don’t think that would be required for a European doctor,” he continued, adding that there is something to be gained from the volume of patients – and that comes in the form of unusual pathologies. “I think the variety of patients available, apart from cataract, make for the different pathologies. Maybe in their country, they would normally see one per day, but in India they could see 10
to 20 of those cases per day,” he said. “I always recommend that they should go and see some other operating rooms to see what each one is doing and pick up what they like, what’s good for their country and follow that.”
Opportunities for training and innovation India is also a hotbed for ophthalmic innovation, notably in instrumentation and intraocular lenses (IOLs) – and much of it is driven by low cost. Dr. Natarajan said the cheapest IOL in India currently runs about USD $2 – the low cost is tied to government and NGO subsidies, along with the sheer volume of patients which allows for lower prices. The IOL market is growing in India – and that’s because the demand is there. “About two-thirds of India’s population will have cataract in the next 30 years – so that’s the market. They’re thinking cataract is going to happen, and everyone is working on the maximum capacity to do the surgery,” he said. Of course, premium IOLs are available in India as well, at a cost that Dr. Natarajan believes is lower than in developed countries. According to Dr. Natarajan, in addition to IOLs, European doctors can take advantage of India’s lower cost instruments and other technologies. “I think the microsurgical instruments – in India, they make the best and they’re cheaper – maybe 1/10 the cost of what’s available in Europe,”
he shared, adding that this could be a great advantage for European surgeons. Of the different Indian companies focusing on microsurgical equipment, several stand out to Dr. Natarajan, including Kholsa and Epsilon (both located in Mumbai) and Appasamy Associates (Chennai), which also manufactures and distributes ophthalmic equipment, microscopes, lasers, pharmaceuticals and IOLs. Lenses coming out of India would also be advantageous to European physicians from a cost-versus-quality perspective. For example, Biotech Healthcare Group (Gujarat) has developed OPTIFLEX TRIO, a diffractiverefractive trifocal IOL used for presbyopia correction; while
Prof. Dr. S. Natarajan with CAKE Magazine Publisher, Matt Young, at the at the ASRS Annual Meeting in Chicago
Care Group (Gujarat) has a single-piece posterior chamber phakic IOL, called IPCL V2.0 (Implantable Phakic Contact Lens). On the imaging end of things, Bangalore-based Remedio is gaining popularity, with products like the C3 Field Analyser, the world’s first clinically validated portable visual field perimeter device, where the test is performed in a wearable headset format is administered using a smart phone. Meanwhile, there are opportunities for companies from the West to enter India as well. “Even now, more than 50% of IOLs are from the West. In India, you have to think of the mass – the numbers – that will help show a profit, even if the devices are more expensive.” References 1
Murthy G, Gupta S, John N, Vashist P. Current status of cataract blindness and Vision 2020: The right to sight initiative in India. Indian J Ophthalmol. 2008;56(6):489-494.
Maharana PK, Chhablani JK, Das TP, et al. All India Ophthalmological Society members survey results: Cataract surgery antibiotic prophylaxis current practice pattern 2017. Indian J Ophthalmol. 2018;66:820-824.
About the Contributing Doctor
Prof. Dr. S. Natarajan is the All Indian Ophthalmological Society (AIOS) president, and head and consultant of Vitreo-Retinal Surgery at Aditya Jyot Eye Hospital in Mumbai, India. He is a multi-award-winning ophthalmologist who has performed over 27,000 exclusive vitreo-retinal surgeries in the past 33 years, and trained 64 vitreo-retinal surgeons across the globe. He is a visiting professor in the Marmoindes University (Argentina), University of Lugano (Switzerland), Balaji Medical College (Chennai, India), and Saveetha Medical University (Chennai, India). [Email: firstname.lastname@example.org]
FDA Approves Delivery Design Optimization Changes for Ophtec’s RingJect
ecently, Ophtec USA (Boca Raton, Florida) received FDA approval for delivery design optimization changes to RingJect™, a single-use injector preloaded with the Ophtec Capsular Tension Ring (CTR), originally designed for use in complicated cataract surgery. The RingJect delivers the Ophtec CTR which is a uniplanar 270 ring, made entirely of ultravioletlight-absorbing PMMA with one manipulation eyelet at each end of the ring. Its patented compression molding technology makes for a durable,
flexible device to stabilize the capsular bag in the presence of weakened or compromised zonules during cataract surgery. Ophtec USA Vice President and General Manager Abraham Farhan expressed gratitude for the FDA approval, and added: “Our surgeons and patients will continue to benefit from our legacy Capsular Tension Ring. We are very excited about the RingJect, as it saves time in surgery and reduces surgical preparation time.” Today, surgeons use RingJect in premium IOL surgeries for better IOL
centration and stabilization “Ophtec has a passion for vision and we look forward to provide the same preloaded sterile Capsular Tension Ring that has offered surgeon’s a high level of safety for complicated cataract cases and which has shown its added value in premium IOL cases with years of successful clinical outcomes,” added Tiago Guerreiro, Ophtec’s global marketing director. For more information, visit www.ophtec.com.
PIE (Posterior Segment - Innovation - Enlightenment) is the World's First Funky Ophthalmology Magazine and Asia-Pacific's First Magazine on...
Published on Oct 8, 2019
PIE (Posterior Segment - Innovation - Enlightenment) is the World's First Funky Ophthalmology Magazine and Asia-Pacific's First Magazine on...