PIE Issue 28: The Diabetic Eye Issue by Media MICE

THE DIABETIC EYE ISSUE

DECEMBER 2023 piemagazine.org

Trials and tribulations when navigating the bittersweet realities of diabetic retinopathy p10

Letter to Readers

The Diabetic Eye Dear Readers, elcome to the year-end issue of PIE. As the official media partners, W Media MICE and PIE magazine are here at the 16th Congress of the Asia-Pacific Vitreo-retina Society (APVRS 2023) in Hong Kong, where the posterior segment of the eye takes center stage once more, exploring advancements and challenges in this subspecialty. With hard copies of this issue available on the show floor, we focus on the intricate realm of diabetic eye complications, exploring groundbreaking possibilities that could revolutionize treatment. Could eye drops replace injections in addressing retinal conditions within the posterior segment (p5)? Dig deeper into a new front-line treatment – subliminal laser therapy for central serous chorioretinopathy (CSCR), presenting a promising avenue in the ever-evolving landscape of ophthalmology (p8). The Cover Story (p12) unfolds the not-so-sweet life, navigating the trials and tribulations of diabetic retinopathy. We delve into the bittersweet realities, shedding light on the challenges faced by individuals grappling with this condition. Our contributing experts dissect the prospects and challenges, offering invaluable insights into the potential future of diabetic eye care.

PIE MAGAZINE | December 2023

Innovation takes center stage, unveiling fresh perspectives and the latest breakthroughs in age-related macular degeneration (AMD), presented at EURETINA 2023 – from gene therapies to combo treatments, witness the cutting-edge advancements shaping the future of eye care (p12). In the Women in Ophthalmology section, join Prof. Dr. Gemmy Cheung – Congress President of the upcoming APVRS 2024 (and PIE magazine’s Advisory Board member) – on a journey of enlightenment as she strives to carve a clear sightline, aiming to bring women ophthalmologists to the forefront of the field. Last but not least, we congratulate our society partners and friends: the European VitreoRetinal Society (EVRS) for its triumphant return to the conference scene after a three-year hiatus (p21), and the collective progress of the joint AOS-PAO 2023 Congress – from overcoming the challenges posed by the pandemic to exploring global trends and regional perspectives shaping the trajectory of ophthalmic care (p22). We hope that the information presented in this issue proves valuable to your practice.

Best regards, Gloria D. Gamat

Chief Editor, Media MICE PIE, CAKE and COOKIE magazines

In This Issue...

Posterior Segment magazine posterior segment • innovation • enlightenment

05 08

Matt Young CEO & Publisher Hannah Nguyen COO & CFO Gloria D. Gamat Chief Editor Mapet Poso Editor

Could Eye Drops Replace Injections? Experts provide insights into the prospects and challenges of using eye drops to treat retinal conditions SubLiminal Laser Therapy for CSCR A new front-line treatment

Cover Story 10

Matt Herman Associate Editor Maricel Salvador Graphic Designer Writers April Ingram Chow Ee-Tan Hazlin Hassan Joanna Lee Sam McCommon Tan Sher Lynn Contributor Dr. Perfecto E. O. R. Cagampang III Ruchi Ranga Customer Care

Trials and tribulations when navigating the bittersweet realities of diabetic retinopathy

Innovation

Enlightenment

International Business Development Brandon Winkeler Robert Anderson Sven Mehlitz

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6001 Beach Road, #09-09 Golden Mile Tower, Singapore 199589 Tel: +65 8186 7677 Email: enquiry@mediamice.com www.mediaMICE.com

Carving a Clear Sightline Prof. Dr. Gemmy Cheung aims to bring women ophthalmologists to the forefront

Conference Highlights

21 Media MICE Pte. Ltd.

From Gene Therapies to Combo Treatments Unveiling fresh perspectives and the latest AMD breakthroughs at EURETINA 2023

Back with a Roar! The European VitreoRetinal Society is back after a three-year hiatus

From COVID Challenges to Collective Progress AOS-PAO Congress 2023 sets sights on global trends and regional perspectives

We are looking for eye docs who can contribute articles to PIE magazine. Interested? Let's talk! Send us an email at editor@mediamice.com. To place an advertisement, advertorial, symposium highlight, video, email blast, or other promotion in PIE magazine, contact sales@mediamice.com.

Advisory Board Members

Dr. Alay S. Banker

Banker’s Retina Clinic and Laser Centre Ahmedabad, India alay.banker@gmail.com

Dr. Barbara Parolini Eyecare Clinic Milan, Italy

parolinibarbara@gmail.com

Prof. Gemmy Cheung

Singapore National Eye Centre (SNEC) Singapore

Dr. Hudson Nakamura

Bank of Goias Eye Foundation Goiânia, Brazil hudson.nakamura@gmail.com

gemmy.cheung.c.m@singhealth.com.sg

Prof. Mark Gillies

Dr. Saad Waheeb

University of Sydney Sydney, Australia

King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia

mark.gillies@sydney.edu.au

saadwaheeb@hotmail.com

Society Friends

Arunodaya Charitable Trust (ACT)

Asia-Pacific Vitreo-retina Society

100% Ophthalmology

He Eye Specialist Hospital

Retinawesome Retina & Vitreous International

Vitreo-Retinal Society - India

The Royal Australian and New Zealand College of Ophthalmologists

ASEAN Ophthalmology Society

Ophthalmology Innovation Summit

Young Ophthalmologists Society of India ( YOSI )

World Ophthalmology Congress

PIE MAGAZINE | December 2023

Subthreshold Ophthalmic Laser Society

EYEDROP THERAPY

Could Eye Drops Replace Injections? Experts provide insights into the prospects and challenges of using eye drops to treat retinal

conditions

by Tan Sher Lynn

Highlighting recent studies and positive Phase 3 trial results, experts explored promising developments in retinal eye drops, addressing issues of patient compliance, safety and efficacy. While acknowledging the challenges in drug delivery and the need for further study, they emphasized the potential of topical drops as a valuable addition to existing treatment options for retinal diseases.

hough anterior segment diseases are generally treated with topical eye drops, it’s a different ballgame when it comes to the posterior segment. Current retinal drug delivery systems are mainly invasive and include injections, hydrogels inserts and implants that promote prolonged drug delivery.

Injections, are the most commonly used in modern ophthalmology. However, they require frequent applications by a specialized ophthalmologist, have major patient compliance issues and a high burden of treatment, and are associated with various side effects.1 Using eye drops that effectively reach the back of the eye could emerge

Posterior Segment

as a major player in the treatment options for retinal diseases. Topical drug delivery remains one of the safest, easiest and most comfortable treatment methods, as it is noninvasive and allows the patient to self-apply. This treatment modality thus holds much promise in the fight against retinal diseases.

Topical drug delivery to the posterior segment According to a recent study published in Frontiers of Neuroscience, eye drops developed by Columbia University researchers could be a more effective and lower-burden therapy for retinal vein occlusion (RVO), a common eye disease currently treated with anti-vascular endothelial growth factor (anti-VEGF) or corticosteroid injections into the eye.2 The study, titled Caspase-9 inhibition confers stronger neuronal and vascular protection compared to VEGF neutralization in a mouse model of retinal vein occlusion, showed that caspase-9, an enzyme that triggers cell death, is overactive in blood vessels injured by RVO. According to the investigators, the eye drops studied contained an experimental drug that blocks caspase-9, improving the health of blood vessels in the retina and reducing toxic signaling that damages the neurons. Commenting on the recent study, Malaysian ophthalmologist Dr. Manoharan Shunmugam expressed that if these eye drops prove to be as effective as current treatment

P IPEI EMM AG AA GZ AIZNI N E E| |D eDceecme bmebre2r 022032 3 5 5

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EYEDROP THERAPY

modalities, they could certainly enhance patient compliance and the administration of such therapies. However, he had some concerns. “There are multiple caveats in this study. While caspase-9 inhibition shows promise in this particular animal model, the development of effective treatments for retinal diseases is a complex process. Factors such as drug delivery, safety and long-term efficacy need to be carefully studied in human subjects. Therefore, there is still some time to go,” he said.

DIAMONDs out of the rough? More positive developments in retinal eye drops have also emerged with the positive early Phase 3 results of the DIAMOND trial for the candidate of OCS-01 (OCULIS) in diabetic macular edema (DME). The promising data was presented during the 23rd EURETINA Congress in October 2023.3 DIAMOND investigators showed that the trial met primary and secondary endpoints with robust statistical significance. Specifically, the primary efficacy endpoint of mean change in best corrected visual acuity (BCVA) versus baseline at week 6 showed a statistically significant increase in visual acuity in the OCS-01 arm compared to the vehicle arm (OCS01: 7.2 letters vs. vehicle: 3.1 letters, p=0.007), which was sustained

through week 12 (OCS-01: 7.6 letters vs. vehicle: 3.7 letters, p=0.016). For the secondary endpoints, a statistically significantly higher percentage of patients achieved ≥15-letter improvement in BCVA and better improvement in retinal thickness in the OCS-01 arm versus vehicle arm (OCS-01 25.3% vs. vehicle: 9.8%, p=0.015); and patients in the OCS-01 treatment arm also showed significant improvement in retinal thickness as compared to vehicle (OCS-01: -63.6 µm vs. vehicle: +5.5 µm, p<0.0001). OCS-01 is a novel, highconcentration (15 mg/ml), topical formulation of dexamethasone, developed to reach the retina via an eye drop. If approved, OCS-01 would become the first topical eye drop for the treatment of DME and address a massive unmet need for non-invasive therapeutic options in this blinding disease.

Challenges in topical drug delivery Dr. Sashwanthi Mohan, a cataract and vitreoretinal specialist from India noted that while retinal eye drop treatments like caspase-9 inhibitors and OCS-1 eye drops may serve as good non-invasive and convenient treatment options, there are nevertheless various challenges or issues that need to be addressed. “Using topical drops for retinal disease treatment presents several challenges, including the need for efficient drug delivery to the retina, overcoming the blood-retina barrier, consistent and accurate dosing, dealing with potential side effects, achieving adequate drug concentration and retention and ensuring patient compliance over long treatment periods,” she explained. Notably, topical drug delivery to the posterior segment is limited by poor bioavailability and short residence time due to the complex anatomy of the eye. These ocular barriers, which include the tear film, cornea, conjunctiva, vitreous,

PIE MAGAZINE | December 2023

blood-aqueous barrier and bloodretina barrier, protect the eye from potentially harmful molecules from the external environment, but at the same time, reduce the effective delivery of medications.3 Hence, only a small portion of the applied dose (about 5%) can penetrate the internal structures of the eye.4

“Using topical drops for retinal disease treatment presents several challenges, including the need for efficient drug delivery to the retina, overcoming the blood-retina barrier, consistent and accurate dosing, dealing with potential side effects, achieving adequate drug concentration and retention and ensuring patient compliance over long treatment periods.” – Dr. Sashwanthi Mohan

Like glaucoma drops, retinal drops are also affected by the issue of poor drug absorption. “However, their design and formulation differ due to the distinct anatomical structures involved,” added Dr. Mohan. “The goal of glaucoma eye drops is to reduce intraocular pressure in the anterior chamber of the eye, and they often use penetration enhancers to improve absorption. On the other hand, retinal eye drops must navigate various ocular barriers, including the bloodretina barrier, to reach the retina at the back of the eye. Strategies to enhance absorption in retinal drops may involve nanotechnology, penetration enhancers, vehicle delivery and pro-drug formulations, among others, to optimize drug delivery to the retinal tissue,” she continued.

Dr. Mohan also noted that the development of effective drugs and the conduct of rigorous clinical trials for long-term safety and efficacy remain a challenge in making topical retinal drops an effective management modality for retinal diseases. And even if these challenges are overcome, Dr. Mohan believes topical drops would not replace existing treatment modalities, but instead complement them. “The potential for eye drops to replace other treatment modalities like injections, hydrogel, lasers and surgeries in ophthalmology depends on factors such as the complexity and severity of the retinal disease, treatment safety and efficacy, patient variability, side effects and regulatory approval processes,” she said. “While eye drops offer advantages like non-invasiveness and ease of use, they may not fully supplant other therapies, as different retinal conditions may require tailored or more targeted treatments, and individualized approaches may involve a combination of different modalities. Topical eye drops can potentially serve as a valuable addition to the existing options rather than completely replacing them,” she further explained.

Patient acceptance and compliance Compared to intravitreal injections, topical drops offer the advantage of higher patient acceptance while negating the risk of injection-related complications. There are, however, still issues with patient compliance, noted Dr. Shunmugam. “Patient compliance issues would prevail for eye drops as they do in glaucoma cases. On the other hand, compliance issues also arise with intravitreal injections due to the poorer acceptance of such injections or experience bias based on the patient’s individual encounter with an intravitreal injection, which has a wide operator-dependent variable that can be difficult to quantify,” he commented. Nevertheless, this can be overcome with good patient education and compliance monitoring. “Since

retinal diseases often require continuous treatment, ensuring that patients consistently administer their drops as prescribed is crucial. To mitigate compliance issues, patients should be educated about the importance of treatment adherence, provided with clear instructions for drop administration and any concerns or side effects should be addressed immediately. Additionally, simplifying dosing schedules, using reminder tools and involving family members can help improve patient compliance with retinal drop regimens, ultimately increasing the chances of successful

treatment outcomes,” Dr. Mohan advised. In essence, topical drops hold great promise, but there is much that remains to be explored. “Topical drops offer the potential for early intervention and reduced invasiveness compared to injections or surgeries. However, matters regarding the diverse retinal diseases to treat, effective drug delivery to the retina, appropriate drug formulation and rigorous testing for safety and efficacy must be properly addressed,” Dr. Mohan concluded.

References 1. Löscher M, Seiz C, Hurst J, Schnichels S. Topical Drug Delivery to the Posterior Segment of the Eye. Pharmaceutics. 2022;14(1):134. 2. Avrutsky MI, Chen CW, Lawson JM, Snipas SJ, Salvesen GS, Troy CM. Caspase-9 inhibition confers stronger neuronal and vascular protection compared to VEGF neutralization in a mouse model of retinal vein occlusion. Front Neurosci. 2023;17:1209527. 3. Positive Phase 3 Stage 1 DIAMOND Trial Results of OCS-01 in Diabetic Macular Edema Presented at 23rd EURETINA Congress. GlobeNewswire. Available at https://www.globenewswire.com/newsrelease/2023/10/10/2757269/0/en/Positive-Phase-3-Stage-1-DIAMOND-Trial-Results-of-OCS-01in-Diabetic-Macular-Edema-Presented-at-23rd-EURETINA-Congress.html. Accessed on November 9, 2023. 4. Wu KY, Joly-Chevrier M, Akbar D, Tran SD. Overcoming Treatment Challenges in Posterior Segment Diseases with Biodegradable Nano-Based Drug Delivery Systems. Pharmaceutics. 2023;15(4):1094.

Contributing Doctors Dr. Sashwanthi Mohan is a cataract and vitreoretinal specialist at Medcare Eye Centre, Dubai, and an education and research associate at Rajan Eye Care Hospital in Chennai, India. She completed her residency at L.V. Prasad Eye Institute, in Hyderabad, earning a gold medal, and pursued a vitreoretinal fellowship at Sankara Nethralaya, Chennai. She’s a keen researcher with numerous peerreviewed publications. Committed to ophthalmic education, she champions Ophthalmobytes and #Retina101bySM on social media. She is a fellow of the International Council of Ophthalmology and a Member of the Royal College of Surgeons, Edinburgh. She also actively contributes to the Ophthalmology Foundation and Cybersight by Orbis. sashu23@gmail.com

Dr. Manoharan Shunmugam is a consultant ophthalmologist and adult and pediatric vitreoretinal surgeon who trained in the United Kingdom and returned to Malaysia in 2013. He has a keen interest in research with publications in a wide range of high-impact journals and has been invited to many international conferences as a speaker. He is also a contributing author of two book chapters in vitreoretinal reference textbooks. He graduated in Scotland and subsequently undertook his ophthalmic specialist training and VR fellowship in London. En route, he further honed his skills with a pediatric VR fellowship at the prestigious L.V. Prasad Eye Institute, in Hyderabad, India. He is the immediate past president of the Malaysian Society of Ophthalmology (MSO) and is also a member of the Asia-Pacific Vitreoretinal Society (APVRS) and Asia-Pacific Academy of Ophthalmology (APAO). manoshun@gmail.com

PIE MAGAZINE | December 2023

Posterior Segment

LASER THERAPY

577 nm yellow laser treatment [Image courtesy of Alejandro Filloy Rius, M.D., Ph.D. (Tarragona, Spain)

SubLiminal Laser Therapy for CSCR A new front-line treatment

by Sam McCommon

There’s an established treatment available for chronic serous chorioretinopathy (CSCR), and that’s subthreshold laser (STL) therapy. If you were to stop reading in this sentence, you could leave with this takeaway: Yes, subthreshold laser therapy works for CSCR…

ut you didn’t think we’d just say that and leave you to do all the guesswork, did you? Of course not. No, instead, we’re here today to discuss the findings and opinions presented by Dr. Alejandro Filloy Rius, a Spanish ophthalmologist who’s an excellent go-to guy for all things STL. Dr. Filloy presented his findings¹ at APAO 2023 in Kuala Lumpur, and there’s some significant good news in what he had to say.

For reference, CSCR affects the macula and can cause blurred vision due to fluid build-up beneath it. The condition usually affects one eye, although it might be present in both, and is more common in men than women. It further affects patients between the ages of 20 and 50, the most, and a personal history of stress is not unusual. While the more frequent non-chronic version may resolve on its own, the first “C” in CSCR means “chronic” which,

PIE MAGAZINE | December 2023

well, means it’s an ongoing problem. Treatment in this condition is required in order to avoid long-term sequels.

CSCR overview CSCR is a bit of an enigma in that it’s not exactly known why it occurs. However, Dr. Filloy explained that current evidence points to anomalies in the choroidal vessels that might cause a disruption in the retinal pigment epithelium (RPE), establishing a negative feedback loop resulting in the aforementioned fluid accumulation. If untreated, CSCR can lead to permanent vision quality loss in a number of ways, including blurring, distortion, blind spots, dulled color vision, and more. It’s a fairly prevalent condition, so it certainly deserves a place on the treatment development docket. The most common treatment for CSCR until now has been photodynamic therapy (PDT) which is applied with its co-adjuvant, verteporfin. Most studies agree that STL and PDT are equivalent in results. However, while some papers suggest that PDT has the upper hand,

Dr. Filloy rejects those claims. We’ll get to the why in just a moment. There is another issue. There has been a worldwide shortage of verteporfin for around two years now, as Dr. Filloy noted, so alternative treatments are necessary. Currently, the shortage has caused a long line on PDT waiting lists, especially in certain countries, endangering the prognosis of these patients. While common knowledge does not yet support SLT over PDT, the evidence certainly appears to.

• Patients would not need sun protection or home isolation afterwards

may have stopped and asked, “Well wait…just how does it work?”

• It would need to be OCT/AF guided • It would need to be easy to perform • It would need to be free of described complications • Retreatments would need to be available if necessary and, of course;

STL vs PDT

• It would need to be effective

To be clear, let’s establish this: Dr. Filloy argues that STL is a viable alternative to PDT as a firstline treatment for CSCR. This is supported by the vast majority of the available literature. Regarding the evidence that argues in favor of PDT (basically the PLACE trial)², Dr. Filloy has the following to say:

And here’s where Dr. Filloy performs his a-ha moment: We have a treatment that ticks all of those boxes, and it’s STL.

First, the main outcome presented in the pro-PDT papers² was the speed of the CSCR resolution, which Dr. Filloy believes to be not the most significant aspect regarding this disease; a slightly slower resolution will hardly impact the outcome of a long-ongoing condition. Second, and linked to the first one, the PLACE study itself finds there are no long-term significant differences in visual results. Third, the laser used was un-patterned. Fourth, few laser spots were applied in the patients compared to what is known to be effective — only a fraction of what Dr. Filloy and most of the STL practitioners believe to be effective. These two last points (pattern and extension of treatment) suppose a violation of the cornerstones of an effective STL treatment. Naturally, these disagreements have led to some controversy.

New treatment requirements So, if we were to have a new, better version of PDT that can treat the backlog of patients requiring CSCR treatment, it would have to have several features: • It wouldn’t require verteporfin • It would have to be cheap and readily available

Solid results for STL And here we enter the meat of Dr. Filloy’s case. He presented a prospective case series using an STL 577 nm yellow laser in a confluent extense pattern, is fovea-sparing and through individually-titrated power. He measured the effectiveness in terms of VA and subretinal fluid (SRF) resolution and looked on the changes in the choroidal structure. Follow-up was performed at 6, 12, and 24 weeks. The study included 43 eyes from 37 patients, 75.7% of which were male. The results were excellent: 93% of patients had improved conditions, showed some degree of improvement, 7% had stabilized, and 0% had worsened. Most patients — nearly 70% — experienced complete resolution between 12 and 24 weeks. Choroidal thickness decreased significantly across the board as well.

A fine display The evidence Dr. Filloy presented regarding the choroidal thinning shows that, indeed, STL does produce an anatomical response in treating CSCR (a kind of response also detected with PDT). Dr. Filloy convincingly argues that STL can be a solid first-line defense for CSCR, especially in light of the ongoing shortage of verteporfin.

This is a good question, and like CSCR itself, just how STL works remains a bit of an enigma. However, Dr. Filloy has some suggestions. Most importantly, as Dr. Filloy explained, “The anti-inflammatory cascade elicited by the subthreshold laser stimulus might “disrupt that disruption”, thus “resetting” the RPE. However, the reason behind the choroidal thinning remains unclear, though it may be due to a two-way mechanism. Given the circumstances and evidence provided by Dr. Filloy, STL represents a significant step forward in treating CSCR. With the current backlog of patients waiting to be treated, a novel treatment for the condition is just what the doctor ordered. We look forward to more data coming out regarding the fisiopathological pathways of STL, but the important thing for now is that it’s clear it does indeed work. Kudos to Dr. Filloy and his team for the findings, and we can’t wait to see what’s next. In the meantime, check out Lumibird® Medical’s site at www. subliminal-laser-therapy.com to find out more exciting developments.

References 1. Torrellas B, Filloy A, Wu L, Chhablani J, Romero-Aroca P. Effectiveness, Safety and Choroidal Changes of a Fovea-Sparing Technique for the Treatment of Chronic Central Serous Chorioretinopathy with Yellow Subthreshold Laser. J Clin Med. 2023;12(3):1127. 2. van Dijk EHC, Fauser S, Breukink MB, et al. Half-Dose Photodynamic Therapy versus High-Density Subthreshold Micropulse Laser Treatment in Patients with Chronic Central Serous Chorioretinopathy: The PLACE Trial. Ophthalmology. 2018;125(10):1547-1555.

Editor’s Note The 38th Asia-Pacific Academy of Ophthalmology Congress (APAO 2023) was held on February 23 to 26 in Kuala Lumpur, Malaysia. Reporting for this story took place during the event.

At this point, however, astute readers PIE MAGAZINE | December 2023

Cover Story

Trials and tribulations when navigating the bittersweet realities of diabetic retinopathy by April Ingram Diabetic retinopathy affects millions of people, highlighting the urgent need for education, awareness and early intervention. Technological advancements, including artificial intelligence and home-based screening, are promising solutions—offering hope in managing this growing epidemic and reducing the burden on eye care professionals worldwide.

triving for that ‘sweet life’ may be our goal, but not when it’s reflected in our HbA1c. Unfortunately, in many parts of the world, the number of people with diabetes, especially Type II, is increasing at staggering rates. Nowadays, a Type II diabetes diagnosis is considered a normal part of aging, with many regard it

PIE MAGAZINE | December 2023

as something that happens to their family members as they grow older. As of 2019, it was estimated that 463 million people, globally, are living with diabetes.1 If that isn’t frightening enough, within the four decades to follow, these estimates are expected to exceed 700 million.1

Diabetic eye care in a growing epidemic Diabetes increases the risk of various

health problems, including heart attack, stroke, kidney failure, and, of course, vision loss. Dr. Thomas W. Gardner—the scientific co-director of the Mary Tyler Moore Vision Initiative and a professor of ophthalmology and visual sciences, molecular and integrative physiology and internal medicine at the University of Michigan—is an expert in the physiology and management of the diabetic eye.

diagnosed with diabetes, nearly a billion eyes need close monitoring for signs of diabetic retinopathy and macular edema, followed by prompt treatment. No small feat for an army of retina specialists and even a larger army of supporting eye care professionals.

“Diabetic retinal disease remains a leading cause of blindness owing to the dramatic increase in the number of persons with diabetes worldwide.” – Dr. Thomas W. Gardner

This diabetes epidemic is straining eye care providers as they try to manage this increasing number of patients. It has been estimated that in the United States alone, 9.6 million people have been diagnosed with diabetic retinopathy, and more than 37 million have diabetes, requiring regular monitoring.2 In India, the demand for diabetic eye care is even greater.

Navigating the burden of diabetes in India Dr. R. Rajalakshmi, a senior consultant ophthalmologist and the head of Medical Retina at Dr. Mohan’s Diabetes Specialities Centre in Chennai, India, and a clinical researcher at Madras Diabetes Research Foundation, shared how diabetes and diabetic retinopathy are impacting the people of India. “Diabetic retinal disease remains a leading cause of blindness owing to the dramatic increase in the number of persons with diabetes worldwide,” Dr. Gardner said. “Recent evidence also shows that half of adolescents with Type I or Type II diabetes have diabetic retinal disease after 12 years.” This highlights the fact that vision loss as a consequence of diabetes is not only a concern for older people with diabetes. With half a billion individuals

“One of the major challenges for India is the disproportionately large number of people with type 2 diabetes,” Dr. Rajalakshmi shared. “The ICMR-INDIAB study has shown that India is home to over 100 million people with diabetes. Approximately 12.5% of people with diabetes in India (i.e., over 12 million) have diabetic retinopathy, of which 4 million have severe sight-threatening diabetic retinopathy.”3-4 Dr. Rajalakshmi has an important role in the SMART India Study, a

PIE MAGAZINE | December 2023

Cover Story

The burdens associated with diabetes may not always be well understood by non-medical professionals in the population; tiny changes are occurring within their bodies before they become even remotely aware of any symptoms. Once the changes become complications, these can be incredibly impactful, especially in workingage patients. “These patients are at high risk of microvascular and macrovascular complications of diabetes and are therefore more economically challenged,” Dr. Rajalakshmi added, stressing the importance of education, awareness, early detection and management of the disease.

multicentric collaborative study done across 10 states and one union territory in India, which includes 42,146 study participants. “The SMART India study (translating research into clinical and community practice: a multicentre Statistical and economical Modeling of risk-based strAtified and peRsonalized screening for complicaTions of diabetes in India) was conducted in people aged Advancements in 40 years or above to estimate screening and intervention the burden of diabetes and its complications, In the past, and create non-physician “Diabetic retinopathy risk prediction personnel models.” would travel has long been with portable considered to be By assessing fundus cameras, ‘microvascular’ disease, capturing photos the population and its needs, to detect the but accumulated SMART India can early signs of evidence now reveals focus its efforts diabetic eye that diabetes also has and initiatives disease within where they are the community profound effects on most needed or in underserved retinal nerve cells even and hopefully areas. But we now intervene earlier. understand that though these changes earlier detection are not revealed by “The study has is beneficial, and fundus photographs shown that changes may glycemic control be occurring or ophthalmoscopic is suboptimal long before examination.” in about 75% of the evidence the participants becomes clear on – Dr. Thomas W. Gardner with known a fundus photo. diabetes.5 This is an important finding because the “Diabetic retinopathy has long been high prevalence of undiagnosed considered to be ‘microvascular’ diabetes and suboptimally controlled disease, but accumulated evidence diabetes can lead to an epidemic of now reveals that diabetes also has diabetes complications. The study profound effects on retinal nerve emphasizes the urgent need to cells even though these changes are identify and optimally treat people not revealed by fundus photographs with diabetes to reduce the burden or ophthalmoscopic examination,” of the condition,” Dr. Rajalakshmi Dr. Gardner explained. “However, shared. tests of retinal function often show

PIE MAGAZINE | December 2023

profound impairment of vision even when the retina appears nearly normal. We now understand that diabetes affects the entire neurovascular unit—the blood vessels, neurons, glial cells and microglial cells.” The silver lining, or perhaps more appropriately, the candy coating to this current situation is that due to enhanced screening protocols, earlier intervention and improved treatment modalities, eye care professionals— particularly retina specialists—are better equipped than ever before to manage the eyes of millions. Despite the continuing growth in the number of people with diabetes at staggering rates and the increasing prevalence of diabetic retinopathy, the severity of the disease has diminished. It can now be managed at earlier stages, reducing the devastating outcomes seen in past generations. The management of diabetic retinopathy can be critical to both the individual and their family. The individuals affected are often of working age, raising children and caring for aging parents. If they lose their capacity to work, provide for their family or drive, the effects can spiral far beyond the individual’s quality of life. That said, even when diabetic retinopathy or other complications have been detected and a treatment plan is in place, adhering to ongoing treatment and screening becomes a challenge in itself. Consider that in the era prior to anti-VEGF therapy for diabetic macular edema, diabetics would visit their ophthalmologist four times per year for monitoring, possibly involving laser treatment to stabilize vision. Today, anti-VEGF treatment promises to deliver vision improvement. However, this also comes with a need for monthly monitoring or treatment appointments—posing a challenge for both patients and retinal specialists. To address these needs, ongoing clinical research efforts are focused on extending the intervals between intravitreal anti-VEGF injections and exploring alternative therapeutic options, such as topical drops,

implants or one-time gene therapy treatments. The recent FDA approval of high-dose aflibercept allows for intervals of 12 to 16 weeks between intravitreal injections, effectively reducing the frequency of visits by half.

Technology’s impact on patient care Presentations of results from up-and-coming clinical trials at the recent American Academy of Ophthalmology (AAO) meeting did not disappoint. And while the retinal treatment pipeline does look a little like rush hour traffic, the future certainly looks bright. There are numerous clinical trials underway across all phases of development. To address compliance issues and potential disparities in care and access to care, several emerging agents are offering home-based options, such as topical or oral treatments, long-term implantables, or the generation of anti-VEGF through gene therapy. As we describe treatments and management strategies for diabetic retinopathy and macular edema, some of the most impactful influences may not come from drugs at all, but from growing technological applications. Dr. R. Rajalakshmi and her team at SMART India acknowledge how advancements in technology will help shape how we care for this growing number of patients. “Innovative technologies like smartphones, teleophthalmology6 and the use of artificial intelligence (AI)7 are valuable strategies to improve screening for diabetic retinopathy and reduce the burden on the healthcare system in India,” Dr. Rajalakshmi said. To gain a deeper understanding of the current technological advancements with direct applications to diabetic eye care, we turned to Dr. Rajiv Raman. He is a senior consultant in the Department of Vitreoretinal Services at Sankara Nethralaya and a professor at the Department of Medical Science and Technology at the Indian Institute of Technology in Madras.

“Over the past two decades, remarkable technological advancements have revolutionized diabetes management,” Dr. Raman shared. “The miniaturization of retinal cameras and the integration of AI for diabetic retinopathy detection have greatly improved DR screening accessibility.”

Experts agree that the best management strategy for the complications of diabetic eye disease is to prevent diabetes in the first place—meaning managing the actionable risk factors associated with the development of Type II diabetes. While we can’t change our age or gender, we do have some control over modifiable lifestyle-related risk factors, such as our blood sugar level, blood pressure and cholesterol level. These factors play a significant role in diabetes and its associated cellular and microvascular morbidities. These risk factor profiles are being refined by incorporating key measures to enhance our understanding of individuals who are likely to experience adverse outcomes, and who will need to be monitored more carefully and counseled accordingly.

“In recent years, there has been a promising shift towards identifying Dr. Raman emphasized the important blood-based biomarkers, such role of technology in screening, as serum cystatin, which can be allowing individuals to become their integrated into risk factor score own retina imaging experts. “There algorithms,” Dr. Raman shared. is an ongoing need for even simpler “This innovative approach offers the hardware that allows patients to potential for effective ‘prescreening’ capture retinal images themselves, of diabetic retinopathy. Combining essentially creating a ‘retinal selfie’ these blood-based biomarkers with for easy monitoring,” he said. risk assessment algorithms could provide a nonAI will also have invasive and “In recent years, an important efficient means there has been a role to play in of identifying managing diabetic individuals promising shift towards eye care in the at risk of DR, identifying blood-based allowing for timely years to come. biomarkers, such as “Harnessing the intervention power of big data, and ultimately serum cystatin, which it is now essential preventing vision can be integrated to develop loss.” populationinto risk factor score specific risk score Global algorithms.” algorithms,” initiatives – Dr. Rajiv Raman Dr. Raman for diabetic continued. “These algorithms would retinopathy play a pivotal role in prioritizing DR screening for individuals at With the surge of diabetes globally, the highest risk. By tailoring risk screening for and managing diabetic assessments to specific populations, retinopathy will need to remain a we can optimize the allocation of health priority for the foreseeable resources and target interventions future. In response to this need, where they are most needed.” important initiatives are taking PIE MAGAZINE | December 2023

Cover Story

the lead to ensure that research continues and that patients and the public have access to validated sources of information and programs for education and awareness. Dr. Gardner shared his involvement with such a program, a legacy established by the icon and actress Mary Tyler Moore, in support of diabetes research. “The Mary Tyler Moore Vision Initiative* is working to eliminate blindness caused by

Contributing Doctors Dr. Thomas W. Gardner, MD, MS, works to determine how diabetes impairs vision and how vision can be restored in persons with diabetic retinal disease. He is a scientific co-director of the Mary Tyler Moore Vision Initiative and a professor of Ophthalmology and Visual Sciences, Molecular and Integrative Physiology and Internal Medicine at the University of Michigan. He also works to integrate patient care, teaching and research in a clinical department, and promotes the development of young clinician-scientists. tomwgard@med.umich.edu Dr. Rajiv Raman, MS, DNB, FRCS(Ed), Hon DSc, is a distinguished figure in the field of ophthalmology and medical technology in India. He is a senior consultant at the Department of Vitreoretinal Services at Sankara Nethralaya, a tertiary eye care organization in South India, and a professor at the Department of Medical Science and Technology at the Indian Institute of Technology, Madras. Dr. Raman’s influence extends globally as he serves as a section editor for the prestigious Nature Journal Eye, Scientific Reports and Heliyon. He is a member of the National Task Force on Diabetic Retinopathy, Government of India and the National Board of Examination in Ophthalmology (DNB). Dr. Raman’s expertise is reflected in his 18 authored chapters, including a pivotal chapter on telescreening for diabetic retinopathy in

diabetes by promoting a modern understanding of diabetic retinal disease. This initiative focuses on how the disease can be more effectively and quantitatively assessed, and how new endpoints for diagnosis and treatment can lead to earlier detection and vision restoration,” he said. A landmark workshop was held in October 2022, featuring 90 attendees with a diverse representation

multiple editions of Ryan’s RETINA. Dr. Raman is a pioneer in teleophthalmology in India and has collaborated with Google to develop and validate automated retinopathy detection algorithms. His research contributions cover various aspects of retinal diseases, with a strong focus on diabetic eye disease. eyesciinsights.com Dr. R. Rajalakshmi, MBBS, DO, FEDD, FRCS, PhD, is a senior consultant ophthalmologist and the head of Medical Retina at Dr. Mohan’s Diabetes Specialities Centre in Chennai, India, and a clinical researcher involved in Ophthalmic Research at Madras Diabetes Research Foundation (MDRF) for 19 years. She is passionate about diabetic retinopathy research. Her principal interests include cost-effective screening for diabetic retinopathy using smartphones for retinal imaging, automated detection of diabetic retinopathy using artificial intelligence and use of teleophthalmology/telemedicine technology for remote screening of diabetic retinopathy. She conceived and designed a validation study of a hand-held smartphone-based fundus camera for retinal color photography for cost-effective diabetic retinopathy screening. The first global study on ‘Automated detection of diabetic retinopathy using Artificial intelligence (AI) for smartphone-based fundus photography’ was from India, by Dr. Rajalakshmi and her team, and has over 300 citations.

PIE MAGAZINE | December 2023

drraj@drmohans.com

from around the world. Patients and representatives from leading biopharmaceutical, bio-tech, and medical device companies, as well as JDRF, the National Institutes of Health, the American Diabetes Association, the US Food and Drug Administration and others, met with researchers and clinicians from the United States, Europe, Japan, Singapore and Australia. The goal of the meeting was to discuss various methods for improved diagnosis of diabetic retinal disease, with an emphasis on visual function and ensuring that the voices of patients are heard. The next workshop was held in November 2023. * marytylermoore.org

References 1. Saeedi P, Petersohn I, Salpea P, et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th edition. Diabetes Res Clin Pract. 2019;157:107843. 2. Lundeen EA, Burke-Conte Z, Rein DB, et al. Prevalence of Diabetic Retinopathy in the US in 2021. JAMA Ophthalmol. 2023;141(8):747-754. 3. Anjana RM, Unnikrishnan R, Deepa M, Pradeepa R, Tandon N, Das AK, et al. ICMRINDIAB Collaborative Study Group. Metabolic non-communicable disease health report of India: the ICMR-INDIAB national crosssectional study (ICMR-INDIAB-17). Lancet Diabetes Endocrinol. 2023;11(7):474-489. 4. Rajalakshmi R, Vasconcelos JC, Prevost AT, Sivaprasad S, Deepa M, Raman R, Ramasamy K, Anjana RM, Conroy D, Das T, Hanif W, Mohan V. SMART India Study Collaborators. Burden of undiagnosed and suboptimally controlled diabetes in selected regions of India: Results from the SMART India population-level diabetes screening study. Diabet Med. 2023;40(10):e15165. 5. Raman R, Vasconcelos JC, Rajalakshmi R, Prevost AT, Ramasamy K, Mohan V, et al. SMART India Study Collaborators. Prevalence of diabetic retinopathy in India stratified by known and undiagnosed diabetes, urban-rural locations, and socioeconomic indices: results from the SMART India population-based crosssectional screening study. Lancet Glob Health. 2022;10(12):e1764-e1773. 6. Rajalakshmi R, UmaSankari G, Prathiba V, Anjana RM, Unnikrishnan R, Venkatesan U, JebaRani S, Shanthirani CS, Sivaprasad S, Mohan V. Tele-Ophthalmology Versus Face-toFace Retinal Consultation for Assessment of Diabetic Retinopathy in Diabetes Care Centers in India: A Multicenter Cross-Sectional Study. Diabetes Technol Ther. 2022;24(8):556-563. 7. Rajalakshmi R, Subashini R, Anjana RM, Mohan V. Automated diabetic retinopathy detection in smartphone-based fundus photography using artificial intelligence. Eye (Lond). 2018;32(6):1138-1144.

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PIE MAGAZINE | December 2023

Innovation

AMD TREATMENT

From Gene Therapies to Combo Treatments Unveiling fresh perspectives and the latest AMD breakthroughs at EURETINA 2023 by Hazlin Hassan

Renowned retina specialists gathered at the 23rd EURETINA Congress in Amsterdam to explore novel approaches to age-related macular degeneration (AMD), a leading cause of blindness in individuals over 55. Presentations delved into the challenges of current treatments, such as the lifelong burden of frequent injections, prompting a quest for alternatives. The Congress highlighted promising strides, including insights into geographic atrophy differences among ethnic groups, advancements in gene therapies and emerging trials offering hope for reduced treatment burdens.

t present, treatments for agerelated macular degeneration (AMD) and neovascular AMD (nAMD) require life-long, frequent injections to maintain efficacy, which poses a significant treatment burden for patients and often results in reduced compliance and undertreatment—leading to potentially limited outcomes. On the final day of the 23rd European Society of Retina Specialists Congress (EURETINA 2023), retina specialists from around the world gathered at the RAI Amsterdam Convention Centre in the capital city of the Netherlands to share some of the latest research findings—ranging from gene therapies, combination treatments and more. This was part

of efforts to seek alternatives to frequent injections, aiming to help patients preserve their vision. Here are some snippets from the session.

Ethnicity’s impact on GA growth According to Prof. Gemmy Cheung, the Arthur Lim Professor in Ophthalmology at the Duke-National University of Singapore Medical School, National University of Singapore, while epidemiological data suggests that geographic atrophy (GA) is rare among Asians, there are differences in phenotypes and growth rates between Asians and non-Asians.

PIE MAGAZINE | December 2023

A multicenter retrospective study carried out by Prof. Cheung and colleagues from the Asia-Pacific Ocular Imaging Society (APOIS) that compared Asian and non-Asian patients found specific differences between the ethnic groups in GA lesion phenotypes, associated features and growth rates. “Ethnicity was by far the factor that had the biggest effect on determining the growth rate,” she said. Participants included in the study were over 50 years old with GA secondary to age-related macular degeneration and had been followed for two years or longer. A total of 144 patients (169 eyes) were included. Her takeaway messages

generally well-tolerated in a long-term follow-up study and will continue to be followed for a total of five years. “With a single injection of ABBVRGX-314, patients demonstrate a long-term, durable treatment effect for Cohort 3 over four years and Cohort 4 over three years,” he said. ABBV-RGX-314-treated patients had stable vision and retinal thickness with a meaningful reduction in treatment burden across all dose levels. There was an 85% reduction in the annualized injection rate.

include the following: The differences in GA phenotypes in Asians compared to non-Asians were smaller lesion areas, fewer foci and less bilateral cases. Asians were also associated with a thicker choroid and fewer drusen. Ethnicity was the biggest factor associated with the growth rate of GA: It was slower in Asians compared to non-Asians. Subgroups with drusen and larger baseline lesion area showed less difference between faster progression in Asians and nonAsians.

An OASIS of hope Promising results are being seen in a number of trials of emerging therapies for exudative AMD, according to a presentation by Dr. Arshad M. Khanani, director of clinical research at Sierra Eye Associates, and clinical associate professor at the University of Nevada, Reno School of Medicine, USA. The OPT-302 trial showed positive results in the phase 2 study, where patients with nAMD who were treated with ranibizumab plus sozinibercept (OPT-302) had greater gains in visual acuity compared to those treated with ranibizumab alone. Superior vision gains were seen at week 24 with sozinibercept 2 mg combination therapy, said Dr. Khanani. There was also improved visual acuity in patients with occultcontaining lesions. Meanwhile, subretinal gene therapy with RGX-314 continues to be

Intravitreal gene therapies are also being trialed involving ADVM022 for the continuous delivery of aflibercept, as well as 4D-150 for the continuous delivery of aflibercept and VEGF-C RNAI. Interim results from the PRISM trial showed that intravitreal administration of 4D-150 to adults with wet AMD was safe and generally well-tolerated with no inflammation in 14 of 15 patients. There were no dose-limiting toxicities, treatment-related serious adverse events, or hypotony reported. There was stable best corrected visual acuity (BCVA) and central subfield thickness (CST) through week 36. Enrollment for the Phase 2 dose expansion stage of the PRISM trial (n=50 patients) has been completed. In addition, tyrosine kinase inhibitors (TKIs) are also being studied in clinical trials, namely OTX-TKI, EYP1901 and CLS-AX. Dr. Khanani continued, stating that the 12-month results from a Phase 1 trial support the advancement of the OTX-TKI axitinib intravitreal implant that is being developed for the treatment of diabetic retinopathy and other retinal diseases, including pivotal trials in nAMD. It maintained vision and CST comparable to aflibercept 2mg at 8 week treatment intervals, with an 89% reduction in treatment burden over a 12-month period with 605 of patients being rescue-free up to 12 months. Safety data showed it was generally well-tolerated.

Implant bioresorption and axitinib elution were consistent with previous clinical data, potentially allowing a window for redosing, Dr. Khanani added. Pharmacodynamic effects observed in this trial support the characteristics of a potential treatment for nAMD, with durability between nine to 12 months with a single injection. OTS-TKI pivotal trials innAMD will be initiated soon. The safety and preliminary efficacy of EYP-1901, a novel intravitreal injection therapy consisting of vorolanib, a small molecule pan-VEGF receptor blocker, as a maintenance therapy in patients with previously treated nAMD were investigated in the Phase 1 DAVIO trial. It found that there was a 73% reduction in treatment burden at 12 months. Results for phase 2 of the trial will be out in Q4 2023. The use of CLS-AX (axitinib injectable suspension) for suprachoroidal use may improve the treatment landscape with potential safety, efficacy, durability and adoption benefits, Dr. Khanani said. Compartmentalization may eliminate symptomatic floaters and anterior segment side effects. It had no doselimiting toxicities and exhibited early signs of durability and reduction in treatment burden. In the OASIS study, there was a 72% reduction in treatment burden over the first three months. In its extension study through 6 months, there was a 77% reduction in treatment burden. CLS-AX is currently being evaluated in the ODYSSEY Phase 2b clinical trial.

Editor’s Note The 23rd Annual EURETINA Congress took place on October 5 to 8, 2023, in RAI Amsterdam Convention Centre, Amsterdam, The Netherlands. Reporting for this story took place during the event.

PIE MAGAZINE | December 2023

Enlightenment

WOMEN IN OPHTHALMOLOGY

R Carving a Clear Sightline Prof. Dr. Gemmy Cheung aims to bring women ophthalmologists to the forefront by Chow Ee-Tan

Prof. Dr. Gemmy Cheung is the Congress President of the upcoming Asia-Pacific Vitreo-retina Society Congress in 2024 and an esteemed figure in ophthalmology, is dedicated to mentoring and creating an inclusive environment for young women in the field. She not only serves as a mentor for aspiring ophthalmologists but also actively supports international fellowships to strengthen training opportunities for ophthalmologists from developing countries.

PIE MAGAZINE | December 2023

enowned in the fields of ophthalmology and vitreoretinal surgery, Prof. Dr. Gemmy Cheung is currently the Arthur Lim Professor in Ophthalmology at the Duke-NUS Medical School, National University of Singapore. An accomplished retina specialist and the Congress President of the APVRS Congress in 2024, Prof. Cheung is dedicated to mentoring and providing an inclusive environment for young women ophthalmologists across the region. In her capacity as head of the Medical Retina Department at the Singapore National Eye Centre, as well as head of the Retinal Research Group at the Singapore Eye Research Institute, Prof. Cheung has established a vibrant platform for exchanges between scientists and clinicians and has opened up abundant training opportunities for fellows, researchers and Ph.D. students. “I believe that training and role modeling are very important for continuing to encourage the development of women in ophthalmology,” Prof. Cheung said

in an interview with PIE magazine. “It is not that long ago that we had the first woman ophthalmologist, and today we witness a substantial representation of young women in medical school, graduating from medical school and entering residency in ophthalmology.”

“In fact, we can start by organizing efforts among local trainees in our department, extending these initiatives to international platforms, to build up a network for women at various stages of their careers, whether it is in training or beyond,” she added.

Improving opportunities for women ophthalmologists

She highlighted one of the challenges faced by many talented young women ophthalmologists when it is time to start looking after their families. The majority often opt for part-time career involvement because of family responsibilities, inevitably leading to a delay in their career progression.

Over the years, Prof. Cheung has had the opportunity to train several fellows from Dubai, India, Myanmar, the Philippines, Malaysia, as well as China, where the local training system “I find it extremely is probably not as humbling to see the well-established determination of as in Europe or Singapore. these young women

who go overseas to

“So, I think we need to look into how we can support these women ophthalmologists during this phase and encourage them to return to full-time roles once their children have grown up,” Prof. Cheung enthused.

As a renowned figure in the international ophthalmology community, Prof. Cheung has not only established an extensive network of international collaborators but has also taken on international leadership roles in the field of AMD and its Asian variant, polypoidal choroidal vasculopathy (PCV). She is also a council member of the APVRS and has been selected as the Congress president of the 17th APVRS Congress to be held in Singapore in late 2024. “It is, indeed, a great honor for me and my team to organize the Congress and to welcome all the delegates to Singapore,” she enthused. “Currently, we’re working very hard within the local organizing committee together with the Secretariat in Hong Kong.”

She said it is “It is also an opportunity to work with look for opportunities much harder for a team that encompasses the College to advance these women of Ophthalmology in Singapore, the ophthalmologists Singapore Society of Ophthalmology, themselves. That spirit to find the right and the representatives from the is really important attachment for a public hospitals and private sector,” and we need to training program, she continued. Addressing which can help encourage that.” gender them progress from Prof. Cheung and her team will and ethnic year one to year five be organizing an exciting and of their ophthalmology training in a informative scientific program while diversity in the field very structured way. ensuring that delegates and speakers Another aspect that Prof. Cheung is have a pleasant stay in Singapore. “I find it extremely humbling to see looking into is increasing awareness the determination of these young to address gender and ethnic “We will prepare engaging women who go overseas to look for diversity in the international realm. sightseeing and social programs. opportunities to advance themselves. With the audit program, we That spirit is really important and “It is a great time for women in look forward to hosting a Young we need to encourage that,” she ophthalmology to come together Ophthalmologists’ symposium as continued. and actively volunteer their services well as some sessions for Women in in various roles because there are Retina,” she shared, emphasizing that Prof. Cheung believes now more and more opportunities at the organizing committee will feature ophthalmologists from Singapore and every level,” she substantial other developed countries should shared. representation “It is a great time support international fellowships, from women. for women in such as the Asia Pacific Academy of As a mentor, ophthalmology to come She also Ophthalmology and the Fred Hollows Prof. Cheung Foundation. This support aims to also considers mentioned that together and actively help ophthalmologist trainees from herself a mentee, a growing trend volunteer their services developing countries obtain training always learning within the APVRS in various roles because in places with a more established new things as Congress is to there are now more and strategically system. part of a peer group. “Learning collaborate with more opportunities at “This kind of scheme is important for doesn’t have to other societies every level.” both genders. But returning to the be unidirectional. worldwide, such topic of women, I would encourage I always continue as the Canadian them to seize this opportunity as this to learn from my colleagues and I Visual Rational Society, the Royal would be a very good opportunity for would encourage an open discussion College of Ophthalmologists in them to broaden their horizon, meet to share our knowledge and findings the UK, as well as various other new people, and, in turn, build up with one another,” she added. institutions or societies that are their confidence,” she continued. going to co-sponsor the symposiums. PIE MAGAZINE | December 2023

Enlightenment

WOMEN IN OPHTHALMOLOGY

This aims to increase diversity, whether it’s gender or international representation.

passions and talents, as well as understanding your strengths and your weaknesses,” she noted.

A passion for eye care

She encourages her trainees and mentees to aim high and not settle for less. Once they have set their goals, the second challenge is all about time management.

Looking back, Prof. Cheung knew she wanted to be in the medical field. Her first choice was either a career in surgery or a role within the medical department. “Ophthalmology offers a nice balance between medical and surgical aspects. Within this field, there are numerous avenues to explore, so I further sub-specialized in retina. I am also passionate about age-related macular degeneration,” she shared. “Within ophthalmology itself, there are also a lot of different opportunities, each emphasizing different aspects. For example, some focus on imaging, while others are on more technical surgical aspects,” she continued. Prof. Cheung is drawn to the imaging aspects because she can correlate them with treatment outcomes. Another aspect of ophthalmology that excites her is the abundance of clinical trials. The treatments administered to patients are supported by a wealth of clinical trial data. “This is another aspect that keeps us going, keeps us always looking out for the next frontier,” she said. The timing of scientific development is also a push factor for her. “For example, when I started fellowship training, it was when anti-VEGF therapy started to come into clinical practice and there were a lot of opportunities to witness how new drugs have developed. We witnessed the testing of these drugs. Some of them came through to the clinic, and some of them fell through and did not succeed in the clinical trial. All in all, it has been a really exciting journey,” Dr. Cheung shared.

A balancing act When asked about the challenges that women ophthalmologists face, Prof. Cheung believes they fall into two areas. “The first is deciding on your career goal and calling. The decision should be based on identifying your

“You can get tips from colleagues, friends, or family on how to balance your time and commitments between home and work. Effective time management and hard work are essential skills for both men and women,” she added. However, Dr. Cheung believes that, on the whole, women do take up more roles in terms of caring for the family and looking after their kids. Although, increasingly, there is a positive trend with new-age men actively taking part in household responsibilities. Prof. Cheung is fortunate to have a husband who actively shares parenting responsibilities. He is also an ophthalmologist, and they underwent training around the same time. Their two sons are currently in university. When it comes to juggling work and family life, her advice to women is to prioritize what is important. Recognizing that we only have 24 hours in a day, we must focus on what is more urgent, she said. “Don’t bite off more than you can chew. But whatever that you commit to doing, deliver them well,” she advised. When asked about the most satisfying aspect of her career, Prof. Cheung always relishes the research work that she continually pursues. “What we practice now is different from what we learned in medical school. The field of science and medicine is evolving all the time. What keeps me very excited is to hopefully stay at the cutting edge of where the evolution of the understanding is—be it about how diseases occur (pathogenesis), how we treat patients, or whether we’re developing new therapies to bring back to our patients,” Prof. Cheung concluded.

PIE MAGAZINE | December 2023

Contributing Doctor Prof. Dr. Gemmy Cheung is currently the Arthur Lim Professor in Ophthalmology at the Duke-NUS Medical School, National University of Singapore. She is head of the Medical Retina Department at, Singapore National Eye Center, and head of the Retina Research Group at the Singapore Eye Research Institute (SERI). Her research interests focus on Asian retinal diseases, specifically age-related macular degeneration (AMD), polypoidal choroidal vasculopathy (PCV), and myopic macular degeneration. She has published more than 300 peer-reviewed articles, including high-impact work advancing the understanding of AMD, especially in the context of an Asian population, and secured research funding of more than SGD $40 million. Internationally, Prof. Cheung has assumed leadership roles in the field of AMD and PCV. She has delivered more than 200 invited lectures and has trained numerous fellows and Ph.D. students. Prof. Cheung has represented the Asian-Pacific perspectives at high-level international ophthalmology meetings, including the annual American Academy of Ophthalmology subspecialty day, the EURETINA Congress, and the Asia-Pacific Vitreo-retina Society Annual Congress. She is a council member of the AsiaPacific vitreo-retina society, regional advisor to the American Academy of Ophthalmology, Exco member of the International Retinal Imaging Society and the AsiaPacific Ocular Imaging Society, and credentialing committee member (past) of the prestigious Macula Society. She serves on the editorial boards of the American Journal of Ophthalmology, Asia-Pacific Journal of Ophthalmology, Retina, Eye, and PLoS One. She has received several prestigious awards from the American Academy of Ophthalmology, the Asia-Pacific Academy of Ophthalmology, the Asia-Pacific Vitreo-retinal Society, and the Macula Society. gemmy.cheung.c.m@singhealth.com.sg

EVRS 2023

Back with a Roar!

Conference Highlights conference but also reveled in the enchantment of Cappadocia.

An enchanting gala night

The European VitreoRetinal Society is back after a threeyear hiatus by Dr. Perfecto E. O. R. Cagampang III

The coveted vitreoretinal conference took place from August 31 to September 3 in Cappadocia, Turkey, and was attended by over 500 delegates representing 53 countries.

The opening night at Perissia Hotel provided an opportunity for members to meet and greet. Meanwhile, the gala night at Uchisar Kaya Hotel, carved out of Cappadocian rock, also attracted a significant turnout. On the second night, the event culminated with the presentation of awards to the deserving winners in various categories: Best Oral Presentation Award: Mageed Gerges Best Video Presentation Award: Şengül ÖZdek Best Poster Presentation Award: Dilek Güven A special award, the EVRS Ambassador Award, was given by the incumbent president, Dr. Giampaolo Gini, to Dr. David Pelayes and Dr. Perfecto E. O. R. Cagampang III.

A farewell party like no other The farewell night proved to be a show-stopping event, highlighting the talents of several members. The officers kicked off the evening with a performance to the tune of Jennifer Lopez’s “Papi,” followed by a Eurovision-style karaoke contest. Dr. David Martins, Dr. Lalit Agarwal and Dr. Melda Yenerel were followed by the winner Dr. Elçin Süren who sang with a flute musical show.

fter a three-year break from in-person conferences, the European VitreoRetinal Society (EVRS) international congress was finally back this year. The EVRS meeting was not held from 2020 to 2022 due to the global COVID-19 pandemic and associated travel restrictions. However, educational activities continued with webinars during this period, including a one-day live surgery event in April 2022.

as a global entity. For a community of eye specialists with strong support from its ophthalmology members, the congress started on a high note and ended with a bang!

Beyond borders

Dr. Sengul Ozdek, together with EVRS president Dr. Giampaolo Gini, Dr. Barbara Parolini and the organizers, brought together the best eye doctors from Europe and around the world. The event featured scientifically engaging sessions characterized by a friendly and openminded atmosphere.

The European VitreoRetinal Society welcomed members from beyond European borders, establishing itself

The presence of attendees filled the entire region with eager members who not only appreciated the

The European VireoRetinal Society has once again demonstrated its resilience and is now ready to soar and embark on more congresses in the future.

Editor’s Note The European VitreoRetinal Society (EVRS) was held from August 31 to September 3, 2023. Reporting for this story took place during the event.

PIE MAGAZINE | December 2023

Conference Highlights

AOS-PAO CONGRESS 2023

From COVID Challenges to Collective Progress

Singapore, Thailand and Vietnam— but also delegates from Australia, Hong Kong, USA and South Asian countries. This event also marked the first in-person meeting for many AOS members since the COVID-19 pandemic, as the previous year’s congress had been conducted virtually in 2022.

AOS-PAO Congress 2023 sets sights on global All these factors contributed to the trends and regional perspectives by Joanna Lee sense of camaraderie during the Advancing together, the joint AOS-PAO 2023 Congress has made substantial progress, overcoming pandemic challenges and delving into global trends and regional perspectives that influence the trajectory of ophthalmic care.

he recently concluded 6th ASEAN Ophthalmology Society (AOS) Congress, held in collaboration with the Annual Congress of the Philippine Academy of Ophthalmology (PAO) from October 18 to 20 in Manila, Philippines, was a memorable celebration characterized by warm camaraderie and an optimistic outlook for a better future in eye care. The Honorable Teodoro J. Herbosa, Secretary of the Philippine Department of Health, graced the event with his keynote speech, alongside welcoming addresses delivered by PAO President Dr. Vicente Victor D. Ocampo Jr. and AOS Congress President Dr. Ruben Lim Bon Siong. During the Plenary Session, the current Secretary General, Prof. Paisan Ruamviboonsuk, delivered the Congress’ first AOS Lecture entitled

Ophthalmic Care in Southeast Asia: The Last Ten Years and the Next Ten Years, demonstrating the current landscape of ophthalmic care in the region and the future goals for its improvement.

AOS celebrates 10th anniversary This year’s Congress, held at the SMX Convention Center in Manila, also celebrated the 10th founding anniversary of the ASEAN Ophthalmology Society. The AOS was founded during a summit in Bangkok, Thailand, on May 18, 2013, when ophthalmology representatives from 10 countries came together to enhance collaboration and strengthen their efforts. Delegates to the AOS-PAO Congress comprised not only representatives from member countries —Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines,

PIE MAGAZINE | December 2023

Congress as participants enjoyed a glittering get-together at the Pista Gala Fellowship Night. The Filipino word “pista” comes from the Spanish word “fiesta,” which means festive celebrations. Attendees had the opportunity to rekindle ties with one another in the spirit of regional and international collegiality, all the while enjoying unique traditional Filipino fare and lively local entertainment.

On the road forward: Key insights and lessons learned In line with the Congress’ theme, Global Trends Through a Regional Perspective, the topics that covered all subspecialties in the field touched on new developments and trends within the region. Some of the highlights of the AOSPAO Congress were the Special Sessions. One in particular was a poignant discussion addressing the impact of COVID-19 on practices within the region. Representatives from the Philippines, Thailand and Malaysia shared their valuable insights into their respective countries’ ophthalmologic responses and lessons learned.

Specifically, doctors from the Philippines shared insights into COVID infection-related uveitis, vaccination-associated uveitis and risks of flare-ups in uveitis patients with COVID, as well as retinal vein occlusions and optic neuropathies linked with COVID. The session also included a panel discussion on the emerging role of artificial intelligence (AI) and telemedicine. It explored the changes brought about by these advancements in the management and surveillance of eye patients. The second Special Session shined a spotlight on the meeting of interregional minds through presentations by the South Asian Academy of Ophthalmology. Comprising ophthalmic societies from eight member countries – namely, India, Bangladesh, Pakistan, Nepal, Sri Lanka, Afghanistan, Bhutan and the Maldives – the session provided insights from diverse South Asian perspectives. The regional collegiality also provided a platform conducive to open and candid discussions during the sessions. For instance, in a laser vision correction session, the panel discussed their respective countries’ experiences in discerning marketing hype from clinical reality.

Community ophthalmology The Philippine Journal of Ophthalmology defines community ophthalmology as the “delivery of eye care involving preventive, curative, promotive and rehabilitative activities as a holistic approach.” It is a “health-management approach in preventing eye diseases, lowering eye morbidity rates and promoting eye health through active community participation at the ground level.” During the AOS-PAO Congress, discussions focused on the relatively emergent subspecialty in the region, addressing topics such as Integrated People-Centered Eye Care and Universal Eye Healthcare (UEHC). The former session featured expert insights and ground experiences in integrated eye care from practitioners and administrators from Australia, Laos, the Philippines and Singapore. Meanwhile, practitioners

and experts from Malaysia, Vietnam, Thailand, Singapore and India shared the challenges of translating policy into action, managing ophthalmic drugs and the complexities of UEHC and HMO relationships.

their international colleagues through collaborative research efforts. The papers reflected a wealth of the latest data and learnings gleaned from several sub-disciplines in ophthalmology.

Focus on ophthalmic education

For instance, an interventional study on the Epidemic of Rhino-Orbital Cerebral Mucormycosis (ROCM) in COVID-19 Pandemic as well as a few rarely discussed diseases, such as Purtscher-like Retinopathy as a Presenting Manifestation of Systemic Lupus Erythematosus and Distinguishing Characteristics of Acute Vogt-Koyanagi-Harada Disease from Acute Central Serious Chorioretinopathy Using the Zeiss Cirrus™ HD-Optical Coherence Tomography were featured, among others.

Recognizing the importance of training and development to the cultivation of best practices and growth in ophthalmology within the ASEAN region, the Congress dedicated several sessions on ophthalmic education and training. Participants from the Philippines, Thailand and Malaysia shared their challenges and experiences in ophthalmology residencies. Discussions not only centered on the current state of ophthalmological training in the ASEAN region and its future but also on the use of technology in training, such as virtual reality classrooms, e-logbooks and teleconferencing. Reflections on lessons learned during the COVID-19 pandemic were also discussed in the session entitled Best Practices Learned After the Pandemic. This was part of the collective effort to press forward in the aftermath of the pandemic.

Eyes on the next generation Young ophthalmologists were not left out of the AOS-PAO’s efforts in presenting topics tailored to the current times. These sessions for the up-and-coming ophthalmic practitioners included discussions on prospects beyond clinical practice and exploring avenues such as the corporate world, research, leadership or academia. Additionally, a dedicated segment on soft skills was featured in the Young Ophthalmologists’ session. In the Personality Development session, participants had the opportunity to learn about “power dressing combining fashion and passion,” getting technical with technology, as well as familiarizing themselves with AI. The event also featured eight Free Paper sessions, providing a platform to showcase a myriad of findings from Filipino ophthalmologists and

Balancing work and play However, it wasn’t just all hard work and no play at AOS-PAO Congress 2023. Besides enjoying the famously congenial Filipino hospitality at the conference, participants also had a chance to relax after the event. Some chose to savor old Manila via a visit to Intramuros, a National Historical Landmark in the Philippines. Others enjoyed the sights and sounds of both the old and new Manila, which included going on a food tour in Binondo. For the more adventurous participants, there was the option to venture outside of Manila to visit scenic Tagaytay and other attractions, such as the Puning Hot Spring and Sand Spa. Additionally, some delegates took on the challenge of a crater hike up Mount Pinatubo, adding an element of exploration and outdoor adventure to their overall experience.

Editor’s Note The 6th ASEAN Ophthalmology Society Congress, in conjunction with the Annual Congress of the Philippine Academy of Ophthalmology, was held from October 18 to 20 in Manila, Philippines. Reporting for this story took place during the event.

PIE MAGAZINE | December 2023