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ASIA-PACIFIC’S FIRST MAGAZINE ON THE POSTERIOR SEGMENT

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HEROIC ISSUE December/January 2018 www.piemagazine.org

magazine

(Come see PIE Person LIVE at Media MICE Booth #3A-04 at APAO Hong Kong!)

posterior segment • innovation • enlightenment

Cover Story

The Adventures of

PIE Person

Vanquisher of Posterior Segment Disease

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Page

OCT and OCTA Innovations

The New Gold Standard in Ophthalmic Imaging Page 42

There Must Be a Better Way! Introducing the Frag Bag for Dislocated Nuclear Material Page

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Inside this issue...

Posterior Segment

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Looking Deeper into the Deviations: Pediatric Screening for PHPV

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Early Detection and Intervention: An Unmet Need in Age-Related Macular Degeneration

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Controversy in Treatment of Ocular TB

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The Surprising Side Effect of Birth Control Pills on the Eyes

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YAG Laser Vitreolysis Improves Symptomatic Vitreous Floaters

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PCV Sufferers Can Rejoice Over a Better Treatment Option

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There Must Be a Better Way! Introducing the Frag Bag for Dislocated Nuclear Material

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Matt Young

CEO & Publisher

Gloria D. Gamat Chief Editor

Brooke Herron Associate Editor

Ruchi Mahajan Ranga Project Manager

Timmo Gunst

Publications & Digital Manager

Writers

April Ingram Collins Santhanasamy Hazlin Hassan Khor Hui Min Olawale Salami www.piemagazine.org Published by

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6001 Beach Road, #19-06 Golden Mile Tower, Singapore 199589 Tel: +65 8186 7677 Fax: +65 6298 6316 Email: enquiry@mediamice.com www.mediaMICE.com

Cover/Cover Story Art

Prafulla Badgujar

Innovations in Retinal Vein Occlusion on Spotlight at APVRS 2017

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ZEISS Brings Innovation to APVRS 2017

Enlightenment Real Life Superheroes: Quantel Medical Sponsors Classic Cars Charity Run

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Commercial DSLRs: An Affordable Low-Cost Alternative for Vitreoretinal Surgery Recording

Passion for Filmmaking While Working in Ophthalmology

Conference Highlights

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Media MICE Pte. Ltd.

The Adventures of PIE Person: Vanquisher of Posterior Segment Disease (a.k.a. Evil Eye)

Innovation

Graphic Designers

Winson Chua Patalina Chua

COVER STORY

APAO 2018 Brings “Creativity and Technology without Boundaries� to Hong Kong Changing the Clinical Paradigm in PCV Management The Posterior Segment was Front and Center at APVRS 2017 Poster Alley

We are looking for eye docs who can contribute articles to PIE magazine. Interested? Let's talk! Send us an email at enquiry@mediamice.com.

42 43 44 47

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OCT and OCTA Innovations: The New Gold Standard in Ophthalmic Imaging

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When Front and Back of the Eye Overlap: Summary of Posters at ESCRS 2017

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Back-of-the-Eye Clinical Pearls Abound in Posters at AA0 2017 AVRTT@6 Invites Vitreo-Retina Experts to a Live Surgery Workshop

To place an advertisement, advertorial, symposium highlight, video, email blast, or other promotion in PIE magazine contact CEO Matt Young at matt@mediamice.com.


PIE MAGAZINE LETTER TO READERS

Dear Reader, H

aving awoken late at our staff’s Airbnb apartment in Lisbon at ESCRS 2017, I meandered around the flat alone. The rest of the PIE staff had flown out already, and had encouraged me to see more of Lisbon. Left to my own devices, I stayed in, put on some alternative rock CDs, and leafed through the tourist magazines nearby instead. An easier, lazier way to “see” Lisbon, to be sure. And then a spark of imagination occurred. One of the tourist magazines was done in the style of comics. I thought to myself, “PIE Man!” In other words, we would make superhero outfits to fit with a superhero theme of the next issue of PIE Magazine, which is the one you’re currently reading. After all, every day there are superheroes of the posterior segment in Asia-Pacific. They’re called ophthalmologists. And they are rising to the challenge of defeating the region’s most serious of eye diseases. Throughout the region, the cataract backlog has been addressed, and while there is still plenty of work to do, retinal disease is the new frontier. It will take super-ophthalmic effort to defeat it. With one caveat. Having been a member of OWL (Ophthalmic Women Leaders, recently amended to Ophthalmic World Leaders), I’m cognizant of the challenges women face in our industry. Further, the issues ophthalmic women face in Asia-Pacific are very different from the issues they face in the West. Hence, rather than naming the central character of our issue “PIE Man”, we decided to name them “PIE Person.” Because the heroes out there in Asia-Pacific are people; both women and men. For our Cover Story we interviewed three ophthalmologists, who turned out to be PIE Men. But then, we will hear from PIE Women directly at the 33rd Asia-Pacific Academy of Ophthalmology (APAO) Congress. At Media MICE Booth #3A-04 at APAO in Hong Kong, February 8-11, we are filming our new video series called PIE Talks, which is about deeper issues beyond the clinical, and our first topic is the challenges of Women in Ophthalmology. This series will be filmed and blasted out by the APAO to its database, which includes 50,000+ ophthalmologists in Asia-Pacific. Indeed, stop on by Media MICE Booth #3A-04 to meet PIE Person, and their sidekick, ANT Person (Anterior Segment Person) at APAO Hong Kong. I should note that we are honored to be selected as the official media partner for the APAO Hong Kong. This is a milestone for us, because having launched PIE Magazine at APAO Singapore in 2017, to be the official media partner of APAO Hong Kong after only one year is something we never envisioned. As you probably know by now, we do things a little differently at PIE Magazine (Posterior Segment - Innovation - Enlightenment). Our magazine looks different from the traditional ophthalmology magazine. We dress differently at conferences. And we have a different point of view; namely,

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we believe the industry can address scientific and medical subjects while having a joyful time doing just that. We can let our guard down, open up, dress in something other than a suit and tie, and forge true industry relationships along the way. And we can do it all in Asia-Pacific, where we are the first and only magazine on the posterior segment. While there were many early supporters of PIE Magazine, there also have been late bloomers - companies and physicians that took time to warm up to our unique style and presence. We respect that. Yet, given the fact that we are now the official media partner of APAO Hong Kong (and also, we were the official media partner of the Asia-Pacific Vitreo-retina Society - or APVRS - in December 2017) we can legitimately say that we are legitimate. There is no denying now that PIE Magazine is established, successful and partnering with industry, physicians and the most important societies in the world. And don’t forget to read the APAO Show Daily (congress newspaper) by PIE Magazine, where most of our advertisers appear this time around… thank you again sponsors! We kept saying, advertise in the APAO Show Daily! Hence, dear reader, you win in this issue too, with our largest issue yet chock full of editorial content. We thank our friends who were there with us from Day 1. And we encourage others to get involved. There has never been a time like now for the posterior segment in Asia-Pacific. If you’re interested in getting involved, as always feel free to write me directly at matt@mediamice.com. Or, just look for me at a show. I’m hard to miss. All the best for 2018! P.S. That alternative rock CD I listened to for inspiration was Radiohead’s OK Computer. A masterpiece.

Matt Young CEO & Publisher PIE (Posterior Segment - Innovation - Enlightenment) Magazine


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

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 – 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: mark.gillies@sydney.edu.au]

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: vishalisara@yahoo.co.in]

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POSTERIOR SEGMENT PHPV SCREENING

Looking Deeper into the Deviations

Pediatric Screenin

Not screening children with eye deviations is an accident waiting to happen.

by April Ingram

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on’t get me wrong . . . children are lovely – but they can also be a challenge. Those who perform vision and ophthalmic screening of pediatric populations know this to be particularly true. Despite their short attention spans and inability to communicate their symptoms, effective screening is necessary throughout a child’s development. It is estimated that 2 to 4% of children have an eye problem that requires treatment – and failure to detect and address these

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various ocular conditions or pathology can have dire consequences. Dr. Rashmi Kumari and Dr. Bhawesh Chandra Saha, Senior Ophthalmology Residents in Patna, Bihar, India, highlight the need for thorough screening of children with eye deviations in their recent publication in the September 2017 issue of Journal of Clinical and Diagnostic Research. They presented a case of a 15-yearold male with bilateral Persistent Hyperplastic Primary Vitreous (PHPV),

also known as Persistent Fetal Vasculature (PFV), without leucokoria, who was misdiagnosed with congenital esotropia with amblyopia. In infancy, he was noted to have an inward deviation and abnormal eye movements of both eyes, and from the age of 7, he complained of defective vision. He was diagnosed with congenital esotropia and his refractive errors were addressed. His family was assured that correction of his residual squint would be treated when he was older.


ng for PHPV At age 15, his symptoms had continued to progress, and he was referred for evaluation of his visual acuity decline and persistent deviation by the tertiary eye center in Patna, Bihar. On slit lamp examination, a fibrous band attached to the posterior surface of the lens capsule was clearly observed in both eyes. This finding was confirmed by ocular ultrasound which showed a thick echogenic membrane-like structure that extended from the posterior surface of the lens to optic nerve head. Examination of the posterior segment revealed a falciform fold arising from the optic disc. Axial length measurements were also suggestive of microphthalmia. These findings all pointed to a diagnosis of bilateral PHPV – and a severely delayed diagnosis at that. Although there was no systemic abnormality detected (as may be expected in bilateral cases), visual acuity could not be improved with refractive correction. This suggests that stimulation deprivation amblyopia had already occurred, likely years earlier. The visual prognosis for this young man was very poor and surgery for the deviation would only provide cosmetic correction; therefore his parents opted not to proceed with surgery. PHPV is a congenital anomaly, resulting from failure of the embryological, primary vitreous, and hyaloid vasculature to regress. In full-term infants, it typically presents unilaterally, without any associated systemic findings. Reports of bilateral PHPV are quite rare, and the vast majority are associated with a systemic

syndrome such as trisomy 13, 15, or 18, Norrie’s disease, or Warburg’s. This case was also unique in that there was no white pupillary reflex, which may have contributed to his delayed diagnosis. Parents will often notice, and be concerned by, a white reflex, prompting earlier examination and intervention. Recommendations for PHPV management include surgery at an early age, prompt optical correction with contact lens, and aggressive amblyopia for successful visual rehabilitation. Surgery in infancy is often required, because many eyes with PHPV develop severe glaucoma, retinal detachment, intraocular hemorrhage, or phthisis. It was surprising, and fortunate, that this young man did not develop these serious complications or require enucleation. Although the patient had been examined by numerous doctors since infancy for his deviating eyes and

poor vision, a complete examination including dilated fundoscopy was never attempted, likely because an alarming pathology, such as leukocoria, was not obvious. Drs. Kumari and Saha note that the diagnosis of PHPV was made quite easily on slit lamp examination with dilated pupil, particularly in this case as the media remained largely clear. They stress the importance of a thorough detailed posterior segment evaluation in every child presenting with squint and nystagmus. Even though visual prognosis in eyes with PHPV is poor, early intervention and management is critical to preserve some degree of productive vision for the child. This case demonstrates just how essential screening of the posterior segment is for children with deviated eyes in order to ensure the absolute earliest detection and management of such pathologies.

Reference: Kumari R, Saha BC .Bilateral Persistent Hyperplastic Primary Vitreous - A Rare Case Report. J Clin Diagn Res. 2017;11(9):ND01-ND02.

About the Contributing Doctors Dr. Rashmi Kumari is the Senior Resident in the Department of Ophthalmology at the Regional Institute of Ophthalmology (RIO) and Indira Gandhi Institute of Medical Science in Patna, Bihar, India. Dr. Kumari was AIOS 2016 APOS Pradeep Swarup Award Winner and delivered a Keynote Address at the 2017, Annual Conference of All India Ophthalmological Society. [Email: dr.rchandras08@gmail.com]

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POSTERIOR SEGMENT OCULAR TB

Controversy Ocular TB Clearly there is still some controversy over ocular TB.

in Treatment of

by Olawale Salami

Anti-tuberculous therapy in a real-life clinical setting significantly reduced the number of flare-ups and enabled long-term remission in patients with presumed ocular tuberculosis.

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uberculosis (TB) remains a global health challenge: The World Health Organization (WHO) estimates that 10.4 million cases and 1.3 million deaths were recorded worldwide in 2016. And although Mycobacterium tuberculosis typically affects pulmonary tissue, the infection may present a myriad of extrapulmonary manifestations. Intraocular tuberculosis presenting as posterior uveitis may be difficult to recognize by

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physicians working outside TB-endemic countries, as it mimics a variety of uveitis entities. Currently, there are no standardized diagnostic criteria for ocular tuberculosis. Instead, confirmation relies on known clinical symptoms’ patterns, tuberculin skin testing and culture, or DNA PCR of MTB in intraocular samples. Interferon gamma release assays (IGRA) are highly specific for MTB infection, but cannot differentiate between latent and active tuberculosis, thereby worsening the controversy. “While ocular TB, a recognized form of extra-pulmonary TB, is associated with high rates of morbidity, there is little clinical information or standard guidelines for its diagnosis,” shared Dr. Rupesh Agrawal, Adjunct

Assistant Professor and Consultant Ophthalmologist, National Healthcare Group Eye Institute NHGEI), Tan Tock Seng Hospital (TTSH), Singapore, shedding light on the ocular TB dilemma. The absence of a unified guide thus poses a challenge in the diagnosis and management of the disease, emphasized Dr. Agrawal. The Collaborative Ocular Tuberculosis Study (COTS), a first-ofits-kind, multicenter global initiative, according to Dr. Agarwal, was established to address the challenges ocular TB care faces via cloud computing and big data. “Through this study, we aim to construct a predictive model to identify diagnostic clinical features to not only enhance the care outcomes and treatment combinations for this


disease but also create an international database of its own kind,” he explained. COTS is led by Prof. Rupesh Agrawal from NHGEI Singapore, Prof. Carlos Pavesio from Moorfields Eye Hospital, London, United Kingdom, and Prof. Vishali Gupta from PGIMER, Chandigarh, India, and has uveitis experts from 25 multinational ophthalmology centers. The team has recently published its first report in JAMA Ophthalmology1 and has several other reports under consideration at various renowned journals.2 “With the support from the scientific fraternity, we can take the study to the next exciting phase of identifying novel biomarkers and transcripts for the diagnosis of this neglected disease [ocular TB],” said. Dr. Agrawal. Diagnosis isn’t the only hurdle doctors and patients face when it comes to ocular TB – how to best treat it remains a dilemma as well. Recent reports support the use of antituberculous therapy (ATT) in patients with a consistent uveitic phenotype and positive TB investigation. However, there is a lack of consensus on treatment indications, regimens and durations, as well as investigation protocols and what exactly constitutes a successful outcome. A recent publication in the Journal of Ophthalmic Inflammation and Infection by Damato and colleagues reported the outcomes of ATT in a cohort of patients treated for presumed ocular tuberculosis, based on clinical findings, systemic assessment and specific testing for tuberculosis.3 In this retrospective study, patients diagnosed with tuberculous uveitis and who received ATT over a four-year period (2010-2014) were selected. The authors included only patients who completed a course of treatment and were followed up for at least 12 months. Data on baseline clinical and demographic characteristics were collected. All patients had full

ophthalmic examinations, systemic workups, chest radiographs, Mantoux testing and interferon gamma release assays (IGRAs). Presumed ocular TB was defined as a consistent ocular phenotype, with findings on chest imaging and/or positive T-spot or Mantoux testing after the exclusion of other causes of uveitis. Majority of patients were referred for ATT for ocular TB mainly based on a positive Mantoux and/or IGRA result, with normal chest X-ray imaging and no systemic symptoms. Flare rates preand post-treatment and time-to-flares were reported. Of the 54 patients in whom treatment was recommended, 7 (13%) patients did not comply. Forty-seven (47) patients received a course of ATT. Treatment duration ranged from 4 to 12 months with a mean of 6.8 months. Treatment regimens varied, and 94% and 86% of patients were flare-free at 6 and 12 months, respectively.

However, the study had some limitations. It was conducted in a real-life clinical setting, with patients unavoidably lost to follow-up or non-compliant with their treatment. Furthermore, flare rate was used as a measure of disease activity – which may not accurately reflect disease in patients with ongoing pathology, where uveitis is chronically uncontrolled, or in patients receiving corticosteroid therapy. The key message from this study is that ATT in a real-life clinical setting significantly reduced the number of flare-ups and enabled long-term remission in patients with presumed ocular tuberculosis. The authors therefore concluded that despite the unresolved controversies regarding diagnosis, the relevance of IGRAs and definition of ocular tuberculosis, if patients have a consistent uveitis phenotype and other uveitic causes are excluded, then ATT is likely to be beneficial.

References:

Agrawal R, Gunasekeran DV, Grant R, et al; Collaborative Ocular Tuberculosis Study (COTS)1 Study Group. Clinical Features and Outcomes of Patients With Tubercular Uveitis Treated With Antitubercular Therapy in the Collaborative Ocular Tuberculosis Study (COTS)-1. JAMA Ophthalmol. 2017;135(12):1318-1327. 2 Agarwal A, Agrawal R, Gunasekaran DV, et al. The Collaborative Ocular Tuberculosis Study (COTS)-1 Report 3: Polymerase Chain Reaction in the Diagnosis and Management of Tubercular Uveitis: Global Trends. Ocul Immunol Inflamm. 2017; 20:1-9 [Epub ahead of print]. 3 Damato EM, Dawson S, Liu X, et al. A retrospective cohort study of patients treated with antituberculous therapy for presumed ocular tuberculosis. Journal of Ophthalmic Inflammation and Infection. 2017;7:23 1

About the Contributing Doctor Dr. Rupesh Agrawal is a consultant ophthalmologist at the National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore. After completing his medical studies from Nagpur, India, he did his post-graduate and fellowship in uveitis and ocular trauma from Sankara Netralaya, Chennai, India. Dr. Agrawal’s research interests are in the areas of ocular inflammatory disorders including cytokines, ocular tuberculosis and HIV, complex cataract, ocular trauma, ocular nanotechnology, blood corpusclar abnormalities in the context of microvascular disorders and retinal imaging. He has published extensively on ocular inflammation and ocular trauma in peer reviewed journals and has presented numerous free papers and delivered lectures on ocular trauma and uveitis both nationally and internationally. Dr. Agrawal is actively involved in numerous collaborative projects on uveitis and he has been the recipient of many research grants on ocular inflammation. In Singapore, he has been recognized by the government for his humanitarian and pro bono projects in remote areas of the world. He has set up VIRAJ Healthcare Foundation to promote healthcare in the community through knowledge, technology and humility. Dr. Agrawal also serves as a senior advisory board member for various organizations, including The Vision Mission, The Beyond Eyecare and VIRAJ Eyecare Group, and is heavily involved in charity projects across Asia. [Email: rupeshttsh@gmail.com]

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POSTERIOR SEGMENT VITREOUS FLOATERS

YAG Laser Vitreolysis Improves

Symptomatic Vitreous Floaters

“The doctor said I had some little floaters in my eyes . . .”

by Collins Santhanasamy

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isual floaters – described by their symptoms of tiny specks, circles and shadows that appear in a patient’s field of vision – become increasingly prevalent with age due to the degenerative vitreous changes that occur throughout life. In youth, hyaluronan ensures that the collagen fibrils remain separated in the vitreous cavity, maintaining the transparency of the vitreous. However, with time, this hyaluronic acid dissociates from collagen, causing cross-linking and aggregation of collagen with fibrous structures that scatter light—a process known as vitreous liquefaction. Clinically, a posterior vitreous detachment (PVD) is often marked by

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a degree of fibroglial tissue known as a Weiss ring that is free floating over the optic nerve. A PVD allows the vitreous body to move when the head or eye moves, and thus, the Weiss ring and vitreous opacities cast shadows onto the retina that are perceived as floaters. A PVD is present in approximately 65% of patients reaching the age of 65 years. Although most patients grow accustomed to the visual disturbance associated with Weiss rings and other floaters, many patients find them bothersome due to various factors including a reduction in contrast sensitivity which affects their quality of life.

Three management options currently exist for patients presenting with symptomatic floaters: •

For patients who find that the floaters are not really impacting their quality of life, a Non-Invasive “learning to live with floaters” management plan focusing on patient education and observation may be the best option.

The second option for symptomatic patients would be a surgical option known as a pars plana vitrectomy (PPV) with either a 1-incision intrector or a standard 3-port vitrector.

The third option currently available for patients is laser vitreolysis, also referred to as Laser Floater Removal (LFR) or YAG vitreolysis.


YAG vitreolysis is a minimally invasive treatment option that involves the use of an extremely precise nanopulse YAG laser which safely vaporizes eye floaters and breaks apart large floaters into smaller, less noticeable pieces. Laser floater removal is currently a relatively new technology, but more and more doctors are beginning to specialize in this procedure. YAG vitreolysis for treatment of floaters was recently tested in a single-center, masked, sham-controlled randomized clinical trial, conducted at Ophthalmic Consultants of Boston, Massachusetts, USA.1 The study included 52 of the practice’s patients with symptomatic Weiss rings: 36 patients were randomly assigned to unilateral treatment with YAG laser vitreolysis, and 16 were assigned to sham YAG vitreolysis (control). The mean (SD) age of participants was 61.4 (8.0) years in the YAG group and 61.1 (6.6) years in the sham group. In all cases, one eye (the eye with the most patient-determined floaterrelated symptoms) was treated, and the other eye was observed. Patients were assigned to the YAG and sham groups in a 2:1 ratio to maximize the number of treated patients and to obtain more robust efficacy and safety data for YAG vitreolysis. After intraocular pressure was measured, the pupil of the study eye was dilated with phenylephrine, 2.5%, and tropicamide, 1%. Proparacaine was given, and an ocular karickhoff 21 mm vitreous lens with goniosol was applied before YAG laser administration. The number of laser shots given per patient was at the discretion of the treating physician, but in all cases, laser application ceased after vaporization of the Weiss ring and all other visually significant floaters. The 36 eyes treated with YAG laser vitreolysis (69% phakic) received a mean of 218 laser shots with a mean power of 1316 mJ. YAG vitreolysis was performed using the Ultra Q Reflex laser (Ellex Medical Lasers, Adelaide, Australia).

A maximum energy per pulse of 7 mJ was used, as described by Tsai et al.2 The energy was initially set at 3 mJ and titrated to an appropriate level at which the surgeon observed plasma formation with the creation of gas bubbles. Patients received only one laser treatment session to prevent unmasking of controls. Participants in the sham group underwent similar treatment; they were fitted with a sham lens that had a lens filter glued to the surface to prevent YAG energy from passing through the lens. The YAG laser energy was at its lowest setting of 0.3 mJ. Patients were not asked to which group they believed they were randomized. All patients were followed up for 6 months with clinical examinations held at week 1, month 1, 3 and 6. Objective masked grading of color photography found that 34 of 36 patients (94%) in the YAG group had significantly improved or completely resolved floaters as compared with 0 out of 16 patients in the sham group. Patients in the YAG group reported significantly greater improvement in self-reported floater-related visual disturbance (54%) compared with sham controls (9%). 19 of 36 patients (53%) in the YAG group reported their symptoms as significantly or completely better after treatment as

compared to 0 out of 16 in the sham group. The YAG group also reported significantly better general vision and peripheral vision with fewer role and dependency on others than the sham controls at 6 months. No adverse events judged to be of clinical relevance occurred after YAG laser vitreolysis in this small prospective study, which was underpowered to identify less common potential complications. However, with use of the rule of 3, there is 95% confidence that there is no greater than a 1 in 12 (8.3%) risk of a serious adverse event after YAG vitreolysis. For patients presenting with visual disturbance secondary to a clinically confirmed Weiss ring, the current study suggests that YAG vitreolysis improves short-term visual outcomes, both subjectively and objectively, without adverse events judged to be clinically relevant. “This pilot study shows encouraging results after YAG vitreolysis for symptomatic Weiss ring floaters. Further research is needed, particularly with larger clinical trials of longer duration that include multiple floater types so that we may better understand the efficacy and safety of YAG vitreolysis,” explained Dr. Shah.

References:

Shah CP, Heier JS. YAG Laser Vitreolysis vs Sham YAG Vitreolysis for Symptomatic Vitreous loaters: A Randomized Clinical Trial. JAMA Ophthalmol. 2017;135(9):918-923. 2 Tsai WF, Chen YC, Su CY. Treatment of vitreous floaters with neodymium YAG laser. Br J Ophthalmol. 1993;77(8):485-488. 1

About the Contributing Doctor Dr. Chirag P. Shah, M.D., M.P.H. is a board certified ophthalmologist, and a member of the American Academy of Ophthalmology, the Retina Society, the American Society of Retina Specialists, and the Association for Research in Vision and Ophthalmology. He has vast experience in the medical and surgical treatment of retinal diseases and he performs advanced retinal surgery for all vitreoretinal conditions. Dr. Shah is the principal investigator or sub-investigator on numerous clinical trials and is able to provide the most sophisticated treatments available. His research interests cover a myriad of retinal conditions, including macular degeneration, retinal vein occlusion, diabetic retinopathy, and retinal detachment. Dr. Shah is the Fellowship Co-Director of the combined Tufts New England Medical Center/Ophthalmic Consultants of Boston vitreoretinal surgery fellowship. A born educator, Dr. Shah values training fellows in one of the top fellowship programs in the country. [Email: cpshah@eyeboston.com]

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POSTERIOR SEGMENT AGE-RELATED MACULAR DEGENERATION

Early Detection and Intervention

Age-Related Macular Degeneration An Unmet Need in

by Francesco Bandello, MD

While cutting-edge innovations are in development to improve the diagnosis and treatment of age-related macular degeneration (AMD), improving patients’ ability to recognize symptoms and doctors’ ability to diagnose and intervene as early as possible is a strategy that can be implemented immediately to improve patient outcomes.

Clinical Manifestations of AMD

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ge-related macular degeneration is a debilitating ocular condition that is estimated to affect nearly 9% of the global population.1 Its early manifestations are subtle, with the greatest loss of vision typically occurring at advanced disease stages.2 Initially, the condition presents with drusen on fundus exam and mild symptoms, such as blurred or distorted vision that progressively worsens with time (Figure 1). Interestingly, the ALSTAR Study at University of Alabama at Birmingham has shown that dark adaptation is impaired at least three years before AMD is clinically evident.3 Therefore, as the earliest recognizable symptom, night vision issues or complaints could lead to detection of subclinical AMD by means of dark adaptation testing. In the advanced stages, the condition manifests as two distinct forms: vascular (‘wet’) AMD and avascular (‘dry’) AMD. As the name implies, wet AMD is characterized by choroidal vascularization in the retina. The integrity of the new vessel walls is not sound, leading to hemorrhage of blood and lipids into the subretinal

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Figure 1. Fundus photo OS of intermediatestage AMD. Drusen are apparent throughout the macula and appear as light-orange spots.

space. This fluid may then form a disciform scar that rapidly and permanently reduces visual acuity. Contrastingly, advanced dry AMD is typically characterized by geographic atrophy, wherein the retinal pigment epithelium, choriocapillaris, and photoreceptors begin to atrophy, resulting in a gradual yet unrelenting loss of vision.

Diagnosis and Current Treatment Options Typically, AMD is diagnosed based on fundus exam, angiography, optical coherence tomography (OCT), and best corrected visual acuity (BCVA). Despite the diverse availability of imaging modalities, a challenge for reducing the global burden of AMD lies in the fact that patients often do not consult a physician until they are already experiencing symptoms associated with intermediate to advanced AMD. As a result, patients may already be well on their way to developing advanced wet or dry AMD by the time the disease is diagnosed. For patients who unfortunately advance to the wet form of AMD, they

can now be well managed if they are diagnosed and treated early enough. While this condition used to be a lifelong sentence of blindness, drugs that act as antagonists of the vascular endothelial growth factor (VEGF) have been shown to not only halt the progression of the condition, but to improve visual acuity as well.4 It has since been estimated that in some countries, AMD-related legal blindness has been reduced by as much as 50% since the introduction of anti-VEGF therapy. However, if the condition is not diagnosed early enough, subretinal macular hemorrhage can lead to permanent damage that cannot be reversed by VEGF antagonists.

The Need for Earlier Diagnosis, Intervention and Awareness It is currently estimated that 8% of the world has early-stage AMD, although 15% of this cohort is expected to progress to late-stage disease within 15 years of diagnosis.5,6 These data, combined with statistics revealing a shift in demographics towards an aging population, speak to a need for earlier diagnosis and intervention. This is especially true given the burden this condition places on the individual as well as the healthcare system. Individuals with late-stage disease often experience severe loss of independence, depression, and an increased risk of falling. Total annual direct costs from AMD-related United States medical claims were estimated to total 575 to 733 million USD.7 These statistics point to a need for improvements in diagnosis and treatment, with earlier intervention promising more favorable outcomes.


Dark adaptation testing is gaining attention as a means of earlier diagnosis of AMD. Dark adaptation is the ability of the eye to transition from light to dark settings, which is impaired in patients with some ocular conditions, including AMD. Functional changes have been shown to precede structural changes, and thus, assessing dark adaptation is a useful strategy for detecting subclinical AMD several years before changes in the fundus are observable. While older dark adaptation modules were time consuming and infrequently used in standard clinical practice, recent advances have led to the availability of next generation technology. Nowadays, devices available include: the Portable Field Dark Adaptometer (PFDA) and the AdaptDx (MacuLogix, Inc, Middletown, PA, USA). In my practice I use the AdaptDx which can perform an objective assessment of a patient’s ability to dark adapt in less than 6.5 minutes. Dark adaptation testing can now be integrated into the clinical setting to quickly and easily assess AMD suspects who present with multiple risk factors and/or a night vision complaint. Patients whose dark adaptation outcomes are abnormal can take several steps to slow or halt the progression of the disease. Lifestyle modifications such as weight loss, smoking cessation, and increased consumption of nutrientdense foods like dark green leafy vegetables may decrease the risk of disease progression. For patients with intermediate-stage AMD, one proven prophylactic is micronutrient therapy. It was found that an oral supplement containing antioxidants and zinc can significantly reduce the risk of patients with moderate AMD from progressing to late-stage disease.8 Supplements containing lutein and zeaxanthin may also help restore macular pigment and improve visual performance, even at the earliest stages of the disease. This is a particularly vulnerable cohort, and identifying and treating these patients before further progression is critical to preventing irreversible vision loss or blindness.

In addition to early diagnosis, increased awareness will be an important and complementary step for improving outcomes among atrisk and AMD patients. Ideally, public health legislation should prioritize the education of every individual over the age of 50 regarding the common symptoms associated with AMD, such as trouble seeing or driving at night. Additionally, emphasis on AMD should be brought to the attention of general practitioners, who can also assist in educating patients and referring them to a retina clinic for AMD testing based on risk factors and symptoms.

Conclusions While ongoing efforts are being made to develop effective treatments for dry AMD and improve existing treatments for wet AMD, there are already abundant opportunities to improve

the current status of AMD globally. Improving awareness of the condition and its symptoms, not only for the patients and their families, but for general practitioners as well, can help increase early AMD diagnoses and reduce unnecessary vision loss. These efforts could greatly improve patient outcomes with little to no additional expenditure and can be implemented immediately, simply by enhancing communication between doctors and patients. Editor’s Note: This article was submitted to PIE Magazine by Dr. Bandello after getting a copy of PIE issue 03 distributed at ESCRS 2017 in Lisbon, Portugal. We are [always] looking for eye docs who can contribute articles to PIE Magazine. If interested, send us an email at enquiry@ mediamice.com.

References:

Wong WL, Su X, Li X, et al. Global prevalence of age-related macular degeneration and disease burden projection for 2020 and 2040: a systematic review and meta-analysis. Lancet Glob Health. 2014;2(2):e106-116. 2 Lim LS, Mitchell P, Seddon JM, et al. Age-related macular degeneration. Lancet. 2012;379(9827):1728-1738. 3 Owsley C, McGwin G, Clark ME, et al. Delayed Rod-Mediated Dark Adaptation Is a Functional Biomarker for Incident Early Age-Related Macular Degeneration. Ophthalmology. 2015;123(2):344-351 4 Rosenfeld PJ, Brown DM, Heier JS, et al. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med. 2006;355(14):1419-1431. 5 Klein R, Klein BE, Knudtson MD, et al. Fifteen-year cumulative incidence of age-related macular degeneration: the Beaver Dam Eye Study. Ophthalmology. 2007;114(2):253-262. 6 Mitchell P, Wang JJ, Foran S, Smith W. Five-year incidence of age-related maculopathy lesions: the Blue Mountains Eye Study. Ophthalmology. 2002;109(6):1092-1097. 7 Rein DB, Zhang P, Wirth KE, et al. The economic burden of major adult visual disorders in the United States. Arch Ophthalmol. 2006;124(12):1754-1760. 8 Marshall LL, Roach JM. Prevention and treatment of age-related macular degeneration: an update for pharmacists. Consult Pharm. 2013;28(11):723-737. 1

About the Contributing Doctor Dr. Francesco Bandello is a professor and chairman at the Department of Ophthalmology University Vita-Salute, Scientific Institute San Raffaele, Milan, Italy. He is the academic dean of “Corso di Laurea Specialistica/Magistrale in Medicina e Chirurgia” at the same university. Professor Bandello is past president of EURETINA, president of Academia Ophthalmologica Europea and vice-president of EuroLam. Prof. Bandello is editor-in-chief of the European Journal of Ophthalmology and former board member of the Club Jules Gonin and Macula Society. He is a member of the Executive Board of ESASO Foundation (European School for Advanced Studies in Ophthalmology), member of the Academia Ophthalmologica Internationalis and the Accademia Nazionale di Medicina. Prof. Bandello is co-author of 11 books and he serves as a peer reviewer for grant applications for the National Eye Institute (NEI). He has authored or co-authored 473 Pub-Med articles and has served as trained Principal Investigator in several clinical trials performed following ICH/GCP and mainly concerning retinal diseases. [Email: bandello.francesco@hsr.it]

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POSTERIOR SEGMENT OCP EFFECTS ON RETINA

The Surprising Side Effect of

Birth Control Pills on the Eyes by Hazlin Hassan

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ho would have thought that birth control pills could affect the eyes? Well, that is precisely what a study from Turkey reported recently. Weight gain and nausea are just some of the well-known side effects of oral contraceptive pills (OCP), but according to this recent study, they can also mimic age-related changes in the eye, potentially affecting the central vision which is essential for daily activities such as driving, reading and watching television. Conducted at the Department of Obstetrics and Gynecology, Health Sciences University Kayseri Education and Research Hospital, Kayseri, Turkey, between January 2014 and April 2016, the study by Dr. Ahter Tanay Tayyar and colleagues compared a total of 24 healthy women taking monophasic OCP (3 mg drospirenone and 0.03 mg ethinylestradiol) for contraception only for at least one year with a control group of 24 healthy women who were not taking an OCP. The aim of the study was to evaluate the effect of OCP on the macula, the retinal nerve fiber layer (RNFL), and choroidal thickness (CT). Optical coherence tomography (OCT) was used to evaluate the posterior ocular segments, and measurements were taken in the follicular phase (day 3) of the cycle in all women, who were between 25-40 years old. “In comparison of the macular region and CT between groups, we found that all variables except foveal center thickness and CT were significantly thinner in the OCP group. Nasal and temporal inferior parts of the RNFL and average RNFL were significantly

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slimmer in the study group versus the control group,” reported Dr. Tayyar and colleagues, explaining the results. Therefore, women who use OCP for more than one year may experience eye problems and should get their eyes routinely checked with OCT. Further clinical trials researching the longperiod effect of OCP on the eyes are needed, the investigators emphasized. The paper noted that OCP does have some risks and side effects with regard to several organs, one of which is the eye. Eye complications in users of OCP include retinal vascular occlusion, optic neuritis and proptosis; in addition, retinal edema, glaucoma and hemorrhagic retinopathy have also been reported previously. Because of extensive evidence that OCP can cause vascular events elsewhere in the body, this is of

particular interest for closer analysis, the study said. Furthermore, these effects have been shown to change depending on the type of progesterone used. Several earlier studies have looked at the effect of sex steroid hormone fluctuations in the menstrual cycle on the eye; and some researchers have shown that these hormone fluctuations exhibited correlations with changes in ocular tissue. Age-related hormonal changes may also affect the ocular tissues, causing thickening due to edema or slimming due to atrophy in the macula and atrophy in the RNFL. Dr. Vishali Gupta, professor of ophthalmology at the Postgraduate Institute of Medical Education and Research (PGIMER) in Chandigarh, India, and PIE Magazine advisory board member, said of the Turkish paper: “This is a very interesting observation indeed – an observation that merits to be studied in detail to look at the effect of OCPs on retinal health.” “We do know that drugs like Spironolactone and Eplerenone help in reducing the fluid from the retina in eyes with chronic central serous chorioretinopathy. However the possible effect of OCP in normal retina is something that is very fascinating and needs further large studies,” explained Dr. Gupta. Editor’s Note: Dr. Vishali was generous enough to contribute on this story, but she was not a participant of the mentioned study.

Reference: Madendag Y, Acmaz G, Atas M, Sahin E, Tayyar AT, et al. The Effect of Oral Contraceptive Pills on the Macula, the Retinal Nerve Fiber Layer, and Choroidal Thickness. Med Sci Monit. 2017;23:5657-5661.

About the Contributing Doctor Dr. Vishali Gupta is a professor at Advanced Eye Center at the Post Graduate Institute of Medical Education and Research in Chandigarh, India. She specializes in the retina, vitreous, and uvea. She has been published in 65 peer-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: vishalisara@yahoo.co.in]


POSTERIOR SEGMENT PCV TREATMENT

PCV Sufferers Can Rejoice Over

Better Treatment Option by Hazlin Hassan

P

olypoidal choroidal vasculopathy (PCV), a disease found more frequently in the Asia-Pacific region than in Caucasian communities, may soon be treated with aflibercept monotherapy, instead of aflibercept plus rescue photodynamic therapy (PDT). According to two-year results from the PLANET study, conducted to determine the efficacy and safety of aflibercept monotherapy versus aflibercept with rescue PDT, aflibercept monotherapy was found to have led to favorable vision gains and high rates of polyp inactivation. This means doctors could do away with costly equipment and unnecessary treatments and patients could avoid unwanted side effects linked to PDT, resulting in a simpler – and better – regimen. “The PLANET study demonstrates that aflibercept monotherapy is noninferior to treatments using aflibercept plus active rescue PDT,” said Professor Tien Yin Wong, Singapore National Eye Centre, during the Bayer Satellite Symposium at APVRS 2017, titled: “Eylea: Extending Horizons in the Management of nAMD and PCV.” Prof. Wong explained that at week 52, patients (in aflibercept monotherapy group) gained more than 10 letters, and this was maintained to week 96; 94% of patients avoided loss of 15 letters or more over 96 weeks. Seventy seven percent (77%) of patients had a dry retina at week 12, with 81% remaining dry by week 96; 80% had inactive polyps at week 52, and this remained at week 96. More than 80% of patients required no rescue PDT treatment over the two-year period. The treat-and-extend regimen was allowed in the second year of PLANET

Less shots! More puppies! All good!!

as an alternative to fixed dosing. Intervals of 10 and 12 weeks were used for 55% and 39% of patients, respectively. Patients with 10- and 12week intervals had outcomes similar to the overall population, and a reduction of 1-2 injections compared with patients who received fixed dosing. Indocyanine green angiography (ICGA) is required in order to guide PDT, and it was noted that some clinics do not have PDT and ICGA. “Aflibercept monotherapy has several advantages over PDT combination therapy,” said Professor Won Ki Lee, from Seoul St. Mary’s Hospital, South Korea. “It avoids potential side effects associated with long-term PDT use, is a simple regimen not requiring access to specialist and provides excellent outcomes in diverse disease subtypes. After positive outcomes with aflibercept monotherapy, questions have been raised concerning the role of PDT combination in the treatment of PCV,” he told the symposium audience. Professor Masahito Ohji from

Shiga University of Medical Science in Japan, presented on data from the ALTAIR treat-and-extend study which adds to the growing body of evidence supporting the use of monotherapy. The Phase IV ALTAIR clinical trial evaluated the efficacy and safety of aflibercept with variable treatment intervals in Japanese patients with nAMD. It was found that the efficacy of aflibercept treat-and-extend regimens remains with either 2- or 4-week adjustments. PCV is a subtype of exudative age-related macular degeneration (AMD) that can cause permanent vision loss due to hemorrhage, exudation, macular edema, and disciform scar formation. In view of the potential visual loss associated with the natural history, PCV patients should therefore be treated accordingly. Editor’s Note: A version of this article first appeared at the APVRS 2017 Show Daily Issue 3, the official conference news of APVRS 2017 (Kuala Lumpur, Malaysia) published by PIE Magazine (www.piemagazine.org).

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POSTERIOR SEGMENT LENS FRAGMENT DISPLACEMENT

There must be a better way! Introducing, the Frag

Bag for Dislocated Nuclear Material

The Frag Bag, securing lens fragment in the mid-vitreous cavity, away from the retinal surface. Tightening of the basket causes simultaneous stabilization and softening of the lens nucleus. As the fragment diminishes in size, the basket is retracted, maintaining a secure hold on the remaining nuclear material. [Image source: Dr. Duncan Berry]

by April Ingram

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n a perfect world, cataract surgeries would be without complication, and any resulting displacement of nuclear fragments into the vitreous cavity would be a thing of the past. Despite improvements in surgical technique and platforms, our reality is that the incidence of posteriorly displaced lens fragments after phacoemulsification ranges between 0.3 and 1.1%. These retained nuclear fragments (especially those 2mm or larger), can go on an inflammation spree, causing lensinduced uveitis or secondary glaucoma and a cascade of ocular issues. So, they must be removed . . . which is easier said than done. Although some small fragments can be absorbed, more significant material must be removed via pars plana vitrectomy (PPV). The usual

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approach for retrieving nuclear fragments in the posterior segment is a standard 3-port PPV and release of vitreous adhesions to the dropped nucleus, followed by fragmentation and removal of nuclear material using a phacofragmatome. Dr. Sharon Fekrat, Associate Professor of Ophthalmology and Surgery at Duke University School of Medicine had been thinking about this technique for many years and knew that there had to be a better way. Particularly in this era of smallergauge vitreous surgery, Dr. Fekrat felt that enlarging one or more sclerotomies to accommodate the 20-gauge phacofragmatome, increasing the likelihood of complications, didn’t make sense. As well, repeated retrieval of retained lens material from the retinal surface increased the risk of iatrogenic

retinal injury. She wondered: “Wouldn’t it be so much easier if we could hold on to the lens material, rather than chasing it?” Retina colleagues from around the world – including Dr. Srinivasan in India, Dr. Mura in Saudi Arabia and others – had also been searching for a similar solution and a better way to address retained dislocated cataract material. Great minds must think alike! As the saying goes, necessity is the mother of invention – and apparently having a family member with insight into urology techniques doesn’t hurt either. For years, Dr. Fekrat had been talking about designing a solution to this problem when a close family member (a urologist), finally mentioned, “Oh yes, we’ve been using a basket like that to retrieve kidney stones through the urethra for ages.” Her reply was a combination of joy and exasperation: “Where have you been all my life?!” Dr. Fekrat and her colleagues Dr. Duncan Berry and Dr. Scott Walter repurposed a 1.5 French N-Circle Nitinol Tipless Stone Extractor (Cook Medical, Bloomington, IN) from the urology operating room. With the basket retracted, the external guidewire fits easily through a 23-gauge valved cannula and the extendible basket, controlled by an external handpiece, expands to a 1 cm diameter, large enough to accommodate the entire crystalline lens. “Despite being a urologic instrument, the Frag Bag is surprisingly well suited to intraocular use,” explained Dr. Walter. The team at Duke recently


published this novel technique in a recent issue of Ophthalmic Surgery, Lasers & Imaging Retina. The report includes a case of an 80-year-old who had posterior capsule rupture with loss of a large nuclear fragment and the Fekrat Frag Bag, as it is sometimes called, was used to remove it. The preoperative visual acuity was 20/100 and after one month was 20/40 with an attached retina and no macular edema. There were no intraoperative or postoperative complications. The team at Duke has continued to use the technique and are excited to see the Frag Bag extractor further modified to be even more user friendly for retina surgery. “The instrument enhances surgeon control, allowing simultaneous stabilization and softening of the lens nucleus with an

adjustable snare,” added Dr. Walter. The response from the vitreoretinal community has been overwhelmingly positive. The video, Frag Bag: A Novel Technique For Removal of Retained

Lens Material, was presented at the 2017 ASRS Film Festival, where it received the prestigious Rhett Buckler Award and was featured as an AAO Editors Choice Video.

Reference: Berry DE, Walter SD, Fekrat S. A Frag Bag for Efficient Removal of Dislocated Nuclear Material. Ophthalmic Surg Lasers Imaging Retina. 2017;48(12):1006-1008.

About the Contributing Doctor Dr. Sharon Fekrat, is an Associate Professor of Ophthalmology and Surgery at Duke University and vitreoretinal surgeon. Dr. Fekrat has co-authored over 130 publications in peer-reviewed medical journals and over 40 textbook chapters. She has co-authored two and co-edited four books including Duke Eye Center’s All About Your Eyes. She has held various leadership roles at the Duke’s affiliate, Durham Veterans Affairs Medical Center, including Chief of Ophthalmology, Interim Chief of Surgery, Interim Deputy Chief of Staff, and is currently Associate Chief of Staff. Fekrat sits on the editorial board of the American Journal of Ophthalmology, Retinal Physician, Ophthalmology Times, Ophthalmic Surgery Lasers Imaging Retina, Retina Times, and the American Academy of Ophthalmology’s (AAO) EyeNet. She has received the Senior Achievement Award from the AAO. [Email: sharon.fekrat@duke.edu]

INDUSTRY UPDATE

From Singapore, NIDEK reaches the world

F

ounded in 1971, and headquartered in Gamagori, Japan, NIDEK is a leading company in the ophthalmic and optical equipment industry. With products currently available in in 120 countries, NIDEK strives to bring the joy of sight to people worldwide. The company is committed to total healthcare, using eye-based technology. “We are both in the optical and medical business,” explained Alan Kwang, Chief Operating Officer and Director at NIDEK Singapore. “In terms of products, we are very aggressive in the surgical sector.” One product that is making tremendous gains is NIDEK’s Aspheric single piece intraocular lens (IOL) with a preloaded IOL injection system. Manufactured in Japan, this IOL adheres to strict quality standards which promote reliability, stability, optimal postoperative outcomes and a smooth lens insertion via a preloaded injector system. Mr. Kwang says they will be showcasing this product

everywhere, but especially in Asia. “We are at every exhibition,” he added. The company actively participates in academic conferences and exhibitions around the world to learn about the latest research findings and to present their own results. Using the latest technology, NIDEK’s innovative products are highly valued among their customers. But it’s not only the products that make NIDEK stand out – it’s also their speedy and meticulous service. International engineers complete a rigorous training at the company’s headquarters in order to offer optimum service. The Singapore office, where Mr. Kwang is based, serves as the marketing arm for Japan and the rest of Asia. “Basically, from here we can reach out to customers, be more on the ground and really understand what’s going on,” said Mr. Kwang. For more information about NIDEK, visit their website www.nidek.sg.

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COVER STORY

The Adventures of Vanquisher of Posterior Segment Disease (a.k.a. Evil Eye) by Brooke Herron

Who is PIE Person? The hero of the posterior segment, of course. Just as PIE Person’s worst enemy is Evil Eye, each ocular-disease-fighting ophthalmologist has their own nemesis to vanquish. So what conditions are considered the most villainous – and what weapons can conquer them? We asked three sight-saving superheroes those questions … and their responses might surprise you. Villain: Central Retinal Artery Occlusion (CRAO)

Superhero: Dr. Au Eong Kah Guan (a.k.a. The Retina Rescuer), medical director and senior consultant, Singapore International Eye Cataract Retina Centre at Mount Elizabeth Medical Centre and International Eye Cataract Retina Centre at Farrer Park Medical Centre, Singapore

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“Central retinal artery occlusion (CRAO) is the worst condition affecting the posterior segment; in addition to often blinding a person, it’s associated with an increased risk of stroke, acute myocardial infarction and death,” said Dr. Au Eong. The life expectancy of patients with CRAO is 5.5 years compared to 15.4 years for an age-matched population without the disease. “In most cases, profound loss of vision occurs despite treatment.” “CRAO is an acute, painless condition that is typically caused by thrombosis or embolism leading to ischemia of the retina and optic nerve head, resulting in severe vision loss,” he explained. This condition damages cells rapidly and retina survival depends on the degree of collateralization and


the duration of retinal ischemia. Prompt diagnosis and early treatment to dislodge or lyse the offending embolus or thrombus is crucial to avoid irreversible retinal damage and blindness.1 Thankfully, Dr. Au Eong doesn’t see this condition frequently – about once or twice a year. This corresponds with the low reported incidence rate: CRAO affects approximately 1 per 100,000 people with less than 2% presenting with bilateral involvement. The mean age for symptoms is 60, and risk factors are similar to other thromboembolic diseases, including: hypertension, smoking, hyperlipidemia, diabetes, hypercoagulable states, and male gender. Approximately one-third of patients with CRAO have clinically significant ipsilateral carotid artery stenosis.1 Another study found that previously undiagnosed vascular risk factors were found in 78% of all CRAO patients.2

Weaponry: Still seeking a super-solution Unfortunately, there is no consensus for optimal treatment of CRAO. Current standard treatment options are aimed at restoring retinal perfusion/oxygenation and include: immediate digital ocular massage to induce oscillations of intraocular pressure and dislodge the offending thrombus; intraocular pressure reduction with acetazolamide, mannitol, topical timolol (anti-glaucoma eyedrops), or anterior chamber paracentesis (often recommended in conjunction with digital ocular massage); breathing into a paper bag or inhaled 10% carbon dioxide to induce respiratory acidosis and vasodilation; and/or supplemental oxygen.1 To this list, Dr. Au Eong added hemodilution, corticosteroids, systemic pentoxifylline and sublingual isosorbide dinitrate as possible therapy options. He notes that, unfortunately, none of these treatments have shown to be more effective than placeboes. (This looks like a job for PIE Person!)

Another therapy option using local intra-arterial fibrinolysis (LIF) to treat CRAO showed some initial promise. “However, the first randomized clinical trial [by the European Assessment Group for Lysis in the Eye (EAGLE)] did not demonstrate an improved visual outcome with treatment,” said Dr. Au Eong. According to the study, patients treated within 12 hours were more likely to profit from treatment. But in a multivariate analysis, there was no clear trend to benefit from LIF – even in patients treated early. Based on this preliminary report (on a rather small sample size), the authors did not recommend LIF in CRAO patients.3 A meta-analysis by Schrag et al. (2015) found that some of the more conservative therapies like ocular massage, anterior chamber paracentesis, and hemodilution actually worsened visual outcomes – calling them futile, and possibly harmful. They did find, however, that systematic fibrinolysis was beneficial within 4.5 hours of symptom onset and suggest that a clinical trial of early systemic fibrinolytic therapy for CRAO is needed.4 Dr. Au Eong agrees that systemic fibrinolysis within 4.5 hours of CRAO has not yet been evaluated in a randomized controlled clinical trial and is therefore, warranted. “Systemic fibrinolytic therapies are simpler and faster to deploy than LIF for CRAO,” he added. “Rapid administration of systemic fibrinolytic agents has been proven to be a feasible and effective treatment for acute ischemic stroke, but only within 4.5 hours of symptom onset. For this reason, systemic fibrinolysis may improve the efficacy of treatment for CRAO.”

Superhero: Dr. Low Cze Hong (a.k.a. Macula Man), senior consultant ophthalmologist and medical director, C H Low Specialist Eye Centre, Mount Elizabeth Medical Centre and Hospital, Singapore

Villain: Age-related macular degeneration (AMD) The good news is people are living longer. The bad news? As life expectancy increases, so does the probability of acquiring an age-related disease – like agerelated macular degeneration. According to Dr. Low, “AMD is a dreaded disease – and it though used to be a rare disorder in Singapore, it is now fairly common.” AMD is a leading cause of irreversible blindness of adults over 50 years old, with a global prevalence of 170 million. It is the leading cause of visual disability in the industrialized world and the third leading cause globally.5 As aging is the greatest risk factor, the prevalence of AMD will continue to rise as the population ages.

AMD is a leading cause of irreversible blindness of adults over 50 years old, with a global prevalence of 170 million. It is the leading cause of visual disability in the industrialized world and the third leading cause globally.

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COVER STORY are fortunate to “haveWemany new anti-VEGF agents at our disposal. These various regimens of treatment have by-andlarge halted the disease’s progression in patients who have early detection and intervention, persist in follow-up and repeated treatment, and can afford it – either through public or self-funded health schemes.

– Dr. Low Cze Hong

“Initially, visual functions are greatly impacted with deterioration of central visual acuity, color and reading vision,” explained Dr. Low. “As time goes on – in some cases, even with adequate treatment – further visual deterioration will result in near total loss of vision.” In its most advanced stages, AMD deprives an individual of his or her ability to perform basic activities such as reading, recognizing faces, and driving. According to the American Academy of Ophthalmology (AAO), although an estimated 80% of AMD patients have non-neovascular or atrophic (dry) AMD, the neovascular form (wet) is responsible for nearly 90% of the severe central visual acuity loss associated with AMD.6

Weaponry: The tried and true “Needle in the Eye” Like CRAO, there is no definitive cure for AMD. And even though there are therapy options that can halt the progression of the disease, the condition can still worsen – even with treatment. Generally, the first line of recommended therapy for neovascular AMD is anti-vascular endothelial growth factor (antiVEGF). Injected intravitreally, anti-VEGF aims to block the growth of abnormal blood vessels in the eye to prevent vision loss. “We are fortunate to have many new anti-VEGF agents at our disposal,” said Dr. Low. “These various regimens of treatment have by-and-large halted the disease’s progression in patients who have early detection and intervention, persist in follow-up and repeated treatment, and can afford it – either through public or self-funded health schemes.” The anti-VEGF delivery system is simple – through a needle via the pars plana. Dr. Low adds that meticulous hygiene and asepsis is vital. In addition, the therapy is generally well tolerated and rarely associated with serious adverse events like infectious endophthalmitis or retinal detachment.6

Superhero: Dr. Ashish Sharma M.S. (a.k.a. The DME Destroyer), innovator and head, MII RetCam Development Team and consultant retina and head research, Lotus Eye Hospital and Institute, Coimbatore, TN, India.

Villain: Diabetic Macular Edema (DME) According to Dr. Sharma, the biggest sight-threatening villain he encounters is diabetic macular edema (DME). “There is a high prevalence in the young working population [in India] – we see these cases every day,” he shared. This is because diabetes is approaching a potential epidemic in India, with more than 62 million individuals currently diagnosed with the disease. It’s predicted that by 2030, up to 79.4 million individuals in India may have diabetes. To make matters worse, Indians are more susceptible to diabetic complications like DME at an early age (20 to 40 years), compared to Caucasians (> 50 years).7 DME is responsible for most of the visual loss experienced by patients with type 2 diabetes,8 making this a major public health concern. “My patients fear that they will lose their livelihood,” said Dr. Sharma. “Furthermore, the injection burden [with anti-VEGF] is sometimes too high.”

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A recent meta-analysis found that anti-VEGF drugs are effective at improving vision in people with DME, with 3 to 4 in every 10 people likely to experience an improvement of 3 or more lines visual acuity at one year.


Weaponry: Needles and implants supercede lasers Traditionally, focal or grid laser photocoagulation has been a treatment for DME. However, recent studies on the effect of anti-VEGF substances in DME, showed resolution of the edema and visual acuity gain. Thus, anti-VEGF therapy has become a prominent treatment for DME. A recent meta-analysis found that antiVEGF drugs are effective at improving vision in people with DME, with 3 to 4 in every 10 people likely to experience an improvement of 3 or more lines visual acuity at one year.9 Intravitreal steroids, also play a role in the management of DME, particularly in refractory cases, due to their anti-inflammatory effect.10 Dr. Sharma agrees and recommends anti-VEGF as primary therapy for phakic DME patients. For pseudophakic DME patients, he prefers the dexamethasone intravitreal implant Ozurdex (Allergan, Inc., Irvine, CA). Dexamethasone implants like Ozurdex, tend to be reserved for patients unresponsive to anti-VEGF therapy and may be considered first line of treatment for pseudophakic patients, or those with impending cataract surgery.11 “If injections are regular, I have good success, with 70 to 80 percent of patients reporting improvement,” said Dr. Sharma. He says that while it is a safe and effective treatment, for best results long-term continuous therapy is required.

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ach of these villains (CRAO, AMD and DME) remain a threat to sight for millions worldwide. Clearly, there is more work to be done – but every day, with new innovations for diagnosing and treating disease in the posterior segment, PIE Person (and his team of Eye Avengers) get closer to vanquishing Evil Eye … for good.

Eye Avengers Assemble! Even superheroes need to recharge their batteries. For eye-sight avengers, this “recharging” often takes place at ophthalmology congresses worldwide – where heroes from far-flung countries and the most specific sub-specialty surgeons converge to increase their superpowers (in this case, knowledge). In 2018, these are the conferences where the PIE People staff of PIE Magazine will likely be found: Asia-Pacific Academy of Ophthalmology (APAO), Hong Kong, Feb. 8 to 11, (Booth #3A-04) • All India Ophthalmology Congress (AIOC) 2018, Coimbatore, India, Feb. 22 to 25 • Advanced Vitreo Retinal Techniques and Technology (AVRTT@6), Ahmedabad, India, March 17-18 • Asia-Pacific Glaucoma Congress (APGC) 2018, Busan, South Korea, Apr. 13 to 15 • The Association for Research and Vision and Ophthalmology (ARVO), Honululu, Hawaii, Apr. 29 to May 3 • World Ophthalmology Congress (WOC), Barcelona, Spain, June 16 to 20 • Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS), Chiang Mai, Thailand, July 19 to 21 • 8th EURETINA Congress, Vienna, Austria, September 20-23 • European Society of Cataract and Refractive Surgeons (ESCRS), Vienna, Austria, Sept. 22 to 26 • American Academy of Ophthalmology (AAO), Chicago, Illinois, USA, Oct. 27 to 30 • The Royal Australian and New Zealand College of Ophthalmologists (RANZCO), Adelaide, Australia, Nov. 17 to 21 • Asia-Pacific Vitreo-retina Society (APVRS), Seoul, South Korea, Dec. 14 to 16 •

Editor’s Note: PIE Person defined: PIE stands for Posterior Segment – Innovation – Enlightenment, as in PIE Magazine. Visit Media MICE Booth #3A-04 at APAO 2018 in Hong Kong, for a chance to meet PIE Person and sidekick ANT (Anterior Segment) Person. See you all there!

References:

Farris W, Waymack JR. Central Retinal Artery Occlusion. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2017. Available at: https://www.ncbi.nlm.nih. gov/books/NBK470354/. Accessed on 18 January 2018. 2 Callizo J, Feltgen N, Pantenburg S, et al; European Assessment Group for Lysis in the Eye. Cardiovascular Risk Factors in Central Retinal Artery Occlusion: Results of a Prospective and Standardized Medical Examination. Ophthalmology. 2015;122(9):1881-1888. 3 Pielen A, Pantenburg S, Schmoor C, et al; EAGLE Study Group. Predictors of prognosis and treatment outcome in central retinal artery occlusion: local intra-arterial fibrinolysis vs. conservative treatment. Neuroradiology. 2015;57(10):1055-1062. 4 Schrag M, Youn T, Schindler J, et al. Intravenous Fibrinolytic Therapy in Central Retinal Artery Occlusion: A PatientLevel Meta-analysis. JAMA Neurol. 2015;72(10):1148-1154. 5 Pennington K, DeAngelis M. Epidemiology of age-related macular degeneration (AMD): associations with cardiovascular disease phenotypes and lipid factors. Eye Vis (Lond). 2016;3:34. 6 AAO Retina/Vitreous PPP Panel, Hoskins Center for Quality Eye Care. Age-Related Macular Degeneration PPP. Jan 2015. Available at: https://www.aao.org/preferredpractice-pattern/age-related-maculardegeneration-ppp-2015. Accessed on 18 January 2018. 7 Kaveeshwar SA, Cornwall J. The current state of diabetes mellitus in India. Australas Med J. 2014; 7(1):45-48. 8 Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. Eye Vis (Lond). 2015;2:17. 9 Virgili G, Parravano M, Evans JR, et al. Anti-vascular endothelial growth factor for diabetic macular oedema: a network meta-analysis. Cochrane Database Syst Rev. 2017;6:CD007419. 10 Berco E, Rappoport D, Pollack A. Treatment options for diabetic macular edema. Harefuah. 2017;156(2):109-113. 11 Mehta H, Gillies M, Fraser-Bell S. Perspective on the role of Ozurdex (dexamethasone intravitreal implant) in the management of diabetic macular oedema. Ther Adv Chronic Dis. 2015;6(5):234-245. 1

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INNOVATION RETINAL VEIN OCCLUSION

Innovations in Retinal Vein Occlusion on Spotlight at by Olawale Salami

APVRS 2017 • The microsphere hydrogel delivery system. Developed by Dr. Kang-Mieler and colleagues, this system contains bio-degradable microspheres with encapsulated anti-VEGF imbedded into a thermos-responsive hydrogel, which confines the microspheres into specific delivery sites. Impressive safety and efficacy results have been shown in non-human primate studies.

Steroid use for management of RVO: Results not typical.

Based on a presentation by Dr. Jennifer Kang-Mieler, Associate Professor of Biomedical Engineering at the Illinois Institute of Technology, Chicago, USA, about Long-Acting Drug Delivery Systems.

“T

here is an urgent need for delivery system that allows for small drug doses, with constant sustained level of exposure over time,” stated Dr. Jennifer KangMieler during a presentation about long-acting drug delivery systems in the retinal vein occlusion (RVO) session at the recently held 11th Asia-Pacific Vitreo-retina Society Congress (APVRS 2017) in Kuala Lumpur Malaysia. Although intravitreal injections remain the most efficient method of drug delivery to the posterior segment, they are also [sometimes] associated with potential complications such as endopthalmitis, retinal tears/detachment, cataract formation and – notably – the bolus amount of drug delivered to the eye. At the moment, US Food and Drug Authority (FDA) approved, corticosteroid-containing drug delivery systems act via a slow process of degradation of their encapsulating polymers. However, due to their unique bio-properties, there are constraints

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with the use of these systems to deliver anti-VEGF agents. Currently, some of the available systems are: • Microneedles. Micrometer-sized needles deliver drugs into the suprachoroidal space. They have been assessed for delivery of triamcinolone in phase 1 and 2 clinical trials with encouraging safety and efficacy results in patients with RVO. • Microcatheters. Small, illuminated cannulas inserted through sclerotomy which allow for visualization of the supra-choroidal space for accurate drug delivery. These have been evaluated in clinical studies, with no serious intra- or post-operative complications. • Encapsulated cell technology (ECT). This system consists of cells, genetically modified to produce a specific drug, encapsulated in a semipermeable hollow fiber membrane. These implants, which are placed in vitreous and can be retrieved, have been shown to continually release drugs for up to 18 months. • Replenish micropumpsTM. Programmable, refillable, microelectromechanical systems that deliver continuous or bolus-targeted drugs to the eye up to 12 months.

Dr. Kang-Mieler concluded that although a variety of approaches to improving drug delivery to the posterior segments are in development, intravitreal injections and/or use of sustained release solid implant intravitreal devices remain the most common techniques at present. Therefore, more innovation is needed as new therapeutic options become available. Based on a presentation by Dr. Mark Gillies, Professor of Clinical Ophthalmology & Eye Health at the Central Clinical School, University of Sydney, Australia, about Steroids for RVO. In another presentation, Dr. Mark Gillies provided a historical perspective on the use of steroids in the management of RVO. He noted that the initial clinical development of steroid injections for macular disease was done in Sydney, and earlier studies found little beneficial effect of intravitreal triamcinolone in age-related macular degeneration (AMD). However, further evaluation in patients with diabetic macular edema (DME) showed remarkable results with a doubling of vision gain and reduced macular edema, thereby establishing a role for steroids in the management of DME. Subsequent clinical studies evaluated the use of steroids in various indications. In the SCORE study, 1 and 4 mgs of intravitreal


triamcinolone was compared with standard of care (laser) in patients with RVO. In patients with branch retinal vein occlusion (BRVO), higher rates of cataract and elevated intraocular pressure (IOP) were recorded in the steroid group as compared to laser treatment. However, in those with central retinal vein occlusion (CRVO), the outcomes were better in patients who received triamcinolone, with vision improvements sustained into three years after initiation. In the GENEVA study, DME study patients received dexamethasone implants (0.7mg, 0.35mg) or sham for RVO. At the 3-month follow-up, there was significant reduction in central macular thickness and improved vision in steroid treated patients as compared to the sham treated. However, at month 6, there was no difference in the outcomes between the group, and further analysis of time-to-first-gain of >15 letters showed better outcomes in the dexamethasone treated patients. The BEVORDEX study provided evidence of optimal dosing interval of steroids in RVO, and concluded that 4-monthly dosing was sufficient to induce sustained reduction in central macular thickness (CMT). The COMRADE B and C studies compared ranibizumab with dexamethasone treatment in RVO. In these studies, the effects on best corrected visual acuity (BCVA), IOP and CMT with dexamethasone diminished after 2 months, suggesting patients may require repeated dosing before month 6. The COBALT study evaluated the efficacy and safety of the dexamethasone implant in BRVOassociated macular edema of < 3 months duration. It showed significant mean BCVA improvement with dexamethasone, good IOP control and significant central retinal thickness reduced in patients. Furthermore, majority of the eyes required only one or two injection every 12 months. Regarding the use of steroids in RVO, Dr. Gillies concluded: “For phakic eyes, use steroids as second line treatment after 6-12 injections of anti-VEGF. However, in pseudophakia, it is best to start with steroids as first line of treatment.”

Based on a presentation by Dr. Raja Narayanan of LV Prasad Eye Institute, India, about Zaltrap and Avastin in RVO: Economy and Effectiveness. Dr. Raja Narayanan discussed theoretical and practical issues on the use of ziv-aflibercept (ZALTRAP) in the management of RVO. Aflibercept is a soluble fusion protein of VEGFR1 and VEGFR2 receptors with a strong binding affinity for VEGF-A, VEGF-B and PIGF. And while Ziv-aflibercept received US FDA approval for colorectal cancer, it can also be used off-label for ophthalmological diseases. Ziv-aflibercept and aflibercept are similar – differing mainly in osmolarity (ziv-aflibercept = 1000 mOsm/kg; aflibercept=300 mOsm/kg). This difference is of vital importance as published studies in animals suggest that vitreal osmolarity > 500 mOsm/kg can induce retinal damage. However, given that the vitreous volume in human eyes is three times larger than that in rabbits, an injection of 0.5ml of 1000 mOsm/kg ziv-aflibercept in the human

vitreous gets significantly diluted, resulting in a final osmolarity of about 300 mOsm/kg, which is similar to that of aflibercept. In a recently published a paper, Dr. Narayanan and colleagues showed that safety of intravitreal ziv-aflibercept was acceptable, with no toxicity on ERG, or clinical examination, after a single injection in 12 eyes. To evaluate the efficacy of ZALTRAP in patients with BRVO, Dr. Narayanan and colleagues have injected 88 eyes over the last 2 years, and 42% of these gained more than 15 letters on VA assessment. Although this is an off-label indication, he concluded that ziv-aflibercept may be an option in cases of RVO, at a dose of 1.25mg/0.05ml. “Newer doses of 2mg/0.08ml are under investigation, however larger prospective studies are needed to validate these findings,” said Dr. Narayanan. Editor’s Note: Search YouTube for “PIE Magazine LIVE @ APVRS” to find the full videos of the talks by Dr. Kang-Mieler, Dr. Gillies, and Dr. Narayanan.

About the Contributing Doctors Dr. Jennifer Kang-Mieler is an Associate Professor of Biomedical Engineering at the Illinois Institute of Technology. Her research focuses on models of retinal vascular occlusion, microcirculation and electroretinography, in which she has over 20 publications. She has received several highly prestigious awards including the Whitaker Foundation Fellowship and recognition from the Committee on Institutional Cooperation Women in Science and Engineering. She is a member of several professional bodies like the Biomedical Engineering Society and the International Society for Clinical Electrophysiology of Vision. [Email: jkangmie@iit.edu] Dr. Mark Gillies is a Professor of Clinical Ophthalmology and Eye Health at the Central Clinical School, University of Sydney, Australia. He is a retinal clinician with a 25-year history of laboratory and clinical research in retinal disease. His current research focuses on the cellular and molecular mechanisms of Müller glialneuronal-vascular interactions and exploration of new strategies for neuroprotection, as well as inhibition of blood-retinal barrier breakdown in retinal diseases. Dr. Gillies is the Scientific Manager of the MacTel Project, an international project to identify a cure for Macular Telangiectasia Type 2. He has more than 140 publications mostly concerned with the treatment of macular diseases and retinal cell biology. [Email: mark.gillies@sydney.edu.au] Dr. Raja Narayanan is the Director-Head, Clinical Research Consultant, Smt. Kanuri Santhamma Centre for Vitreo Retinal Diseases at the LV Prasad Eye Institute in India. He completed his basic medical education from Delhi University, followed by a Master of Surgery in ophthalmology from Guru Nanak Eye Center, New Delhi. He underwent a preceptorship in uveitis, ocular immunology and uveitis service at the Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, USA. He is currently Adjunct Associate Professor of Ophthalmology at the University of Rochester, New York. He has published widely in peer-reviewed journals and is currently on the Editorial Board of PLOS ONE and International Journal of Retina and Vitreous. [Email: narayanan@lvpei.org]

23


INNOVATION RETINAL IMAGING

ZEISS Brings Innovation to

APVRS 2017

by Matt Young

F

rom imaging to instrumentation, ZEISS (Carl ZEISS Meditec, Jena, Germany) showcased new innovations in its retinal armamentarium at the recently held 11th Asia-Pacific Vitreo-retina Society Congress (APVRS 2017) in Kuala Lumpur, Malaysia. These products will make a difference to both the clinician and patient by allowing for prevention and early detection, as well as accurate diagnosis and treatment planning. The CLARUS 500 sets itself apart from the current marketplace of widefield fundus imaging with its advances in color, clarity and comfort. Terrance Siew, regional product manager for the Southeast Asia

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ophthalmic diagnostics at ZEISS says these traits will be of special importance to clinicians in the Asia-Pacific region. “The color of CLARUS will be the true color, as if doctors are looking at the fundus directly from the slit lamp,” explained Mr. Siew. “It will be the natural true colors of the retinas. ZEISS employs Broad Line Fundus Imaging (BLFI) technology here, which is proprietary. Sometimes with a false color, surgeons might hesitate and have doubts about whether colorization of the fundus is due to disease or is simply a natural component of the eye. The color accuracy is important for diagnosis and documentation of the ocular disease. The existing technology

does not have true color – CLARUS is the new generation.” Mr. Siew continued: “Clarity involves ultra-high resolution. At this moment, CLARUS is the only such device that has resolution down to 7 microns. That’s roughly twice as good as other devices. Microns determine clarity, and you see more details with clarity. This will give the doctor more confidence in managing their patients. So with certain subtle changes, if you don’t have a very high resolution camera you might miss it.” Comfort is another virtue of the CLARUS 500. With existing technology, you essentially have to bring patients toward the devices. “The CLARUS has


a chin rest and head rest. Patients stay still on the chin rest and you move the optics toward the patient,” said Mr. Siew. CLARUS also has the live infrared (IR) preview. This will help to minimize the frequency of recapturing images. “Typically doctors do nonmydriatic fundus imaging,” he said. “Therefore, the average for Asian eyes is roughly two camera shots. Otherwise, after two shots the pupil would be constricted, and the doctor will not be able to recapture again efficiently.” Finally, it is the first in the market to have fundus autofluorescence (FAF) for Blue and Green. CLARUS has both because different wavelengths will highlight different diseases better. For example, dry AMD is visualized better in FAF-Green while Geography Atrophy is revealed better in FAF-Blue. Beyond CLARUS, ZEISS featured two other extremely powerful additions to the retina physician’s armamentarium at APVRS 2017: AngioPlex and CALLISTO 3.6. “We think AngioPlex is the next generation of vascular imaging,” said Mr. Siew. “It provides noninvasive depth-resolved images of the retina microvasculature in the eye, so it helps ophthalmologists detect retinal diseases earlier and improves treatment and management of the diseases.” AngioPlex provides quantifiable parameters for better decision making by providing a full spectrum of OCT data. ZEISS is also introducing AngioPlex Metrix, which provides quantification values of vessel and perfusion density, allowing doctors to objectively monitor and assess change over time with anti-VEGF drugs. Mr. Siew explained that perfusion density – or in other words how much perfuse vasculature is available – could be favorable or unfavorable, depending on the circumstance. New vessel growth, which is not supposed to take place, could lead to a higher rate of perfused density. Alternatively,

if you have an area of nonperfusion due to diabetic retinopathy, that is not favorable. Hence, perfusion density is a complex issue, and needs to be monitored. AngioPlex Metrix also can help to flag patients with early diabetic retinopathy changes with the automatic detection of FAZ area and circularity. “AngioPlex will be very valuable because it will expand the capabilities of OCTA,” he added. “I believe it may become a standard initial examination

step for patients with retinal diseases.” In 2017, ZEISS also launched CALLISTO 3.6 – currently the only microscope in the world that performs as an all-in-one system, covering applications from the cornea to the retina to cataract and glaucoma. Before the advent of CALLISTO 3.6, hospitals needed to buy two microscopes for doctors doing cataract toric implantation, and for doctors performing retina work. “Now they can buy an all-in-one microscope,” said Jil Teo, Senior Regional Product Manager, OPMI and Phaco Systems, Southeast Asia. “That’s really good for hospitals and institutes – especially since many countries now in the region are focusing more on toric IOL implantation.” She added that CALLISTO 3.6 particularly benefits surgeons doing complicated cataract procedures with some retina involvement. The biggest benefit here is that instead of OCT only being a useful tool for retinal specialists, it becomes much broader spectrum. In addition, having an intraoperative OCT with the benefits of CALLISTO 3.6 for cataract surgery assistance justifies ROI for hospitals with budgetary constraints.

About the Contributors Mr. Terrance Siew is an expert in the field of ophthalmic diagnostics equipment and has special interest in the OCT technology. He has been invited to give lectures and teaching workshop at many meetings around the Asia-Pacific region. Mr. Siew has a degree in Bachelor of Engineering in Electrical & Electronics (major in Data Communications) from the National Electrical University, Malaysia. He has been with Carl ZEISS Meditec since 2006. [Email: terrance.siew@zeiss.com]

Ms. Jil Teo has a rich experience (over 18 years) in Pharmaceuticals and Ophthalmic Medical device industry. She holds a Diploma in Sales and Marketing from Singapore Temasek Polytechnic, a Bachelor of Science (2nd Class Honors) Degree in Marketing from the National University of Ireland, and a Master Degree of Science in Management from the University of Ireland. She has held numerous job designations at Carl ZEISS Meditec since 2013. [Email: jil.teo@zeiss.com]

25


INNOVATION DSLRs FOR VR SURGERY

Commercial DSLRs Vitreoretinal Surgery Recording An Affordable Lowâ&#x20AC;&#x2018;cost Alternative for

by Khor Hui Min

R

ecording surgeries is a great way to teach residents and fellows as part of their ophthalmic training. This video-assisted skill transfer offers more opportunities for training and demonstration, in a world where people are always short of time. At the moment, quality highdefinition (HD) recording systems are used to record surgeries, but they come at a high cost. To overcome this hurdle, a group of researchers explored various cost-effective alternatives, including a single chip charged coupling device (CCD) and webcambased cameras. These cameras were found to be adequate for recording anterior segment surgery, but were not up to the mark for recording vitreoretinal surgeries, due to the low light conditions. In anterior segment surgeries, a bright light emitting diode from the microscope provides sufficient illumination. On the other hand, a fine endoilluminator probe provides dim lighting in retinal surgeries. According to the investigators, good quality vitreoretinal surgery recording requires the following qualitiesâ&#x20AC;&#x201D;high quantum efficiency for capturing videos in poor lighting, high signal to noise ratio to prevent grain in images, and broad dynamic range to enable well-illuminated and dark areas to be visualized equally. Until now, only the high-end 3-chip CCD medical cameras provided the satisfactory quality required, but at a hefty price tag of $21,000 (USD). The study authors explored the use of high-end digital single light reflex (DSLR) cameras and found them to be an affordable alternative to the CCD cameras for ophthalmic surgery recording, particularly vitreoretinal surgery.

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I said, QUIET on the set!


The DSLR model selected for the study was the Sony A7S2, as it had the best reviews on low-light performance on the Internet. The Sony A7S2 is a mirrorless, full frame DSLR camera. The investigators compared the DSLR to the HD 3-chip CCD camera and found that the DSLR camera fulfilled all the necessary requirements and are available at an affordable price of USD 2,500. The Sony A7S2 has the following specifications: (1) ISO up to 400000, (2) Able to record videos in full HD and 4K resolution, (3) Internal 4K recording to an SD card, with no additional external recorder required for recording 4K videos, and (4) Simultaneous 4K and HD dual recording. A Sony A7S2 mirrorless DSLR was latched to a DSLR adapter (3D Medisys India) for Sony E-mount cameras. The adapter is fitted with an array of lenses which focuses the light rays diverted from the beam splitter onto the camera sensor.

The adapter is attached to the camera body in the same way as attaching a lens. The other end of the adapter is connected to the beam splitter tube and is secured in place with a tightening ring. Recording was done in the manual mode as it gives the maximum control over the brightness of the recording by varying the ISO. From this study, the investigators have found that an ISO of 200–400 is best for anterior segment surgery recording, and an ISO of 400–600 is most suitable for vitreoretinal surgery recording under a direct viewing system such as irrigating contact lens, while an ISO of 1600–2500 is best for recording under wide-angle viewing systems. Customized settings are possible with the camera, by fixing the upper and lower range and the amount of

exposure (brightness) of any recording. Any slight vignetting (dark borders at the edges of the frame) is overcome by digitally magnifying the image. A total of 60 score values for each parameter (color, contrast, and quality) were obtained for each camera, consisting of three different eye videos per camera rated by twenty observers. Most results were rated either 8/10 or 9/10 for both the cameras. The video quality of the commercial and medical cameras were comparable for all parameters assessed in the different videos except for color and contrast in posterior pole view and color on wide angle view. Therefore, the study authors concluded that commercial DSLRs are an affordable low-cost alternative for vitreoretinal surgery recording and are adequate for skill demonstration and teaching.

Reference: Khanduja S, Sampangi R, Hemlatha BC, et al. Use and validation of mirrorless digital single light reflex camera for recording of vitreoretinal surgeries in high definition. Indian J Ophthalmol. 2018;66:106-109.

INDUSTRY UPDATE

R

esults of the 2-year EVEREST II Trial presented at the recently held Asia-Pacific Vitero-retina Society Congress (APVRS 2017) held in Kuala Lumpur Malaysia, showed that the combination therapy of ranibizumab 0.5 mg and verteporfin photodynamic therapy (vPDT) led to a visual acuity gain of 9.6 letters compared to the 5.5. letters gain achieved in the ranibizumab monotherapy group. Quantel Medical’s Vitra PDT (689 NM PDT laser) is the only laser commercially available for PDT treatments, according to the company, and is widely available in Asia, including South Korea, India, Thailand, Hong Kong and Singapore.

Mr. Julien Tixier, posing beside a unit of the PDT laser at APVRS 2017.

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ENLIGHTENMENT CHARITY RUN

Real Life Superheroes Quantel Medical Sponsors Classic Cars Charity Run

Helping to Make the Holidays Happier for Orphans by Hazlin Hassan

F

or some, there is nothing more meaningful than bringing joy to children – especially during the holidays. To help spread cheer, Quantel Medical, a global ophthalmic medical device company, sponsors an annual event for orphans during the holidays – the Classic Cars Charity Run. For the last six years, Franck Morand, Quantel Medical’s manager for the Asia-Pacific region, has been the organizer of Classic Cars Charity Run. During the last event in December 2017, more than 70 orphans (aged 7 to 18) from Baan Mai Sawan New Life Center were treated to a fun-filled day at the Promenada shopping mall in Chiang Mai, Thailand. At the mall, the children enjoyed a viewing of DisneyPixar’s animated box office hit Coco, followed by lunch and dessert.

Kids from the Baan Mai Sawan New Life Center posing with one of the classic cars during the festive charity run.

Kids from the Baan Mai Sawan New Life Center enjoy themselves at the Christmas lunch.

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Group shot of the 70 kids from the Baan Mai Sawan New Life Center in a festive mood at the Promenada shopping mall, Chiang Mai.

The children were driven toand-from the Promenada in a vibrant convoy of vintage cars by members of the Classic Cars Enthusiasts (Chiang Mai region). Mr. Morand says he asks his fellow classic car enthusiast friends to lend a hand with the events: “I ask them if they are free to give their time for a day with their beloved classic car to join, what I call a ‘Classic Car Charity Run,’ at least once a year.” “I think we are privileged people to be able to get involved in a passion such as classic cars, so I think we should give to kids in need,” continued Mr. Morand. He says this is not only a way to give back, but that it also creates awareness about the tough lives that children without parents often lead. “The most important thing is to give a bright day to them,” he added. Noting that the holidays can be a lonely time for those without family, Mr. Morand makes an effort to spread joy during the holidays. In the past, he has

taken the orphans to different places, like the local Night Safari and Horizon Village Resort. “The best reward we get are the smiling faces of the kids who have had a good time.” Mr. Morand is pleased with the response he gets for the event each year. “In addition to donations, several classic car owners are very generous and help us close the budget. And every year, I ask Quantel Medical to assist and they never fail to do so, which is really great.”

Founded in 1993 and headquartered in Clermont-Ferrand, France, Quantel Medical is dedicated to developing leading technologies to improve the diagnosis and treatment of ocular diseases. The company has a strong emphasis in research and development, resulting in many firstto-market product introductions and a comprehensive product portfolio of diagnostic ultrasound, surgical lasers and a range of disposable products for ophthalmologists.

About the Contributor Franck Morand is Quantel Medical’s Manager for the Asia-Pacific region, and is based in Chiang Mai, Thailand. He manages a sales and marketing network of distributors, from the Subcontinent to Australasia and the Pacific Islands. He holds a master’s degree in English and Economics and Applied Languages, from Universite of Clermont-Ferrand, as well as International Business from the CEFRI Institute in Paris. He spent four years overseas after completing his initial studies, travelling around the world and teaching in New Zealand, which turned out to be a classic car paradise, and spent another two years teaching in Tunisia, North Africa, for his National Service. He is an avid classic cars enthusiast and a member of the Classic Cars of Lanna group which gathers old car fans in the Chiang Mai and Northern Thailand area. Mr. Morand speaks French, English, Spanish, and can get by in the Thai spoken language. [Email: franckmgv8@gmail.com]

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ENLIGHTENMENT OPHTHALMOLOGY AND FILM

Passion for Filmmaking While Working in Ophthalmology by Khor Hui Min

PRICELESS CEREMONY Synopsis

One day, a boy came home to find that his mother had suddenly died. However, he refused the services of the undertaker since he did not have enough money to pay for it. Instead, he calls on his best friend and the son of a monk to help him to give a small, low budget funeral ceremony for his dead mother. Can a person who has passed away really go on to the next world without a ceremony that costs a lot of money? Or is it enough to pay with the sincere feeling of the heart?

ABSOLUTE SILENCE Synopsis

W

hen Kohay Fukuo was 12 years old, he watched the famous movie Titanic. The film moved him deeply, making such a lasting impression on him that he wanted to move to Ireland and become a filmmaker. Eventually, he studied in the United Kingdom, where he first earned a bachelors, then a masters degree in Media Art. At university, he experimented with making short films with a basic camera. He made several films, but was not satisfied with the quality and the rudimentary editing facilities available. Today, in addition to being a successful regional sales executive with Nidek (Singapore) – a company that provides ophthalmic equipment designed for the diagnosis and treatment of retinal diseases, glaucoma, and other vision-impairing afflictions – he continues to make films. Mr. Fukuo says that his passion for filmmaking has contributed positively to his work in ophthalmology. “I feel very fortunate that my company, Nidek, is very supportive of my filmmaking,” he said. “They have given me many opportunities to explore my passion for the art.”

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Mr. Fukuo was born in Japan, but it was always his dream to expand his horizons by moving to Singapore. His work with Nidek provided that opportunity when he was transferred from the company’s Japan office to Singapore. He was also very happy to be given the chance to screen his two short films – Priceless Ceremony (2013) and Absolute Silence (2014) – in the Cannes Film Festival. “My current plan is to make a local Singaporean movie with Japanese influences,” added Mr. Fukuo. He presently uses a top-of-the-line Canon COS100 Mark II, which is specially designed for movie making. He would also like to bring new art and media culture into Asia. “I always tell my friends that my objective is to do something good for Asia before I die.”

The parents of a boy and girl died in a traffic accident. The following week, a Yakuza (Japanese gang member) came to collect money owed by their parents. The house was included in the deal as collateral. Right after being told to leave if they could not pay off their parent’s debts, the large Earthquake and Tsunami suddenly occurred. Instinctively, the Yakuza feared that the price of the land had dropped, while the (older) sister runs out of the house in a panic. The (younger) brother kills the Yakuza. Then, the dead body of the Yakuza is washed away by the Tsunami. The murder vanished in the waves. This movie studies the situation where human reasoning is warped from the darkness of crisis and conflict due to abrupt catastrophic events, and the raw feelings that ensue. This is the story of a person who takes a step forward from that point.

About the Contributor Mr. Kohay Fukuo joined Nidek Japan in 2013. He started off working in the Tokyo office, but has since been transferred to the Singapore office. He enjoys his work as a regional sales executive and continues to explore the art of filmmaking while in Singapore. [Email: kohay.fukuo@nidek.sg]


CONFERENCE HIGHLIGHTS APAO 2018 PREVIEW

APAO 2018

Brings ‘Creativity and Technology without Boundaries’ to

Hong Kong

by Brooke Herron

A

ll eyes will be on Hong Kong during the 33rd Asia-Pacific Academy of Ophthalmology (APAO) Congress (APAO 2018), a major driving force of ophthalmic development in the region. Held in conjunction with the 29th Hong Kong Ophthalmological Symposium, APAO 2018 will take place at the Hong Kong Convention and Exhibition Centre (HKCEC) from February 8 to 11. The meeting, which is co-hosted by the Hong Kong Ophthalmological Society and the College of Ophthalmologists of Hong Kong, will welcome thousands of ophthalmologists from all over the

32

world with the theme: “Creativity and Technology without Boundaries.” “We are much honored that Hong Kong has once again been chosen to host the prestigious APAO annual congress, which has now become the premier ophthalmic professional and scientific event,” said Prof. Clement Tham, APAO 2018 Congress President and Secretary-General & CEO for APAO. The last time Hong Kong hosted the event was in 2008. With the goal of eliminating blindness through teaching, research and service, the APAO fosters cooperation and encourages

collaboration between ophthalmological societies in different countries. Accordingly, the APAO is very active in the world of ophthalmology: it organizes an annual congress, coorganizes scientific meetings and conferences, publishes the Asia-Pacific Journal of Ophthalmology, recognizes ophthalmologists’ achievements in research, education and blindness prevention, runs a leadership development program and an international fellowship program, offers training and learning opportunities to young ophthalmologists, and provides an online platform on which


In a world where innovation and discovery are “occurring at a faster rate than ever before, the role of speed, efficiency, and how the changing economic landscape will direct future inquiry will also be examined. – Dr. Suber Huang

ophthalmologists from different parts of the world can interact and consult with one another.

Keynote Lectures and Awards A highlight of APAO 2018 will be the four prestigious keynote lectures, awarded to leaders and innovators in ophthalmology. Each speech will address critical ophthalmic issues in Asia-Pacific. Dr. Suber Huang (United States) received the Jose Rizal International Medal, which recognizes outstanding persons from outside the Asia-

Pacific, whose contributions have been exceptionally valuable to ophthalmological developments in the region. Currently, Dr. Huang is the president and CEO of the Retina Center of Ohio, assistant clinical professor of ophthalmology at Bascom Palmer/University of Miami, and he is also chair of the NEI/NIH National Eye Health Education Program. His current research includes the Argus II retina prosthesis, gene therapy for neovascular age-related macular degeneration (nAMD), tissue replacement for atrophic AMD, immunomodulation by stem cells, visual analytics in diabetes, and economic modelling of ophthalmic innovation. Honors include the Top Doctors and Best Doctors in America award each year since 2003, AAO Secretariat Award (twice), AAO and ASRS Senior Achievement and Honor Awards, among numerous others. In 2017, Dr. Huang was inducted as a charter member of the Retina Hall of Fame. His lecture, titled “Innovation and Collaboration in Ophthalmology: Envisioning the Future Advancements in Technologies for Treatment,” will explore three research programs and examine how their success provides insight into how leadership, collaboration, shared resources, and common purpose are critical determinants for future research design. “In a world where innovation and discovery are occurring at a faster rate than ever before, the role of speed, efficiency, and how the changing economic landscape will direct future inquiry will also be examined,” added Dr. Huang. The De Ocampo Lecture, given by Prof. Yizhi Liu, MD, PhD, (China)

is the highest award for excellent academic achievements in clinical and/ or basic eye research. He is professor and director of Zhongshan Ophthalmic Center at Sun Yatsen University and director of the State Key Laboratory of Ophthalmology. He currently serves as chair of the APAO Public Education Standing Committee, vice president of the Chinese Ophthalmological Society, and president of the Guangdong Ophthalmological Society. As a clinical ophthalmologist, Prof. Liu is recognized as a pioneer in China for performing phacoemulsification and intraocular lens implantation and he is a global leader in the research areas of cataract and stem cell-mediated ocular tissue self-repair. Thus far, he has carried out approximately 200,000 surgical operations for cataract patients and his innovations in the cataract technology system have brought great improvements. For his work, he has been recognized with numerous awards, like the APAO Arthur Lim Award (2014), Asia-Pacific Association of Cataract and Refractive Surgeons Gold Medal (2017), Guangdong Provincial Science and Technology Outstanding Contribution Award (2016), Chinese Physician Award (2016), among others. Titled “Lens Regeneration Using Endogenous Stem Cells with Gain of Visual Function in Treatment of Congenital Cataract Regenerative Medicine in Ophthalmology Using Stem Cells,” his lecture will recount results from a recent study where Prof. Liu and his team regenerated lenses with visual function in human infants with cataracts. “Human lens regeneration using endogenous stem cells with biological function and a subsequent

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CONFERENCE HIGHLIGHTS APAO 2018 PREVIEW

Human lens “regeneration using endogenous stem cells with biological function and a subsequent novel treatment strategy for cataracts have been achieved for the first time in our study, which may provide a new paradigm for tissue regeneration using endogenous stem cells.

– Prof. Yizhi Liu, MD, PhD

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novel treatment strategy for cataracts have been achieved for the first time in our study, which may provide a new paradigm for tissue regeneration using endogenous stem cells,” said Prof. Liu. The Susruta Lecture recognizes extraordinary contributions to the cataract subspecialty, specifically ophthalmologists who contribute substantially to the control and elimination of mass cataract blindness, which is a perennial problem in the Asia-Pacific region. The 2018 lecture will be delivered by Dr. Pak-Chin Chow (Hong Kong), a man with great passion and vision in the prevention of blindness – particularly blindness caused by cataract. Dr. Chow is the vice chairman of Project Vision, which brings self-sustainable cataract extraction programs to the underprivileged rural population in China. He also wholly funded and established a charity eye center in Gansu, China, in 2012 and was actively involved in training local doctors, who since have performed over 1,000 surgeries to date.

Additionally, Dr. Chow is the founding chairman and patron of the Hong Kong Medical Association Charitable Foundation, founding chairman of Eye Care Charitable Foundation, medical director of the Asian Foundation for the Prevention of Blindness, and the Honourable Ophthalmologist Ambassador of “SightFirst China Action,” a blindness eradication campaign that was commended by the World Health Organization(WHO) as one of the largest and most successful ever. For his commitment and devotion to the eradication of cataract blindness, Dr. Chow was awarded the Outstanding Service in Prevention of Blindness Award and the Distinguished Service Award by the APAO in 2005 and 2010, respectively. He was awarded the Hong Kong Humanity Award by the Hong Kong Red Cross in 2007, as well as the Hong Kong Loving Hearts Award by Asia Television Ltd in 2012. In his lecture, “Eradication of Cataract Blindness: An Impossible Dream? Empowering Prevention of Blindness for Fighting


Major Causes of Visual Impairment and Low Vision,” Dr. Chow will highlight ways to overcome the hurdles to solve cataract blindness in China. “Hopefully, this may serve as a point of reference for other countries and regions in their quest to conquer difficulties on their roads to eradicating cataract blindness,” he said. Dr. Paisan Ruamviboonsuk (Thailand) received the Arthur Lim Award, which recognizes ophthalmologists who have demonstrated exemplary leadership in the field of ophthalmology and subsequently made substantial improvements in ophthalmic teaching and training in their countries and beyond. Dr. Ruamviboonsuk is the immediate past president of the Royal College of Ophthalmologists of Thailand (RCOPT), and was president of the Thai Retina Society from 2009 to 2013. He has been an APAO council member since 2013 and a council member of the Asia-Pacific Vitreo-retina Society (APVRS) since 2010. His achievements include the initiative on prevention of blindness from diabetic retinopathy (DR) which encompasses different approaches in eye care, such as research, training, education, service improvement, and policy advocacy. This initiative received the National Service Award from the Office of PublicSector Development Commission of Thailand. He has collaborated closely with the APAO Gateway Project and Sight For All Foundation to reduce blindness and improve ophthalmic education in Laos by recruiting Thai ophthalmologists to work there. In the past, Dr. Ruamviboonsuk has received the APAO Distinguished Service Award and APAO Achievement Award. He was president of the 10th APVRS Congress in 2016 and will be the president of the 34th APAO Congress in 2019. His lecture, “Deep Learning for Diabetic Retinopathy Screening: Just the Tip of an Artificial Intelligence Iceberg in Ophthalmology and Medicine,” will discuss how deep learning and artificial intelligence is being integrated into medicine, including ophthalmology.

A Robust Scientific and Social Program

Discover Hong Kong and Have Fun Too!

APAO 2018 also boasts a star-studded Scientific Program with more than 600 experts from around the world, with an emphasis on cutting-edge scientific innovations, surgical techniques and technologies. “Our scientific program will be the best showcase for the theme of our APAO 2018 Congress, ‘Creativity and Technology without Boundaries,’ with the clear objective of preparing today’s ophthalmic practitioners for the ever-evolving future of eye care,” said Prof. Tham. “In addition to the impressive scientific program, in 2018, for the first time at an APAO congress, we have wet laboratory instruction courses and prizes for the best submissions,” added Carmen Chan, Chair, APAO Organizing Committee. “We have also prepared a social program that will provide excellent opportunities for delegates to have fun with old friends and meet new ones.” The social program will include the Opening Ceremony, Welcome Reception, Presidential Dinner and Gala Dinner. Additionally, APAO will organize its third annual Charity Run during the APAO Congress. The Charity Run will begin at the Hong Kong Observation Wheel and cover a 3-km route, with magnificent views of Hong Kong’s Victoria Harbour. There will also be a Women in Ophthalmology (WIO) Lunch and a Young Ophthalmologists’ Night.

Beyond the exciting lectures, scientific and social programs at APAO 2018, attendees should make time to explore the vibrant and cosmopolitan city of Hong Kong. Known as “Asia’s World City,” Hong Kong is a modern international hub of finance and trade with soaring skyscrapers and bustling streets, and elements of traditional Chinese and British heritage are evident through language, food and culture. APAO 2018 will take place at the award-winning Hong Kong Convention & Exhibition Centre (HKCEC). The Centre is conveniently located downtown (in the heart of the business district) and is one of the largest purpose-built complexes in Asia. With an anticipated 5,000 delegates in attendance, APAO 2018 will surely provide an excellent occasion to network and seek collaborative opportunities. “Additionally, Congress attendees can enjoy beautiful and historic attractions, along with delicious cuisine and unlimited shopping experiences, in the dynamic city of Hong Kong. We very much look forward to seeing you in Hong Kong during the 33rd APAO Congress. It is an event not to be missed!” said Charles McGhee, APAO president.

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CONFERENCE HIGHLIGHTS APVRS 2017 SYMPOSIUM

Changing the

Clinical Paradigm in P

by Collins Santhanasamy

The symposium “Changing Clinical Paradigm in Polypoidal Choroidal Vasculopathy (PCV) Management” held during the 11th Annual AsiaPacific Vitreo-retina Society Congress (APVRS 2017) in Kuala Lumpur, Malaysia, highlighted several key evidence-based findings from studies conducted on therapeutic options available for PCV management.

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P

olypoidal choroidal vasculopathy (PCV) was first described by Dr. L Yannuzzi during a presentation of cases at the American Academy of Ophthalmology (AAO) in 1982. It is a disease of the choroidal vasculature and is present in both men and women of many ethnicities. PCV is characterized by serosanguineous detachments of the pigmented epithelium and exudative changes that can commonly lead to subretinal fibrosis. Thanks to better imaging techniques, the disease is more

understood than it was 10 years ago. The incidence of PCV in Asia, as a nonvascular age-related macular degeneration (nAMD) subtype, is 40% – compared to only 15% in Europe. The existing treatment options are: • Anti-VEGF + prompt verteporfin photodynamic therapy (vPDT) combination therapy • Anti-VEGF + deferred vPDT therapy • Anti-VEGF monotherapy (with or without rescue)


PCV Management Results from the EVEREST II Study The 24-month results from the EVEREST II study were presented for the first time to the audience by Prof. Adrian Koh, an associate professor from Camden Medical Centre in Singapore. EVEREST II is a completed 24-month, phase IV, randomized, double-masked, multicentre study whose primary objective was to compare the effects of combination therapy (ranibizumab 0.5 mg + vPDT) versus monotherapy (ranibizumab 0.5 mg only) with respect to change in best-corrected visual acuity (BCVA) from baseline and complete polyp regression at month 12. The study also evaluated the safety profile of the two dosing regimens of ranibizumab and compared the number of PDT and ranibizumab injections between both treatment arms. A total of 322 patients from 42 sites across seven Asian countries including Hong Kong, Japan, Malaysia, Singapore, Korea, Taiwan and Thailand, participated in this 1:1 randomization study and were placed into either a combination or monotherapy group. Prof. Koh announced that there were two important outcomes from this study. The first was that the visual acuity (VA) gained was 9.6 letters in the combined group as compared to 5.5 letters in the ranibizumab monotherapy group, which was a highly statistically significant finding. The second important outcome was that the percentage of complete polyp regression at two years was more than double in combination therapy (56.6%) as compared to monotherapy (26.7%). In the combination group, 69.6% of patients also had fluid-free retinas at month 24 as compared to only 47.1%

in the monotherapy group. Furthermore, the mean change in BCVA of the combination therapy group at month 24 was better than the monotherapy group with both treatments allowing patients to avoid visual loss. (Least squares mean change in BCVA 9.6 as compared to 5.5) This showed that the excellent results seen in month 12 were maintained even until month 24, and that more superior results were observed in combination therapy with respect to improving BCVA and achieving complete polyp regression from baseline to month 24. The change in central subfield foveal thickness (CSFT) from baseline up to month 24 was at 152.9 microns which held steadily from month 3 onwards. Fifty-eight percent (58%) of the patients in the combined therapy group had no signs of disease activity at all. The median number of ranibizumab injections administered prior to month 24 in combination therapy was half (6) the amount of injections in the monotherapy. Interestingly, about one third of the patients did not require significantly more injections from the initial loading dose. These patients were required to have one vPDT and three ranibizumab 0.5mg injections in the first 3 months and that was all that they required for the rest of the two-year study, while 19.5% of patients in the monotherapy group required 20-24 monthly injections during the two-year study. As expected, due to the decreased number of injections, patient compliance was greater with 87% of patients adhering to the treatment protocol as compared to only 77% in the monotherapy group. No significant increase in rate of retinal hemorrhage, atrophy or fibrosis was observed over the two-year period.

Both treatment arms showed similar low rates of ocular adverse events. “By looking at the BCVA loss at both 12 and 24 months, we were confident that this was indeed a sight saving procedure,” said Prof. Koh. There were fears that the additional use of vPDT would increase the risk of hemorrhage, even in the short term, but this was not so, in fact across the board from month 3 onwards, hemorrhage decreased from the baseline with very fast resolution and no recurrence of hemorrhage during the study period. Verteporfin injections are used in combination with photodynamic therapy to treat abnormal growth of leaky blood vessels in the eye. The median number of vPDT treatments administered on patients was two. “This relieved some of our fears that multiple, repeated vPDT would cause progressive atrophy. We did not find any safety signals here.” Prof. Koh emphasized. In summary, both treatment options achieved high visual outcomes in PCV patients, however, in patients with symptomatic macular PCV, the combined addition of vPDT to ranibizumab was superior to ranibizumab monotherapy in improving visual acuity and regression of polyps at month 24. This combination resulted in an additional vision improvement of 4 letters, superior polyp resolution and other anatomical outcomes, fewer injections overall and similar safety profile as monotherapy. Further in the symposium, Dr. Timothy Y. Y. Lai, MD, FRCS, FRCOphth, from the Chinese University of Hong Kong presented the latest updates on the use of anti-VEGF monotherapy in PCV management. Results of various studies were discussed.

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CONFERENCE HIGHLIGHTS APVRS 2017 SYMPOSIUM Results from the DRAGON Study DRAGON was a phase IV, randomized, double-masked, multicenter, controlled study conducted in China where 334 patients with nAMD were randomized 1:1 into two groups, which differed in terms of the dosing regiments of ranibizumab. These two groups were further subdivided into PCV and nonPCV groups respectively. The first group received fixed monthly doses while the other group received monthly injections until maximum VA was achieved (minimum 3 injections) followed by PRN injections for the remaining months. After the first year, all patients were switched to the PRN regiment and the study was completed at month 24. At baseline, 41.7% of these patients were suffering from PCV. Patients in the PRN-PCV group received a mean number of 8.4 injections in the first year. From month 12 to month 23, the mean number of injections in the monthly-PCV group and in the PRN-PCV group was 4.9 and 6.0, respectively. This study yielded results which showed that ranibizumab monotherapy was indeed effective in restoring vision in patients with PCV, resulting in high VA gains of 10 -12 letters at 12 and 24 months.

Results from the FUJISAN Study FUJISAN was a 12-month, prospective, multicenter, randomized study in Japanese patients with PCV. The purpose of this study was to compare the 12 month treatment outcomes of initial vPDT + ranibizumab versus deferred vPDT + ranibizumab in patients with PCV. Seventy-two (72) patients underwent 1:1 randomization into two groups. The first group, initial vPDT + ranibizumab 0.5mg and the second group, deferred vPDT + ranibizumab 0.5mg. The study was completed at month 12 where the difference in mean change in BCVA from baseline to month 12 was compared between the two treatment groups.

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Both groups received three monthly ranibizumab 0.5mg injections followed by 9 months of ranibizumab 0.5mg PRN. vPDT treatment was given on day one in the initial vPDT group and was conducted PRN at months 3, 6 and 9 in both groups respectively. After month 3, 45% of patients in the deferred group received PDT. At the end of the 12-month study, no significant difference in VA gain was observed between both treatment groups with the mean change in BCVA from baseline to month 12 (ETDRS letters) being 8.1 and 8.8, respectively. However, it was seen that the mean number of additional ranibizumab injections was lower in the initial vPDT group as compared to the deferred vPDT group after the mandated initial three injections (1.5 vs 3.8). The study also showed that the proportion of patients who did not receive any additional ranibizumab treatment after the initial three monthly injections was significantly higher in the initial vPDT group as compared to the deferred vPDT group (50% vs 17%). In summary, the DRAGON, EVEREST II and FUJISAN studies now provide us with much needed level 1 randomized clinical trial (RCT) evidence for the use of ranibizumab in PCV achieving good visual outcomes at month 12 for PCV patients similar to nAMD in clinical trial settings. Anti-VEGF monotherapy with ranibizumab also showed moderate effect on complete polyp regression at month 12 (35%). Initial PDT can result in fewer ranibizumab treatments as compared to deferred PDT.

Results from the LUMINOUS Study Dr. Shigeru Honda from Kobe University Graduate School of Medicine in Japan, spoke on the topic of “real world evidence in PCV and clinically important considerations.” Dr. Honda began his presentation by stating that PCV treatment should focus on 3 R’s: the Recovery of vision, the Regression of the polypoidal lesion and the Reduction in the number of injections in patients. Then he proceeded to present results of the LUMINOUS study.

The LUMINOUS study is a global, five-year, multicenter, observational study across all approved indications to evaluate the long-term effectiveness, safety and treatment patterns associated with ranibizumab 0.5mg in routine clinical practice. Thirty thousand one hundred and thirty-eight (30,138) patients from 488 sites across 42 countries were recruited to be a part of this study. Six thousand two hundred and forty-one (6,241) of these patients were treatment naïve nAMD patients and from these patients, 572 had PCV. At month 12, in the Asian population, the mean VA gain was 6.3 letters in PCV patients as compared to 5.1 globally. The mean number of injections in the Asian population was also slightly lower as compared to the global population (3.4 v/s 3.7). Interestingly, none of these patients underwent combination therapy. Dr. Honda only presented the first year data from the said study. The complete five-year data of the study will be presented soon. Dr. Honda then presented four successful combination therapy cases to the audience highlighting that impressive results were observed in all four cases where anti-VEGF + vPDT was used. Dr. Honda concluded by stating that the combination of anti-VEGF and vPDT may provide better outcomes in PCV patients and that the anti-VEGF + vPDT combination therapy is most likely safer than vPDT therapy alone, thus suggesting that a combination therapy may be a preferable choice in PCV patients. Editor’s Note: The APVRS 2017 Show Daily, Day 3 issue (page 10), published on December 10, 2017, reported the following paragraph: “The data also showed that with aflibercept (Eylea, Bayer, Leverkusen, Germany), patients gain many more letters of visual acuity than with ranibizumab (Lucentis, Novartis, Basel, Switzerland).” Given that the article discussed two-year PLANET study results, and the PLANET study results included no data relating to a ranibizumab treatment arm for comparison, this sentence is not accurate. We regret the error.


CONFERENCE HIGHLIGHTS APVRS 2017 POSTERS

The Posterior Segment was Front and Center at

APVRS 2017 Poster Alley

Self-monitoring for wet AMD? There’s an app for that.

by Gloria D. Gamat

The Asia-Pacific Vitreoretina Society (APVRS) Annual Meeting is the region’s paramount retinal congress, and it just happened last December. Let’s take a look at the highlights…

Anti-VEGFs: How do they measure up?

A

nti-VEGF agents, administered via the intravitreal route, have become common treatments for age-related macular degeneration (AMD). However, there is a paucity of data on the pharmacokinetic parameters of these agents. Furthermore, little is known about the cytotoxicity, impact on barrier function of retinal pigment epithelial cells (RPE), and permeability through the sensory retina and RPE. In a poster titled Permeability and anti-VEGF effect of bevacizumab, ranibizumab and aflibercept in polarized retinal pigment epithelial cells, presented at the recently held Asia-Pacific Vitreo-retina Society Congress (APVRS 2017) held in Kuala Lumpur, Malaysia, Hiroto Terasaki and colleagues from the Kagoshima University in Japan conducted a variety of experiments where they measured the permeability of anti-VEGF agents through highly polarized RPE cells. In addition, they assessed RPE barrier function through immunostaining (ZO-1) and transepithelial resistance (TER) measurements. Finally, they assessed differential anti-VEGF effects and cytotoxicities of each anti-VEGF agent. The authors found no significant differences in the cytotoxicities of ranibizumab, bevacizumab and aflibercept. Ranibizumab had the highest permeability though the RPE of the three agents, closely followed by bevacizumab. Furthermore, Terasaki and colleagues quantified anti-VEGF effects of the three agents on RPE cells. They found no differences in anti-VEGF effects at the apical side of the RPE cells. However, on the basal side, aflibercept and ranibizumab had the highest anti-VEGF of the three drugs. The study authors therefore concluded that the findings of this study might be useful in the choice of antiVEGFs in clinical practice.

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CONFERENCE HIGHLIGHTS APVRS 2017 POSTERS Evaluating Successful Vitrectomy for Advanced Diabetic Eye Disease

P

roliferative diabetic retinopathy (PDR) is one of the microvascular complications of diabetes and is a leading cause of visual impairment in the diabetic population. Untreated PDR can lead to advanced diabetic eye disease characterized by fibrovascular tissue proliferation, tractional retinal detachment with or without rhegmatogenous retinal detachment. Pars plana vitrectomy (PPV) is proven to be the standard of care in advanced diabetic eye disease (ADED). It allows for removal of vitreous hemorrhage and reduces fibrovascular tissue-induced traction on the retina, resulting in improvement of vision. To evaluate visual and anatomical outcomes following vitrectomy for ADED and identify poor prognostic factors, Dr. Bethel Indira Livingstone and colleagues from the Department of Ophthalmology, University of Malaya, Kuala Lumpur, Malaysia, reviewed medical records of PPV performed in patients with ADED over a six-year period (January 2011-December 2016). Their findings were presented at the APVRS 2017 in a poster titled Factors affecting visual and anatomic success in vitrectomy for advanced diabetic eye disease: A single centre study. A total of 260 vitrectomies in 256 patients (55% male) were analyzed. The visual success rate at 6-month follow-up, defined as postoperative gain of at least two Snellen’s lines, was seen in 68.8%, while anatomical success (complete reattachment without tamponade) was recorded in 96.2% of patients. Factors associated with poor visual outcomes are age > 60 years, and presence of rhegmatogenous retinal detachment + tractional retinal detachment (TRD). The authors therefore concluded that “vitrectomy improves visual and anatomical outcomes in majority of patients with ADED. Our study supports performing vitrectomy before vision deteriorates to < 6/60 because of the significantly better prognosis.”

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Fixing the Retina Once and For All: 360-degree Laser Treatment for Rhegmatogenous Retinal Detachment

R

hegmatogenous retinal detachment (RRD) is the separation of the neurosensory retina from the underlying retinal pigment epithelium due to a retinal break. Currently, surgical management of RRD includes a variety of combinations of the following: scleral buckling, cryotherapy to all the breaks, sub-retinal fluid drainage, primary vitrectomy, endo-laser, endo-drainage, intraocular tamponade, laser to primary break or a 360-degree retinopexy. However, re-detachment and the need for a second procedure remains a risk. Dr. Shamik Mokadam from the Anjani Eye Hospital, Nagpur, India, and collaborators evaluated the efficacy of doing a 360-degree endo-laser treatment in eyes undergoing primary vitrectomy for RRD, and their findings were presented in a poster titled Primary vitrectomy with 360-degrees laser surgery for rhegmatogenous RD at the recent APVRS 2017 Congress. They conducted a retrospective review of 116 case records of all patients who underwent primary vitrectomy for RRD between 30th November 2014 and 1st December 2015 at the Sir Charles Gainder hospital, Perth, Australia. They collected data on preoperative patient examination findings as well as postoperative data at week 1, week 4 and month 3 follow-ups. The primary outcomes evaluated were the rate of anatomical re-attachment of the retina with just one surgery and the requirement for a second surgery in case of a re-detachment or epi-retinal membrane formation. One hundred ten (110) eyes were included in the study; the mean age of patients was 60 years and majority (65%) of eyes was phakic. Postoperatively at the 3-month follow-up, the 360-degree laser treatment resulted in complete attachment in 101/110 eyes (91.8%) with a mean best corrected visual acuity (BCVA) of 6/12. The authors therefore concluded that “360-degree laser treatment as part of primary vitrectomy for RRD reduces the re-detachment rates, therefore obviating the need for a second procedure.”

Assessing Patient-reported Vision Related Quality of Life in Mild/Moderate Age-related Macular Degeneration

A

ge-related macular degeneration (AMD) is a leading cause of blindness and visual impairment in developed nations, and is predicted to increase with aging populations. Mild/moderate AMD remains the most common stages and can adversely affect patient vision and quality of life. Therefore, there is an urgent need for user friendly tools to assess vision-related quality of life (VR-QOL) in patients with mild/ moderate AMD. In a poster titled Patient-reported vision related quality of life and functional retinal assessment in mild/moderate age related macular degeneration, Dr. G.K. Broadhead from the Sydney Retina Clinic, and collaborators investigated possible clinically accessible markers of VR-QOL and analyzed the correlation between clinically available tests of retinal function and patient reported VR-QOL on the visual function questionnaire 25 (VFQ-25) in mild/moderate AMD. Their study recruited 61 patients with mild/moderate AMD affecting at least one eye. With visual acuity (VA) of 6/20 or better in affected eyes. Exclusion was based on diagnoses of uncontrolled glaucoma, uveitis, diabetic retinopathy and advanced AMD. Results from patients’ functional tests (microperimetry or MP, BCVA, flicker perimetry and multifocal electroretinogram) were then correlated with patient-reported VR-QOL using the VFQ-25. The authors found that in patients with mild/moderate AMD, VFQ-25 questionnaire scores correlated strongly with findings on MP. However, the correlation was weaker for other functional tests. The authors concluded that “further research is needed to better understand the relationship between functional testing and patient reported VR-QOL.”


Spironolactone Resolves Sub-retinal Fluid in Patients with Central Serous Chorioretinopathy

C

entral serous chorioretinopathy (CSC) is a posterior segment disease characterized by localized and limited serous detachments of the neurosensory retina, often associated with focal detachments of an altered retinal pigment epithelium. The incidence is estimated to be 1 per 10,000, affecting men in about 80% of cases. The pathogenesis remains poorly understood. Some studies have shown that activation of the mineralocorticoid receptor in the retina and choroid may play a role in increased choroidal thickness and susceptibility to CSC. Mirinae Jang and colleagues from the Department of Ophthalmology at Jeju National University in South Korea, evaluated effect of spironolactone, a mineralocorticoid receptor (MR) antagonist on non-resolving CSC. Their findings were presented at the APVRS 2017, in a poster titled Spironolactone in the treatment of non-resolving central serous chorioretinopathy: A comparative analysis. They hypothesized that increased choroidal thickness and higher susceptibility to CSC may be due to excessive occupancy of the MR by glucocorticoids and/or excessive MR activation. To test this hypothesis, they conducted a retrospective chart review of patients attending the ophthalmology department of the Jeju National University Hospital, between April 2013 and June 2016. They included data from 30 eyes of 30 patients with symptomatic chronic CSC. Patients had either received spironolactone 50 mgOD or were observed without medication. They collected data on BCVA and sub-retinal fluid (SRF) measured at baseline, month 1 and month 3. After three months of treatment, there was complete resolution of sub-retinal fluid levels in majority of patients. Furthermore, patients who received spironolactone had statistically significant improvements in visual acuity. It was notable that there were no complications associated with the treatment. Dr. Jang therefore concluded that “in naïve eyes with persistent SRF due to central serous chorioretinopathy, spironolactone significantly reduced the SRF and had a positive effect on recovery of visual acuity.”

Hyper-reflective Track Lines Predict Poor Outcomes in Macular Edema

N

ovel imaging features in macular edema (ME) secondary to retinal vein occlusion (RVO) could improve risk stratification, facilitate individualized therapy and case selection for enrollment into clinical trials. Hyper-reflective track lines extending vertically from inner to outer retina were observed on spectral domain OCT scans, following resolution of branch retinal vein occlusion (BRVO). In a paper presented at the APVRS 2017 titled Significance of hyper-reflective lines on SD-OCT in macular edema secondary to central retinal vein occlusion, Dr. Mohab Eldeeb from the Montreal Retina Institute, and collaborators from other Canadian centers, sought to determine the causative factors implicated in the development of these track lines and patient outcomes. The study authors performed a retrospective case-control study of 45 eyes with central retinal vein occlusion (CRVO) associated ME treated with anti-VEGF. Eyes were categorized as either track lines positive or negative, by the presence or absence of track lines by SD-OCT, following first resolution of ME. The authors found that 16 out of 45 (35%) eyes had track lines after ME resolution. Track lines-positive patients had larger baseline central retinal subfield thickness and more cuts with intraretinal fluid, as compared to track lines-negative patients. Furthermore, data at one-year follow-up showed that track linespositive patients had worse and rapidly progressive visual acuity loss and ellipsoid zone destruction. The authors explained that the presence of track lines on SD-OCT may represent fluid fluxes between the inner and outer retina, through a disrupted external limiting membrane, which may play a role in the worsened visual acuity and structural retinal damage observed. However, further analysis will be important to elucidate the clinical feasibility of using track lines as prognostic biomarkers for patient monitoring.

INDUSTRY UPDATE Hoya Surgical Optics Launches New R&D Centre in Singapore to Address Global Burden of Cataract

I

n Singapore, cataract is one of the top three causes of visual impairment. According to local studies, nearly 65% of Singaporeans aged 60-65 and 95% of those over 75 will need cataract surgery to restore their vision. And as the population ages, the disease burden will increase, thus creating an urgent need to find new solutions that bridge the existing gaps in cataract surgery. Hoya Surgical Optics (HSO) understands this. Along with support from the Singapore Economic Development Board (EDB), HSO recently opened its new global research and development (R&D) facility in Singapore, making it the first intraocular lens (IOL) company with an integrated hub in the country (its headquarters and manufacturing facilities are also located there). This centre will develop new technologies for IOLs, which are implanted during cataract treatment. “The new centre will focus on the ideation and innovation of new technologies and solutions and will complement our R&D centre in Japan, which will focus on the design of the physical products,” said Mr. John Goltermann Lassen, chief executive officer, HOYA Surgical Optics. “With Singapore now as our global hub, it gives us close proximity to our people and allows us to formalize collaborations with Singapore’s eye community. Ultimately this will benefit both the research entities as well as the patients.”

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CONFERENCE HIGHLIGHTS ESCRS 2017 LECTURE

OCT and OCTA

Innovations The New

Gold

Standard in Ophthalmic Imaging

by Brooke Herron

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igh-quality and high-definition images are critical for patient screening and diagnosis. As such, it is important to learn how to optimize optical coherence tomography (OCT) settings to obtain the best images possible. Additionally, the new optical coherence tomography angiography (OCTA), aside from being non-invasive, is changing the way ophthalmologists see the retinal and choroidal vasculature. Mr. Adil El Maftouhi, OD, Ocular Imaging Specialist at Centre Rabelais Clinic (Lyon) and at XV XX Hospital (Paris), uses the Avanti with AngioVue OCT & OCTA platform (Optovue, Fremont, CA, USA) for high-quality and high-definition imaging in the anterior and posterior segments. He relayed his tips to optimize images using Avanti with AngioVue during a Satellite Symposium of the European Society of Cataract and Refractive Surgeons annual meeting (ESCRS 2017) in Lisbon, Portugal, last October. In the anterior segment, Mr. El Maftouhi uses Avanti OCT for cataract and IOL imaging: “We can also image the intraocular lens and bring additional information to the clinical diagnosis, such as posterior capsule opacity or sometimes opacity within the IOL.” Using OCTA in the anterior

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segment can help to identify retinal diseases. Mr. El Maftouhi suggests first turning the focus to +20D using retinal OCTA cube 6x6mm HD. Then pull back on the joystick and move the Z motor parameter slowly until you obtain a good B-scan. “OCTA applied to the anterior segment may produce more information compared to the slit lamp exam,” he added. Mr. El Maftouhi also provided tips for imaging in the posterior segment: “To optimize vitreous imaging with enhanced HD line scan, acquisition must be done with the vitreal focus. Then, add +1.50 D in the initial focus to optimize the vitreous signal during acquisition. In post-processing, tune the cursor to improve the noise of the B-scan and select the vitreous setting.” Similarly, he gave suggestions to optimize choroidal imaging, which

must be done with a choroidal focus. “Decrease -1.00 D in the focus to optimize the signal,” said Mr. El Maftouhi. “To measure the choroidal thickness, set the averaging to a minimum of 100 B-scans.” In addition to image ocular tumors, set the averaging to 200 B-scans to obtain the thickness of the lesion – the penetration depends on the tumor. In postprocessing, tune the cursor to improve the noise, and select the retina setting. In addition, he notes that Widefield En Face OCT is very helpful in daily practice for both screening and diagnosis, and that recent developments in OCTA with 3D PAR have simplified the segmentation and the CNV Visualization. “Using dynamic segmentation is very useful to avoid artifacts and improve the sensitivity,” concluded Mr. El Maftouhi.

About the Contributor Mr. Adil El Maftouhi has been practicing as an imaging expert since 2001 at 15-20 Hospital in Paris, France. He is also codirector of the Centre Rabelais ophthalmic center in Lyon. His clinical and research interests are focused on imaging techniques for both the anterior and posterior segments, with a very special interest for OCT and OCTA technology. He has authored numerous peer-reviewed publications and book chapters on the topic. [Email: adortho@hotmail.com]


CONFERENCE HIGHLIGHTS ESCRS 2017 POSTERS

When Front and Back of the Eye Overlap Summary of Posters at ESCRS 2017 by Olawale Salami

PIE Magazine Issue 03, distributed in Lisbon, Portugal, the venue of The XXXV Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2017) was one of the rare occasions we tackled issues where anterior and posterior segments collide.

EyeMax IOL: A New Approach to Macular Disease

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he EyeMax™ IOL is a single piece acrylic IOL implanted during routine phacoemulsification surgery. Its hyperaspheric optics project better focused images 10 degrees around the central macula compared to standard monofocal IOLs. In a study of 54 eyes with initial cataract and AMD, patients received phacoemulsification with EyeMax implant. The postoperative refractive target was +2.0 (with spectacles). Patients were followedup at month 6, up to month 18. According to Dr. Federico Badala from the Micro Chirurgia Oculaire, Milano, Italy, visual acuity improved in all AMD patients at 6 months follow-up following the implantation of EyeMax IOL. Smaller macular lesions were associated with greater improvements postoperatively. In addition, visual acuity better than 1/10 showed significantly greater improvements on follow up. Furthermore, binocular implants of EyeMax were associated with greater than expected improvements in visual acuity. The EyeMax implant was developed by surgeon Bobby Qureshi and Professor Pablo Artal, an optics expert at the University of Murcia in Spain, and the procedure is only available privately.

Low Visual Acuity after Uncomplicated Phacoemulsification: Suspect an Acute Serous Macular Detachment

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n a poster presented at ESCRS Congress in Lisbon, Portugal, last October 2017, Dr. Anna Nowinska and colleagues from the Medical University of Silesia, Poland, reported a case of early serous macular detachment and edema after uncomplicated phacoemulsification surgery. The case was reported in a 46-year-old patient who presented 10 years after ocular blunt injury. Documented preoperative findings were normal, and the retinal morphology was assessed normal by optical coherence tomography (OCT). Subsequently, patient underwent an uncomplicated phacoemulsification surgery (2.6mm) with intraocular posterior capsule acrylic lens implantation. OCT examination revealed an acute serous macular detachment and edema. By day 2 postoperatively, central macular retinal thickness had increased to 537 um. At this point patient received oral acetazolamide, nimesulidum, polphillin, topical dexamethasone and yellox. On day 7 postoperatively, OCT scan showed that central retinal thickness had reduced to 189 um. Further evaluation on day 10 postoperatively revealed that best corrected visual acuity (BCVA) had improved to 0.8 and OCT scan showed central retinal thickness of 189 um, and intra-/sub-retinal fluid fully reabsorbed. Subsequent followup at month 6 showed no recurrence of macular detachment or edema. The authors therefore concluded from this case report that “acute serous macular detachment should be considered on cases of low visual acuity during early postoperative period after uncomplicated phacoemulsification surgery” and that “OCT examination may be useful in early diagnosis”.

Is Phacoemulsification Safe in Patients Receiving AntiVEGF for Neo-vascular AMD?

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n recent years, interest has focused on the understanding of visual and anatomic outcomes of phacoemulsification surgery in patients receiving anti-VEGF therapy. Dr. David Ellis and colleagues from the East Sussex NHS Trust shared interesting data on this at the ESCRS 2017 in a poster titled Long term visual and anatomical outcomes in patients with active neovascular age-related macular degeneration (nAMD) following cataract surgery the authors conducted a retrospective review of clinical data from patients at the East Sussex Healthcare NHS Trust. The study included nAMD patients receiving anti-VEGF therapy who had undergone phacoemulsification. Optical coherence tomography (OCT) scans, best corrected visual acuity (BCVA), central retinal thickness and macular volume was collected preoperatively and at month 1 and month 12 follow-up visits. In this study, the authors found significant improvements in BCVA at 1 month and further improvements at 12 months. There was a marginal central retinal thickening that increased at 1 and 12 months postsurgery. Macular volume was not significantly increased postsurgery. Based on these findings, the authors concluded that “overall, it appears safe to perform phacoemulsification in patients with active nAMD when considering both visual outcomes and anatomical changes”.

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CONFERENCE HIGHLIGHTS AAO 2017 POSTERS

Back-of-the-Eye

Clinical Pearls Abound in Posters at

AAO 2017 by Olawalale Salami and Gloria D. Gamat

Breakthroughs in vitreoretina are expanding exponentially. Here are some clinical pearls that caught our attention from the posters at AAO 2017 in New Orleans, Louisiana, USA.

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Patients with Uncomplicated Posterior Vitreous Detachment May Not Require Routine Follow-up in the Absence of New Symptoms

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osterior vitreous detachment (PVD) is a common condition in older patients. While most patients experience no ill effects, 10-15% of patients experience retinal pathology such as retinal tears, vitreous hemorrhage or retinal detachment. Tears may develop at the time of initial presentation of symptoms or at a later time. For this reason, it is standard practice to follow up patients 4-6 weeks after the initial presentation. These follow up visits could be costly for patients and physicians. Dr. Michael Ross and colleagues evaluated whether a routine, early follow-up appointment was necessary in patients with no emergent symptoms. They performed a multi-chart review of patients with Schaffer negative PVD at the Montreal General and Royal Victoria Hospital, both academic centers in Montreal, Canada, over a two-year period. Their findings were presented in a poster at the American Academy Annual Meeting (AAO 2017) held in New Orleans, LA, USA, in a poster titled Posterior vitreous detachment and incidence of delayed retinal breaks: a retrospective, 2 year study at an academic centre.


IgG4-related Ophthalmic Disease (IgG4ROD) in Hong Kong: Lessons Learned from the First 10 years

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The mean age of patients studied was 58.5 years. Initial and follow-up visits were performed by physicians with variety of backgrounds (i.e. residents and attending physicians). The authors found 0/105 patients who returned for follow-up visits had new pathology. According to Dr. Ross, this is the first study that looked into incidence of delayed retinal breaks in PVD, and it confirms the low rate of new pathology detected on routine follow-up exam, particularly in asymptomatic patients. The small sample size and retrospective nature are some of the drawbacks of the study. However, Dr. Ross concluded that “uncomplicated PVD patients may not require routine follow-up in the absence of new symptoms.”

gG4-related ophthalmic disease is, patho-physiologically, a fibroinflammatory condition characterized by ocular inflammatory infiltrate with IgG4-rich plasma cells and elevation of IgG4 level in serum. It may present as dacryoadenitis, myositis, orbital inflammation, hypophysitis or pachy-meningitis causing cranial neuropathies. Dr Kelvin Chong and colleagues from the department of Ophthalmology, Prince wales hospital shared data on their 10-year experience with IgG4ROD in Hong Kong. Their findings were presented at the AAO 2017 in a poster titled IgG4 related ophthalmic disease (IgG4ROD) in Hong Kong: lessons learned from the first 10 years. Dr. Chong and colleagues conducted a retrospective, twin center case series, in which medical records of consecutive patients with biopsy proven IgG4ROD over a 10-year period were reviewed. They collected clinical, serological, radiological and histological data, evidence of systemic involvement, visual loss and treatment response. Forty-one (41) patients (15 female) were identified with a median age of 56 years. The most common clinical features were bilateral, painless upper eyelid swelling, and lacrimal gland enlargement. Eighty-seven percent (87%) had raised IgG4 levels. Treatment with systemic steroids resulted in complete to partial remission in all patients treated, but relapses were common, mainly involving the salivary gland and the liver. Five percent (5%) of patients suffered irreversible visual loss due to infiltrative optic neuropathies. This is the first multicenter study on biopsy-proven IgG4ROD in the Chinese population. The findings are similar to existing literature on this subject.

Improved Patient Outcomes with Fluocinolone Acetonide Implants + PPV in Treatment of Chronic Diabetic Macular Edema

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urrent guidelines recommend pars plana vitrectomy (PPV) as a treatment for chronic diabetic macular edema in eyes with moderate vision loss. Several studies have evaluated the safety and efficacy of fluocinolone acetonide intravitreal implant (Iluvien, Alimera Sciences, Berlin, Germany) as an effective treatment for chronic DME. With this background, Dr. Lauren Mason and colleagues from the University of Alabama hypothesized that combining PPV with Iluvien implants could result in improved patient outcomes. Their findings were presented in a poster titled Fluocinolone acetonide intravitreal implants Vs combined vitrectomy with implants for chronic diabetic macular Edema at the AAO 2017. They reviewed data from 19 eyes in 12 patients attending the retinal clinic at the University of Alabama. Eleven (11) eyes received Iluvien implant alone, while 8 eyes underwent combined PPV plus Iluvien implant. Mean follow-up time was 9.5 months. Pre-, intra-, and postoperative data was collected and main outcomes assessed were best corrected visual acuity (BCVA), mean central retinal thickness (CRT) on optical coherence tomography (OCT) and rate of postoperative complications. Mean BCVA improved from 20/200 pre-treatment to 20/125 post-treatment in the combined PPV+ implant group, while it was 20/194 to 20/185 in the implant only group. Sixty-two-point-five percent (62.5%) of eyes in the PPV+ Implant group versus 11% in the implant only group gained > 3 lines BCVA. Mean CRT decrease was significantly higher in the PPV+ implant group, and no post-operative complications were recorded. The authors therefore concluded that “combining fluocinolone acetonide intravitreal implants (Iluvien) and PPV resulted in significantly better BCVA and CRT than Iluvien implant alone in patients with chronic DME.”

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CONFERENCE HIGHLIGHTS AAO 2017 POSTERS

Can Self-testing by Patients Using a Smartphone App Detect Worsening Wet AMD?

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he availability of highly effective new treatment modalities for wet age-related macular degeneration (AMD) rekindled the discussion on the importance of early identification, selfmonitoring and targeted management. Dr. Martin Schmidt and colleagues from Oculocare Medical AG, Switzerland, assessed whether regular patient self-measurement with Alleye® (Smartphone app by Oculocare Medical AG) based on a hyperacuity alignment task, can identify worsening AMD early within a PRN treatment regimen. Their findings were presented at the AAO 2017 in a poster titled Sensitivity and positive predictive value of selfmeasurement with Alleye® to detect worsening of wet age-related AMD. They performed a prospective cohort study in which patients were instructed to perform Alleye about three mins per week. The Alleye score ranges from 12 (maximum) to zero. Score changes of -1 or more from baseline were defined as positive. Sensitivity and positive predictive value were calculated. At the end of the study, 88 eyes were included. Mean age was 73.9 years and mean baseline BCVA was 71.9 letters. Sensitivity of Alleye was 90.8 % (95% CI 81.9-96.2) and the positive predictive value was 53.9%. Dr. Schmidt concluded: “Our findings show that patient selfmeasurement with Alleye helps rule out the necessity for an anti-VEGF therapy and can be used to individualize management.”

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Aqueous Suppressants Associated with Improved Visual Outcomes in Patients Receiving Anti-VEGF for Neovascular AMD

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ecent studies suggest that topical aqueous suppressants may improve persistent exudation in neovascular AMD eyes receiving anti-VEGF agents. Dr. Jason Hsu and colleagues from the Retinal Center of the Wills Eye Hospital, Philadelphia, USA, performed a secondary analysis of data from the Comparison of AMD Treatments Trials (CATT) study, with the aim of evaluating the effect of IOP lowering medications on outcomes in patients with AMD. Their findings were presented at the AAO 2017 in a poster titled Effect of IOP lowering medications on neovascular AMD treatment outcomes in the comparison of AMD treatment trials (CATT). The authors reviewed medication logs for continuous two-year use of agents that increase aqueous flow (group A), or suppress aqueous production (group B). They then compared functional and anatomic outcomes at year 2 and modelled for treatment responses of visual acuity and optical coherence tomography (OCT) thickness in patient categories. At the end of the secondary analysis, Dr. Hsu and colleagues concluded that “over the twoyear period, the use of aqueous suppressants during intravitreal VEGF therapy for neovascular AMD was associated with improved visual outcomes and significantly greater improvements in retinal thickness.” This effect was not seen with agents that reduce IOP by increasing aqueous outflow. Larger randomized phase 3 trials are planned to validate these findings.

Projection-resolved OCTA improves Evaluation of Posttrabeculectomy Retinal Perfusion

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ptical coherence tomography angiography (OCT-A), a noninvasive imaging modality has shown its usefulness in the evaluation of glaucoma by detecting optical nerve head and peri-papillary retinal perfusion. Using a projection-resolved OCTA algorithm (PR-OCTA), Brock Alonzo and collaborators from the Casey Eye Institute, Oregon Health and Science University, examined vessel density in each plexus before and after trabeculectomy. Their findings were presented at the AAO 2017 in a poster titled Optical coherence tomography angiography of peripapillary retina preand post- trabeculectomy. In this observational study, the authors enrolled patients with glaucoma who underwent trabeculectomy due to inadequate control. One eye of each subject was scanned using Angiovue 4.5mm OCTA (Optovue, Fremont, CA, USA). Vessel density and all plexuses were analyzed. Preoperative and follow-up data at 3 and 6 months were collected. The authors analyzed PR-OCTA data from 15 patients. They found that vessel density increased more in the radial peri-papillary capillary plexus, than the deeper plexus following trabeculectomy. Focal capillary drop could be visualized in the radial peri papillary plexus of glaucomatous eyes. The authors therefore concluded that “structural and angiographic OCT parameters may be useful in the clinical evaluation of glaucoma.”


CONFERENCE HIGHLIGHTS AVRTT@6 PREVIEW

Experts to attend Live Surgery Workshop for

Ophthalmologists

There’s nothing like a good workshop.

by Ruchi Mahajan Ranga

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rganized by Retina Foundation & Eye Research Center (Ahmedabad, Gujarat, India), the 6th Advanced Vitreo-Retinal Techniques & Technology (AVRTT@6) will take place on 17-18 March 2018. This live surgery workshop will provide ophthalmologists with a one-of-a-kind opportunity to interact with experts in the field, while learning about the latest advances in vitreo-retina. Directed by Dr. Manish Nagpal and Dr. P.N. Nagpal, the course has attracted international experts for its panel, including: Dr. Andrew Chang (Sydney, Australia) and Dr. Kourous Rezaei (Chicago, USA); and national experts including Dr. Hemanth Murthy (Bangalore), Dr. Shobit Chawla (Lucknow), Dr. S. Natarajan (Mumbai), Dr. Subhendu Boral (Kolkata), Dr. Karobi Lahiri (Mumbai), and Dr. Alay Banker (Ahmedabad). Talking about the course and its agenda, Dr. Manish Nagpal shared: “AVRTT began with the main concept of providing updates on surgical advances. The course

takes places once every two years in March and consists of medical retina imaging, video-based updates and live surgery telecast using the latest instrumentation.” Spread over a day-and-a-half, the live surgery telecast will include about four patient cases where experts will demonstrate the use of latest equipment and machinery from Alcon (Fort Worth, TX, USA). Unlike basic ophthalmology workshops, this event is designed to teach practicing retinal surgeons from all over India how to benefit from the latest instrumentation. During the presentations, there are video-based sessions where surgeons can exchange clinical pearls. In addition, the live surgery audience can also ask questions through moderators during and after the surgery. After the procedures are completed, the audience can then direct their questions to the surgeons themselves. “Many times, surgeons hear and talk about new techniques – and this course provides them with an opportunity to learn how they’re actually

done,” said Dr. Nagpal. “By being exposed to new techniques, using new instruments and machines, and sharing knowledge and expertise, the attendee surgeons are able to perform better, which increases efficiency as well as safety for their patients.” Dr. Nagpal says that in order to break the monotony of similar repetitive workshops, AVRTT focuses mainly on advanced retinal and surgical techniques, with an emphasis on new retina updates – this is complemented by expertise and guidance from renowned international experts. “Our focus is only on the latest advances, which could change things for attending surgeons when they go back and practice,” he said. “The twoyear period between the consecutive courses of AVRTT enables them [attending ophthalmologists] to grasp enough advances in the field to relay to the attendees, while eliminating any repetitive content.” During the course, all of the live surgeries will be performed at the Retina Foundation & Eye Research Center and then transmitted to Narayani Heights, the venue for the meeting. And now in its sixth year, the event looks to again exceed expectations in the dynamic field of vitreo-retina. AVRTT@6 Live Surgery Workshop 17-18 March 2018 Narayani Heights Airport-Gandhinagar Road, Adjacent Apollo Hospital, Bhat, Gandhinagar, Gujarat, 382428 India To register, visit this link: www.retinafoundation.com/ upcomingevents.html or send email to meera@retinafoundation.com

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PIE Magazine Issue 04: The ebook version (APAO Hong Kong issue)  

PIE (Posterior Segment - Innovation - Enlightenment) is Asia-Pacific's First Magazine On The Posterior Segment. PIE Magazine is published by...

PIE Magazine Issue 04: The ebook version (APAO Hong Kong issue)  

PIE (Posterior Segment - Innovation - Enlightenment) is Asia-Pacific's First Magazine On The Posterior Segment. PIE Magazine is published by...