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ISSUE

& cataract • anterior segment • kudos • enlightenment

27 | 06 | 20 posterior segment • innovation • enlightenment

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

Welcome to

HIGHLIGHTS

05

Ocular surface disorders are more than surface-deep.

08

Experts weigh-in on reducing treatment burden in medical retina.

10

In glaucoma, surgical or not, it’s all about the pressure!

Published by

Matt Young

CEO & Publisher

Robert Anderson Media Director

Hannah Nguyen

Production & Circulation Manager

Gloria D. Gamat Chief Editor

Brooke Herron

WOC2020Virtual® by Brooke Herron

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he 37th World Ophthalmology Congress (WOC 2020) is officially here: And although we’re a bit sad to be sequestered in our own countries, rather than traveling to beautiful Cape Town, South Africa, we are thrilled that WOC has embraced the new digital normal (WOC2020 Virtual®). This is vital — especially in large and diverse continents, such as Africa — where access to medical care varies. In the days leading up to WOC2020 Virtual®, this need was illustrated during the Eye Health Forum on China-Africa Cooperation, co-organized by the International Agency for the Prevention of Blindness (IAPB), Orbis International- two groups also supporting WOC2020 - and He Eye Specialist Hospital (HESH). The webinar, held on June 23, featured in-depth discussion on how to improve overall service capacity of eye health in African countries to prevent blindness.

HOTSHOT

Editor

Ruchi Mahajan Ranga Project Manager

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Andrew Sweeney Hazlin Hassan Joanna Lee Sam McCommon Media MICE Pte. Ltd.

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

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Working together to overcome challenges IAPB’s CEO Peter Holland didn’t beat around the bush: He noted that there are enormous challenges and obstacles to overcome to improve eye care services in Africa — this, coupled with the COVID-19 pandemic — has added to the difficulty. However, it’s not all doom and gloom: Mr. Holland expressed that there has been progress and improvement in integrating eye care into primary care in some African locations. “To make progress, we have to work together across national boundaries,” he continued. Cont. on Page 3 >>

The PIE and CAKE Radio Show is LIVE and ON AIR. Broadcasting from Da Nang, Vietnam, with DJ Bananaman Mouse (Matt Young) and his sidekick MC Edits (Brooke Herron) in time for WOC2020 Virtual ... Click here to watch the full video.

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27 June 2020 | Issue #1

TREAT WITH

Achieve unsurpassed and sustained visual acuity (VA) gains with proactive extended dosing1–5

nAMD

DME

RVO

EYLEA® is indicated for adults for the treatment of neovascular (wet) age-related macular degeneration (AMD), visual impairment due to macular edema secondary to retinal vein occlusion (branch RVO or central RVO), visual impairment due to diabetic macular edema (DME), and visual impairment due to myopic choroidal neovascularization (myopic CNV).

REFERENCES: 1. EYLEA® approved package insert Singapore March 2019, Bayer (South East Asia) Pte Ltd. 2. Wells JA, Glassman AR, Ayala AR, et al. Aflibercept, bevacizumab, or ranibizumab for diabetic macular edema: two-year results from a comparative effectiveness randomized clinical trial. Ophthalmology. 2016;123:1351-1359. 3. Korobelnik JF, Do DV, Schmidt-Erfurth U, et al. Intravitreal aflibercept for diabetic macular edema. Ophthalmology. 2014;121:2247-2254. 4. Eleftheriadou M, Gemenetzi M, Lukic M, et al. Three-year outcomes of aflibercept treatment for neovascular age-related macular degeneration: evidence from a clinical setting. Ophthalmol Ther. 2018;7:361-368. 5. Pielen A, Clark WL, Boyer DS, et al. Integrated results from the COPERNICUS and GALILEO studies. Clin Ophthalmol. 2017;11:1533-1540.

Bayer (South East Asia) Pte Ltd 2, Tanjong Katong Road #07-01, Paya Lebar Quarter 3, Singapore 437161. Tel: +65 496 1888 Fax: +65 6496 1491 Website: www.bayer.com

PP-EYL-SG-0054-1(09/19)

ABBREVIATED PRESCRIBING INFORMATION EYLEA SOLUTION FOR INJECTION IN VIAL 2MG. Approved name(s) of the active ingredient(s) One ml solution for injection contains 40 mg aflibercept. Each vial provides a usable amount to deliver a single dose of 50 µl containing 2 mg aflibercept. Indication EYLEA is indicated for the treatment of neovascular (wet) age-related macular degeneration (AMD), macular edema secondary to retinal vein occlusion (branch RVO or central RVO), diabetic macular edema (DME) and myopic choroidal neovascularization (myopic CNV). Dosage Regimen wAMD: The recommended dose for EYLEA is 2 mg aflibercept, equivalent to 50 µl. EYLEA treatment is initiated with one injection per month for three consecutive doses, followed by one injection every two months. Based on the physician’s judgement of visual and/or anatomic outcomes, the treatment interval may be maintained at two months or further extended, such as with a treat-and-extend dosing regimen, where treatment intervals are increased in 2- or 4- weekly increments to maintain stable visual and/or anatomic outcomes. If visual and/or anatomic outcomes deteriorate, the treatment interval should be shortened accordingly to a minimum of two months during the first 12 months of treatment. There is no requirement for monitoring between injections. Based on the physician’s judgement the schedule of monitoring visits may be more frequent than the injection visits. Treatment interval greater than 4 months between injections have not been studied. Branch RVO or central RVO: The recommended dose for EYLEA is 2 mg aflibercept, equivalent to 50 microliters. After the initial injection, treatment is given monthly until visual and/or anatomic outcomes are stable. Three or more consecutive, monthly injections may be needed. The interval between two doses should not be shorter than one month. If there is no improvement in visual and anatomic outcomes over the course of the first three injections, continued treatment is not recommended. If necessary, treatment may be continued and the interval may be extended based on visual and/or anatomic outcomes (treat and extend regimen). Usually, monitoring should be done at the injection visits. During treatment interval extension through to completion of therapy, the monitoring schedule should be determined by the treating physician based on the individual patient’s response and may be more frequent than the schedule of injections. DME: The recommended dose for EYLEA is 2 mg aflibercept, equivalent to 50 microliters. EYLEA treatment is initiated with one injection per month for five consecutive doses followed by one injection every two months. There is no requirement for monitoring between injections. After the first 12 months of treatment with EYLEA, and based on visual and/or anatomic outcomes, the treatment interval may be extended, such as with a treat-and-extend dosing regimen, where the treatment intervals are gradually increased to maintain stable visual and/or anatomic outcomes; however there are insufficient data to conclude on the length of these intervals. If visual and/or anatomic outcomes deteriorate, the treatment interval should be shortened accordingly. The schedule for monitoring should therefore be determined by the treating physician and may be more frequent than the schedule of injections. If visual and anatomic outcomes indicate that the patient is not benefiting from continued treatment, EYLEA should be discontinued. Myopic CNV: The recommended dose for EYLEA is a single intravitreal injection of 2 mg aflibercept, equivalent to 50 microliters. Additional doses should be administered only if visual and anatomic outcomes indicate that the disease persists. Recurrences are treated like a new manifestation of the disease. The monitoring schedule should be determined by the treating physician based on the individual patient’s response. The interval between two doses should not be shorter than one month. Method of administration Intravitreal injections must be carried out according to medical standards and applicable guidelines by a qualified physician experienced in administering intravitreal injections. Following intravitreal injection patients should be instructed to report any symptoms suggestive of endophthalmitis (e.g., eye pain, redness of the eye, photophobia, blurring of vision) without delay. Each vial should only be used for the treatment of a single eye. Contraindications Hypersensitivity to the active substance aflibercept or to any of the excipients, active or suspected ocular or periocular infection, active severe intraocular inflammation. Special warnings and special precautions for use Endophthalmitis, increase in intraocular pressure, immunogenicity, systemic adverse events including non-ocular haemorrhages and arterial thromboembolic events. As with other intravitreal anti-VEGF treatments for AMD, the safety and efficacy of Eylea therapy administered to both eyes concurrently have not been systematically studied. When initiating Eylea therapy, caution should be used in patients with risk factors for retinal pigment epithelial tears. The dose should be withheld and treatment should not be resumed earlier than the next scheduled treatment in the event of: a decrease in best-corrected visual acuity (BCVA) of ≥30 letters compared with the last assessment of visual acuity; a subretinal haemorrhage involving the centre of the fovea, or, if the size of the haemorrhage is ≥50%, of the total lesion area. The dose should be withheld within the previous or next 28 days in the event of a performed or planned intraocular surgery. EYLEA should not be used in pregnancy unless the potential benefit outweighs the potential risk to the foetus. Women of childbearing potential have to use effective contraception during treatment and for at least 3 months after the last injection of aflibercept. Undesirable effects Very Common: Conjunctival hemorrhage, eye pain. Common: Retinal pigment epithelial tear, detachment of the retinal pigment epithelium, retinal degeneration, vitreous haemorrhage, cataract (cortical, nuclear, subcapsular), corneal erosion, corneal abrasion, intraocular pressure increased, vision blurred, vitreous floaters or detachment, injection site pain, foreign body sensation in eyes, lacrimation increased, eyelid edema, injection site hemorrhage, punctate keratitis, conjunctival hyperemia, ocular hyperemia. For a full listing of precautions and undesirable effects, please refer to the full product insert. For further prescribing information, please contact: Bayer (South East Asia)Pte Ltd. 2 Tanjong Katong Road #07-01 Paya Lebar Quarter 3 Singapore 437161. Date of revision of text March 2019.


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

continuous professional development (CPD); a functional national system to monitor human resource development (HRD) for eye care; and coherent national policies to support HRD for eye care. According to Prof. Etya’ale, enabling training is the currently most important aspect: Without it, ophthalmic training will continue to be inadequate in Africa. Specifically, he described the need for competent clinical and surgical trainers (including subspecialties), modern infrastructure and an environment to teach via wet labs and simulators. Further, Prof. Etya’ale said that far too many ophthalmic personnel in SSA go years — sometimes decades — without any continued development or refresher courses. He emphasized that the need for subspecialists in SSA is acute.

>> Cont. from Page 1

During COVID-19, coming together as a global community isn’t easy — but thanks to technology, ophthalmologists can continue to impart knowledge, teach and improve eye care without the requirement of physical presence. “We can use artificial intelligence, we can use blended learning. The technology has been impressive, and it’s getting better as we come up with new ways to attack this problem,” said Bob Ranck, president and CEO of Orbis International. According to the World Health Organization (WHO), more than 2.2 billion people worldwide live with vision impairment; of those, and in at least 1 billion, blindness could have been prevented or has yet to be addressed. “Vision impairment is four times higher in low-income countries,” said Mr. Holland. He also stressed the patientto-doctor disparity in Africa, noting that Africa has 50% fewer ophthalmologists than is needed to meet the population. “Eye care is not just an enabler of health; it’s an enabler of growth. Improving eye care and eye health transforms people’s lives and is essential to helping reduce poverty,” said Mr. Holland. “2020 has been a year unlike any other, and it’s reinforced the need for partnerships such as this.”

The eye health crisis in Africa When it comes to access to care, there is a big mismatch in Africa. According

to Dr. Wei He, founder and president of HESH (Sichuan Province, China), 36 of Africa’s 57 countries are in crisis, and the continent owns 24% of the world’s disease burden. Additionally, Africa comprises 10% of the world’s population, but only shares 1% of global health resources. These numbers alone showcase the urgency of the need. Dr. He also notes that there is also a mismatch in China: The biggest problem is myopia, and the country also claims to have the most diabetic patients in the world. To combat these issues, the Chinese government takes an industrial and innovative approach utilizing gene technology, big data, artificial intelligence, robotics, intelligent manufacturing, biomedical and biomaterials, and traditional Chinese medicine — a model they hope to replicate. “We’re thinking about how we can help our African partners to recreate our model in Africa,” said Dr. He.

Sight for Africa: The road ahead According to Professor Daniel Etya’ale, the former WHO VISION 2020 global coordinator for Africa, there are several things that need to occur in Sub-Saharan Africa (SSA) urgently: They need a highly skilled and trained workforce; a strong and enabling training environment; a well-structured and well-funded

One of these subspecialties is glaucoma: persons of African descent are 4-5 times more likely to experience blindness from glaucoma than Europeans, said Nathan Congdon, a professor of Queen’s University Belfast (Northern, Ireland). Prof. Congdon reviewed a study from urban China, which concluded that it’s more cost effective to screen for glaucoma than to not, and summarized that screening prevented more than 3 million years of blindness across China’s whole population. Prof. Congdon explained that they are hoping to replicate this model in Africa through outreach glaucoma screening and by adding glaucoma screening to existing cataract and diabetic retinopathy programs. Will the road ahead be bumpy? Sure. But together, we can truly make a difference in the lives and livelihoods of millions of people with sight-threatening disease.

Editor’s Note: Reporting for this story occurred during the Eye Health Forum on ChinaAfrica Cooperation webinar on June 23, 2020 at 11 a.m. UTC.

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pathologists, no radiotherapy available and no MRI, financial problems for payment of care, political instability or wars, corruption, malaria, ebola virus, and now coronavirus.

Retinoblastoma

Earlier diagnosis leads to better results by Hazlin Hassan

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rare form of eye cancer, retinoblastoma occurs when nerve cells in the retina change, and eventually forms a tumor. It most commonly affects young children, but can also occur in adults. Experts at the 37th World Ophthalmology Congress (WOC 2020 Virtual®) discussed the latest advances in how to treat and manage the disease.

Challenges in retinoblastoma treatment in Ghana Retinoblastoma is the most common malignant intraocular tumor in children worldwide, explained Dr. Vera Adobea Essuman of the ophthalmology department at Korle Bu Teaching Hospital in Accra, Ghana. Nearly 70 cases are seen yearly in eye clinics in Ghana, she said, noting that it is the third most common childhood malignancy in Korle Bu Teaching Hospital after lymphomas and leukemia, and is the most common ocular tumor. Most patients come with late disease presentation clinically and histopathologically. Anecdotally, overall survival is less than 50%. Only 33% of patients were alive at the last follow-up, she said, while the outcomes of 47% of patients were unknown. They either abandoned treatment or may have died at home. Currently there is no center for comprehensive management, no national guidelines and funding is a challenge,

shared Dr. Essuman. However, a national effort is underway to establish a national strategy. There is also a need to determine what the baseline epidemiology is currently, to measure progress in the future. Among patients with retinoblastoma, the most common presentation was leukocoria. Signs of advanced disease such as proptosis and orbital inflammation were also common. Dr. Essuman emphasized that the majority required combination treatment on account of advanced disease. “There is a need for a national strategy to improve on early detection with appropriate treatment, and clear referral pathways nationwide to ensure improved survival of children with retinoblastoma,” she concluded.

Early diagnosis leads to better results One promising program in several African countries has shown improved results with early diagnosis and intervention. “In developing countries, late diagnosis is a major problem. Survival is less than 50%,” said Dr. Laurence Desjardins of the Curie Institute in Paris, France. She noted that in Africa, most patients come in at a late stage. Other problems include no pathology, no multidisciplinary collaboration, lack of anesthesiologist and operating room facilities, lack of ophthalmologist and

The Alliance Mondiale Contre le Cancer (AMCC) Program to Improve Care for Retinoblastoma in Sub-Saharan Africa has been collaborating with African hospitals in French-speaking countries since 2011 for the care of retinoblastoma. It started in Mali in 2011, and was extended to Democratic Republic of Congo, Senegal, Cote d’Ivoire and Madagascar. The program provides early diagnosis actions, treatment protocols, and training for physicians. In Mali in 2011, retinoblastoma patients who were intraocular (where the cancer is still within the eye and had not spread outside the eye) had a reported 43% survival rate. In 2018, the survival rate of intraocular unilateral retinoblastoma was 87%. “We have demonstrated that improvement is possible. But only 58% of children are diagnosed at a curable stage. Early diagnosis is mandatory,” she said. The program is targeted to continue until 2028 and will be extended to more countries with a goal of attaining a 70% cure rate.

Surviving retinoblastoma in developing countries More than 80% of children with retinoblastoma live in low and middleincome countries, said Dr. Masood Naseripour from Iran University of Medical Sciences. In Iran, shared Dr. Naseripour, the fiveyear survival rate is around 98.8%, and the 10-year survival rate is 91.4% “Retinoblastoma is a curable disease when diagnosed early and treated in time,” noted Dr. Naseripour. “In spite of survival disparity in different countries, the expanding horizons in developing countries are promising and continuing on all fronts and results are hopeinspiring,” he shared. However, Dr. Naseripour emphasized that low-income countries need to be supported by other high-income countries or international organizations such as the World Health Organization (WHO).


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

Scratching the Surface

Ocular Surface Disorders by Sam McCommon

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ne of the first presentations that kicked off 37th World Ophthalmology Congress (WOC2020 Virtual®) was the Diagnosis and Treatment of Ocular Surface Diseases live session. Some true nuggets of wisdom were shared by all presenters, three of which are discussed below.

The ocular surface microbiome That the eyes are subject to infection is news to no one — but the type of bacteria involved in inflammation and infections may surprise some. Prof. Shigeru Kinoshita’s discussion on meibomitis-related ocular surface disorders led to an interesting conclusion. Some 60% of patients who suffered from meibomitis-related keratoconjunctivitis (MRKC) showed bacterial colonization of the meibum by P. Acnes bacteria — the same bacteria that causes, well, acne. This is in comparison to just under 25% of healthy patients. Additionally, MRKC patients also showed colonization by other bacteria, including P. Aures, though Prof. Kinoshita noted it wasn’t as strong as P. Acnes. “Eliminating bacteria like P. Acnes from the meibum is essential to reducing ocular surface inflammation,” Prof. Kinoshita concluded. He compared it to the now-known fact that the H. Pylori bacterium is responsible for gastritis, and when it is eliminated the gastritis goes with it. He recommended

a combination of topical and systemic antibiotics to defeat the bacteria. Dr. Vilavun Puangsricharern of Chulalongkorn University in Bangkok, Thailand, also discussed the ocular surface microbiome, but in a different context. Her presentation focused on Stevens-Johnson syndrome(SJS), a rare disorder of the skin and mucous membranes that causes chronic ocular disease in a large number of its survivors. The extreme version of Stevens-Johnson syndrome is toxic epidermal necrolysis (TEN). The syndrome is associated with an increased risk of eye infection. Dr. Puangsricharem noted that under normal circumstances the ocular surface microbiome has relatively low species diversity compared to other microbiomes like the gut. Patients who suffered from SJS, however, had much greater species diversity in the ocular microbiome, especially more pathogenic bacteria. The implication is that a disruption of the microbiome can lead to colonization by more dangerous types of bacteria.

Ocular surface squamous neoplasia (OSSN) Dr. Tsutomu “Ben” Inatomi of Kyoto Prefectural University of Medicine in Kyoto, Japan, shed light on a most unfortunate condition: cancerous tumor growth of the ocular surface. These growths occur in three phases: dysplasia, preinvasive

carcinoma (referred to as in situ), or invasive carcinoma. One study showed that the vast majority (72%) of cases were in the limbus, though the eyelid and bulbar conjunctiva can also be affected. Surgical excision is the gold standard for tackling this carcinoma according to Dr. Inatomi because it has a quick resolution and is both diagnostic and therapeutic. However, it does have its drawbacks. It can leave tumor cells remaining, leading to a potential recurrence. It can also lead to eye dysfunction due to the large amount of tissue removed. Furthermore, it can lead to stem cell deficiency and scarring. Dr. Inatomi proposed several methods for reconstructing the ocular surface. An intriguing option is cultivated oral mucosal epithelial transplantation (COMET). COMET takes oral mucosal tissue and, through several steps, transplants it to the ocular surface. One of the major benefits? There is no risk of rejection since it comes from the patient’s own body. He also recommends that if more than one third of the limbus is affected surgeons should perform a keratoepithioloplasty, which can provide stem cells to help with recovery. On the note of recovery, Dr. Inatomi recommended both intra- and postoperative chemotherapy to resolve the carcinoma and prevent recurrence, especially if excision could not remove the entire tumor. When asked about preoperative chemotherapy, however, he posited it was not a good idea because it could make determining the margin of the tumor difficult.

“Eliminating bacteria like P. Acnes from the meibum is essential to reducing ocular surface inflammation.”

Shigeru Kinoshita, M.D., Ph.D. Kyoto Prefectural University of Medicine, Japan @WOC2020 Virtual®

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Optimizing Outcomes with IOL Power Calculations by Brooke Herron

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ollowing cataract surgery, neither patients nor surgeons welcome a refractive surprise — thus, accurate intraocular lens (IOL) power calculations are crucial to outcomes. To dig deeper, Dr. Cathleen McCabe (USA), Dr. Chitra Ramamurthy (India), and Prof. Thomas Kohnen (Germany) offered their insights into these formulas during a session titled Progress in IOL Calculations on the first day of the 37th World Ophthalmology Congress (WOC2020 Virtual®). “In terms of accuracy, do we really calculate or estimate for intraocular lenses (IOLs)?” asked Prof. Kohnen — an interesting point to make during a

session on power calculations. He said that it’s estimation for this reason: “The upper limit of accuracy is ±0.50D — even in the best scenario — and 90% of patients achieve this.” He then discussed results from a study he co-authored that compared nine formulas to calculate power of a panfocal IOL in 38 eyes of 75 patients. “We saw that Barrett Universal II and Hill-RBF both had 80% at ±0.50D,” he explained, adding that only 60% of patients were within ±0.25D using Barrett’s; this dropped to 57.3% using Hill-RBF. Nevertheless, Prof. Kohnen and colleagues concluded that the Barrett II Universal formula and Hill-RBF achieved the best results.

The older generations should not be used anymore, he continued. “I use the new formulas in all my patients because my outcomes are better. But we are not yet at 100%, and therefore, we still talk about estimation rather than calculation.” Out with the old and in with the new, was also the message delivered by Dr. Ramamurthy. “With the advent of the newer biometers and newer formulas . . . today, if we use the right formula, every single patient can reach this target [within ±0.50D].” Not only does the formula need to be right, its variables do too. It is important to customize and personalize the A-constant, anterior chamber depth and surgeon factor based on individual biometry techniques and equipment, using data from at least 30 cases, concluded Dr. McCabe.

WE STAND WITH THE WORLD OF OPHTHALMOLOGY during this time of challenge, and also of hope. All around the globe we stand united with colleagues, organizations, ophthalmologists and industry, to make 2020 and beyond what it should be: Clearly, a better future.

In partnership with:

PRECISION MADE IN GERMANY.

WWW.GEUDER.DE


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

New Eye Care Realities Distancing safely while using your OCT device

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

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

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

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

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

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

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

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Reducing the Treatment Burden in Medical Retina by Brooke Herron

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ome monitoring for age related macular degeneration (AMD), drug delivery systems and new medical agents were among the highlights discussed during the Latest Developments in Medical Retina session on the first day of the 37th World Ophthalmology Congress (WOC2020 Virtual®).

Home monitoring for AMD patients The pandemic has taught us many things — and among them, it’s brought the importance of home monitoring to the forefront. So, how does home monitoring compare with in-office optical coherence tomography (OCT)? During her presentation, Prof. Anat Loewenstein from the Tel Aviv Medical Center in Israel, reported results from a study that evaluated self-operability by elderly AMD patients with VA ≥20/400: 90% of patients successfully self-operated at home and captured graded images of their macula using ForeseeHome® (Notal Vision, Tel Aviv, Israel) device. She said the patient assessment was positive and further, the fluid detection sensitivity was 91.5% and the specificity was 97%. “We think that home-based monitoring can improve personalization in treatment regimens to provide a PRN or treat-andextend approach,” she added.

On slow release devices Also on the forefront of AMD treatment are the differing approaches to sustained drug delivery. These include slow release drug reservoirs/pumps, modifying drugs for extended release, and gene therapy, said Dr. Dante Pieramici from California Retina Consultants, prior to discussing some of these in depth. “There have been some devices that are experiencing widespread use in the treatment of DME, RVO and uveitis…

the Ozurdex dexamethasone implant as well as Iluvien (fluocinolone acetonide),” he said. Dr. Pieramici next presented an implant from Neurotech that uses encapsulated cell technology and has reported positive results. “A phase 3 trial is currently underway and is due to report data sometime in 2021,” he shared. Other devices of note included the Ophthalmic MicroPump System™ developed by Replenish, Inc. (California, USA) and the Port Delivery System with ranibizumab (PDS), a novel permanent refillable eye implant developed by Genentech (California, USA).

Longer lasting retinal disease drugs “We need to have drugs that stay inside the eye for a longer time, said Prof. Francesco Bandello from VitaSalute San Raffaele University in Milan, Italy. “Reducing the treatment burden is a concern for patients and doctors alike, and longer duration drugs could alleviate the problem of under-treatment without compromising on efficacy,” he explained. One promising agent for neovascular age related macular degeneration (nAMD) is brolucizumab. However, due to 14 cases of retinal vasculitis recently reported by the American Society of Retina Specialists (ASRS), he said further studies are needed to assess its inflammatory profile, confirm efficacy findings and evaluate its use in an expanded disease spectrum. Furthermore, Prof. Bandello discussed the fluocinolone acetonide implant. “Real life studies reveal that a single implant of fluocinolone acetonide is able to improve VA and reduce central foveal thickness,” he shared. Abicipar pegol, in a new class of

drugs called DARPins, is also currently under evaluation for treating nAMD, reported Prof. Bandello. Studies are also in development to assess abicipar pegol for treating DME.

On early vs. late starts In a free paper presentation at WOC2020 Virtual®, Prof. Dr. Sebastian Wolf, Professor of Ophthalmology, Director and Chairman University Eye Hospital Bern (Bern, Switzerland), and colleagues, presented results from the ARIES study, which assessed whether intravitreal aflibercept injections administered in an early treat-andextend (T&E) regimen were non-inferior to a late-start T&E regimen in 271 nAMD patients. The authors noted that “around half of the letter-score difference between the groups was already evident at week 16.” And at week 104, the mean change in BCVA from week 16 was –2.1 and –0.4 ETDRS letters; from baseline it was +4.3 and +7.9 ETDRS letters, in the early and late groups, respectively. The mean number of injections was 12 in the early group, versus 13 in the late group, and the investigators concluded that the observed mean reduction in the number of injections with early-start T&E following initial dosing was clinically relevant. Meanwhile, the mean change in CRT from baseline to week 104 was −162µm and −159µm in the early and late groups, respectively. “These results demonstrate a relative consistency of functional and anatomic outcomes with both early- and late-start IVT-AFL T&E regimens for the treatment of nAMD,” concluded the authors.

“We think that home-based monitoring can improve personalization in treatment regimens to provide a PRN or treat-and-extend approach.”

Prof. Anat Loewenstein (Tel Aviv Medical Center, Israel @WOC2020 Virtual®


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

and may present logistical issues for specialist team members to be in the same place at the same time.

Using brachytherapy to zap extraocular melanoma Conjunctival melanoma, mostly confined to the Caucasian population, is managed successfully with conservative treatment, said Dr. Richard Jennelle of the University of Southern California, USA. “Complete surgical resection is currently favored. Surgical resection with or without adjuvant treatment is the current standard of care,” Dr. Jennelle added. Most tumors present as epibulbar tumors, and have a propensity for systemic metastasis.

The Latest on Diagnosing and Managing Ocular Surface and Orbital Tumors by Hazlin Hassan

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omputer-aided 3D customized facial implants, radiation and a multidisciplinary approach to treating conjunctival melanoma – these are just some of the latest updates in the clinical diagnosis and management of ocular surface and orbital tumors discussed by renowned specialists on the first day of the 37th World Ophthalmology Congress (WOC2020 Virtual®).

New ways of treating conjunctival melanoma A rare condition, the survival rate for conjunctival melanoma is high when managed well, Professor Max Conway from University of Sydney, Australia, told delegates at the WOC2020 Virtual®. Misdiagnosis and mismanagement, however, is associated with morbidity and mortality. In order to improve outcomes and patient care, the goal is to reduce disparities in outcomes, improve clinical decision making, ensure access to molecular testing and targeted therapies where appropriate, ensure appropriate followup and collect data for research.

A multidisciplinary approach allowed for shorter time frames from diagnosis to treatment and more accurate diagnoses. It also provided a greater likelihood of receiving care in accordance with clinical practice guidelines, including psychosocial support, enabled increased access to information and entry to clinical trials, leading to better survival rates for patients. “We are trying to encourage all ophthalmologists who treat ocular melanoma, especially general ophthalmologists to adopt an early team management model,” he said. That means to utilize the resources of the multidisciplinary team (MDT) from the earliest stage to help plan and share in the management of their ocular melanoma patients. “Patients should also be fully involved and informed of treatment options including risk versus benefits in understandable form,” he said. The MDT approach does not come without its challenges and dilemmas. It is traditionally not the way ophthalmologists have worked, and may be excessive for good prognosis tumors at an early stage. It requires facilities which some centers may not have,

Non-epibulbar tumors on the other hand are often associated with worse prognosis. Many different institutions have individual approaches to adjuvant therapy, from topical chemotherapy to cryotherapy and brachytherapy, a type of radiation therapy. “Adjuvant brachytherapy is safe and potentially effective in the management of this disease,” concluded Dr. Jennelle. There is also evidence to suggest that primary brachytherapy may be effective in a manner similar to the management of choroidal melanoma.

The face of the future A variety of injuries may result in the disruption of the anatomically complex region of the face surrounding the orbit. If inadequately treated, permanent disfigurement, visual dysfunction and unpleasant aesthetics may impair a patient for life. Reconstruction of craniofacial defects has made great leaps and bounds since custom-made implants have been developed over the last few years. Reconstruction of the orbit previously used titanium mesh, but now surgeons can use 3D-printed polyetheretherketon (PEEK) patient specific implants, reported Dr. Stijn Genders of the The Leiden University Medical Center, The Netherlands. “This material is very easy to adjust during surgery, and it will always be a good fit,” he shared.

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27 June 2020 | Issue #1

Under Pressure The Changing Landscape of Surgical Glaucoma by Sam McCommon

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riday afternoon at the 37th World Ophthalmology Congress (WOC2020 Virtual®) witnessed a crucial discussion on glaucoma surgery. It was the place to be to discuss intraocular pressure (IOP), as well as a host of other related topics. Below are two notable highlights, though the entire discussion was enlightening.

Lasers at large

Of course, evidence is required for effectiveness to be proven. Among the studies Dr. Lerner shared was one that focused on patients with serious glaucoma. MP-TSCPC achieved a 75% success rate of reducing IOP by 30% to between 6-21 mmHg after a year, compared with continuous-wave lasers — which only achieved a 29% success rate. Another study in a post-keratoplasty group showed a 94% cornea survival rate — good news. Dr. Lerner did note that a higher rate of complications may be associated with a higher power level in the laser. At a standard 2W laser, the effective period appeared to be between 160 seconds to 240 seconds, producing between 100150 joules of energy.

The treatment is rather new, and doctors are not entirely sure how it is effective yet. Dr. Lerner proposed three potential methods of action for MP-TSCPC to be effective in reducing IOP:

• Has medically uncontrolled glaucoma for which surgeries have failed or might fail

In her presentation on refractory glaucoma, Dr. Giorgis noted that MPTSCPC can be a tool in a surgeon’s kit in certain circumstances. If a patient:

• Is not a candidate for incisional surgery

• Action on the ciliary epithelium • Or has a poor visual potential

• An increase in trabecular outflow

They could be a prime candidate for the treatment. She pointed out, like Dr. Lerner, that MP-TSCPC has a better

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There’s much yet to learn about MPTSCPC and Dr. Lerner called for more data and randomized clinical trials. But for now, it is a new and potentially useful tool to safely reduce IOP.

Attacking glaucoma at its root

Micropulse transscleral cyclophotocoagulation (MP-TSCPC) was mentioned as a viable treatment by both Dr. Fabian Lerner of Argentina and president of the World Glaucoma Association, and Dr. Abeba Giorgis of Ethiopia. In contrast to continuous-wave lasers, a micropulse laser appears to have a better safety profile. The laser uses on/off cycles, with the off cycles allowing time for thermal dissipation — thus preventing tissue damage.

• An increase in uveoscleral outflow due to an increase in extracellular space

safety profile than continuous-wave lasers.

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Dr. Daemon McClunan, out of Cape Town, South Africa, took a fresh view of glaucoma at its fundamental level. He posited that the root cause of glaucoma is translaminar pressure — with age, genetics, and other factors as making a person more or less resilient to translaminar pressure’s effects. He explained his hypothesis with an analogy of a tree and wind. A tree that is well rooted in firm soil, like someone who has favorable factors, can stand up to a strong wind — translaminar pressure in this case. A poorly rooted tree can withstand much less wind than a well rooted one. So, he said, why not simply eliminate the wind? His company, Liquid Medical, has created two devices that attempt to redefine glaucoma treatment — called the OptiShunt and iPortVR — both work with subarachnoid space behind the eye. The upshot? According to Dr. McClunan, the space is self-regulating, it eliminates translaminar pressure, and it prevents the occurrence of a bleb — which can lead to lifetime complications. The three-month data showed an excellent safety profile: no severe adverse events, no unexpected adverse events, and no intraoperative adverse events. Win, win, win. Concurrently, the treatments achieved a mean 74% reduction in IOP, from 41 mmHg to 11 mmHg, a 100% success rate in reducing IOP and an 80% reduction in medications. There were some pressure drop events, as Dr. McClunan noted in the Q&A segment of the session — but this may be the beginning of a paradigm shift in glaucoma treatment.


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

Simplifying Glaucoma Management by Hazlin Hassan

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laucoma, the leading cause of irreversible blindness in the world, is an important ophthalmic condition continuously being addressed especially in developing regions. Most people with glaucoma do not experience early symptoms or pain, and is sometimes referred to as a ‘stealth thief of vision’, because as it progresses, glaucoma can cause permanent vision loss or even total blindness within a few years. At the on-going 37th World Ophthalmology Congress (WOC2020 Virtual®), glaucoma is a heavily discussed topic…

What matters in glaucoma progression? In 2014, the Mayo Clinic found that 15% of patients still progressed to blindness at least in one eye, despite advances in diagnosis and therapy, said Prof. Remo Susanna, Jr. from University of Sao Paulo School of Medicine, Brazil.

Deep learning for the detection of glaucoma “Artificial intelligence is changing our lives from when we look on Amazon or Netflix, and it makes suggestions from autonomous driving to ophthalmology,” said Dr. Linda Zangwill of the University of California, San Diego (USA). “In fact Google hopes AI can predict heart disease by looking at retinas,” she said, adding that it (AI) can already predict age and gender.

during this time of challenge, and also of hope.

“In summary, deep learning of photos and OCT images can provide high accuracy for detection of glaucoma and prediction of VF damage,” she said. Diagnostic accuracy of deep learning algorithms is influenced by the severity of the glaucoma, quality of labeling, and composition of training data sets, she added. C

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Managing glaucoma correctly and carefully

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Mean time from diagnosis to blindness was 7.2 years, with a median time of six years. This suggests that a subset of patients with glaucoma may be particularly susceptible to progressions, possibly because of non-IOP related factors.

Dr. Maria Fernando Delgado Morales of the Sociedad de Cirugia Ocular in Colombia, stressed that early diagnosis is key in treating glaucoma. Clinical examination, on the other hand, is the mainstay and must be exhaustive and carefully conducted, she highlighted.

IOP fluctuation has for a long time been considered an important risk factor in the development and progression of glaucoma. However, several studies have shown that IOP fluctuation is not an independent risk factor for glaucoma progression.

Fortunately, imaging is rapidly evolving, with advanced segmentation and faster speeds.

On the other hand, IOP peak has been considered an important risk factor for glaucoma progression and there are several papers confirming this finding. “There is clear evidence that high IOP levels (peak IOP) and mean IOP are associated with increased risk, but the same level of evidence is not seen for IOP fluctuations as an independent risk factor,” shared Prof. Susanna.

We Stand With The World of Ophthalmology

“But why do people still go blind from glaucoma? Underestimated severity of damage, insufficient IOP reduction, IOP spikes not detected, and difficulties in detecting progression rates,” Dr. Morales pointed out. Dr. Morales’s take home points revolved around early prevention of damage:”Do not forget IOP fluctuations and peaks, many will progress despite the low IOP, and last but not least…each patient is unique,” she concluded.

All around the globe we stand united with colleagues, organizations, ophthalmologists and industry, to make 2020 and beyond what it should be:

Clearly, a better future. In partnership with:


VISION ACADEMY people | research | ed u c a t io n

Making a real difference in the fight against vision loss As a leader in ophthalmology, Bayer is committed to transforming management of retinal disease through a groundbreaking program. The Vision Academy, sponsored by Bayer, is fighting to save sight around the world.

The Vision Academy Fighting to save sight The Vision Academy is a unique, independent group of over 90 world leaders in ophthalmology across 36 countries, working to develop knowledge and provide guidance where none currently exists. The group has unrivaled knowledge of patients’ needs and tackles key issues that no other program is addressing, by: Identifying and researching impactful clinical challenges Expertly reviewing clinical evidence to develop clear clinical guidance Developing multichannel educational programs to support local clinical practice Mentoring the next generation of retinal experts To learn more, visit www.visionacademy.org

I am proud to be part of this ambitious initiative. The Vision Academy is tackling key issues that no other program is addressing, for the benefit of patients.

Professor Anat Loewenstein Co-chair, Vision Academy Steering Committee

June 2020 | MA-PFM-OPHT-ALL-0183-1

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CAKE & PIE POST (WOC2020 Virtual® Edition) - DAY 1  

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