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& cataract • anterior segment • kudos • enlightenment

28 | 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



Discover the ‘smooth’ ways of treating children with corneal surface diseases.


From smaller gauge instrumentation to better vitrectomy machines, vitreoretinal experts discuss emerging advancements in surgical retina.


In nAMD treatment... which option is the best?

Published by

Matt Young

CEO & Publisher

Robert Anderson Media Director

Hannah Nguyen

Production & Circulation Manager

Gloria D. Gamat Chief Editor

Brooke Herron Editor

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The Different Approaches to Managing Retinal Diseases by Hazlin Hassan


aturday’s session at the 37th World Ophthalmology Congress (WOC 2020 Virtual®) on How to Manage Retinal Diseases: Evidence-Based Medicine saw lively debates on opposing ways in which vitreoretinal specialists handle retinal diseases. During the enlightening session, speakers showed that there are no right or wrong answers, but rather different options for managing patients with retinal diseases in today’s challenging times.

Anti-VEGF is better than laser for developing nations For Dr. Rizwana Amod from Cape Eye Hospital, South Africa, the use of anti–vascular endothelial growth factor (anti-VEGF) therapy can replace the laser in developing countries. “Anti-VEGF therapy has changed the face of ophthalmology and revolutionized the management of retinal vascular disease,” she told the congress. It has set a new standard of care and is the single intervention with the greatest impact on retinal disease and vision, she added. Developing countries are faced with a laundry list of challenges including affordability, budgetary restrictions on drugs, equipment


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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“No treatment is a reality in developing countries because affordability and access to specialized care is prohibitive.” Dr. Rizwana Amod Cape Eye Hospital Cape Town, South Africa

and infrastructure, scarcity of specialist ophthalmic services, long waiting periods for appointments, extremely limited eye services at district clinics and hospitals, lack of screening and health education Cont. on Page 3 >>



h a ve “ Toge t her we ther to f igh t , toge ce w e h a ve t o f a f t he problem o y, oph t halmolog n d to and to unite a become one.” , Dr. Ab disamad Haye




28 June 2020 | Issue #2


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




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


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

>> Cont. from Page 1

limited, and late clinical presentations resulting in poor outcomes. As such, they need treatment which is appropriate and effective, affordable, easily available, accessible and provided equitably to all patients. Anti-VEGF works well, and treatment can be administered by community-based health workers including professionally trained nurses. Laser on the other hand is limited in availability, not affordable, not accessible, and not equitable, she noted. “No treatment is a reality in developing countries because affordability and access to specialized care is prohibitive,” she said. Intravitreal anti-VEGF is an easily implemented and important tool for developing countries to help reduce the burden of blindness due to retinal disease. Thus, anti-VEGF therapy provides a great reason for optimism because they have demonstrated their effectiveness and portends a future with significantly less global blindness, she concluded.

“Sometimes vitrectomy surgery can be expensive so the laser buys us time for the patients to get their finances in order as the majority of people in developing countries pay out of pocket.” Dr. Kwesi Amissah-Arthur University of Ghana Medical School Accra, Ghana

But laser cannot be replaced by anti-VEGF On the other hand, Dr. Kwesi AmissahArthur of the University of Ghana Medical School, argued that the laser cannot be replaced by anti-VEGF treatments. He pointed out that none of the anti-VEGF agents are available on the national health insurance scheme in Ghana, where the average monthly salary is US$100 but the cost of a shot of bevacizumab is US$60. Compliance is also an issue, he noted. So in some instance, perhaps the laser is a better option. “Sometimes vitrectomy

surgery can be expensive so the laser buys us time for the patients to get their finances in order as the majority of people in developing countries pay out of pocket,” he argued.

“Social distancing is here to stay. We must find ways in which to measure our patients at home and to monitor their vision. The only barrier may be patients who feel they are ‘bad with technology’.” Dr. Dawn Sim Moorfields Eye Hospital London, United Kingdom

of patients on a daily basis. Social distancing is here to stay. We must find ways in which to measure our patients at home and to monitor their vision,” said Dr. Sim. “The only barrier may be patients who feel they are ‘bad with technology’,” she added.

“This is a very hot topic. My position is that at the moment, home monitoring of neovascular AMD patients is still not available at a very good level.” Prof. Francesco Bandello University Vita-Salute Scientific Institute San Raffaele Milan, Italy

Home testing is the future amid virus fears

But then again, early detection is key

Dr. Dawn Sim from Moorfields Eye Hospital in the United Kingdom, feels that home monitoring is the way to go to protect both the patient and the doctor while the world reels from the COVID-19 pandemic.

Prof. Francesco Bandello, from University Vita Salute San Raffaele, Italy, however, disagrees. “This is a very hot topic. My position is that at the moment, home monitoring of neovascular AMD patients is still not available at a very good level,” he told delegates.

“With the pandemic putting frontline health workers under mounting pressure, is it possible for ophthalmologists to safely see patients without putting themselves at risk?” she asked. What’s needed now is a “virtual triage” where patients are sorted for medical treatment on the basis of need before they present physically to a healthcare facility. So patients basically need to run through home vision tests and symptom checkers before heading down for a faceto-face appointment. Dr. Sim cited a randomized control trial in 2014 on home monitoring which yielded positive results: “What they found was in the group that was given a home monitoring device, there was a smaller loss of visual acuity in those that were testing their sight at home compared to those that were not (median: -4 versus - 9 letters).” The conclusion? Persons at high risk for choroidal neovascularization (CNV) benefit from home monitoring for earlier detection and better visual acuity (VA) results after anti-VEGF therapy. “No longer will we be able to cram our waiting rooms up and see a large number

Age related macular degeneration (AMD) is the most frequent cause of severe vision loss in the developed world for people above 55 years of age, he pointed out. CNV is responsible for most AMDrelated severe vision loss. Prof. Bandello suggests treatment regimens such as Pro re nata (PRN) which involves a loading dose of three consecutive monthly antiVEGF injections, followed by monthly visits. Or the treat-and-extend regimen (T&E) which is a similar loading phase to PRN, followed by injections at every visit but with the interval between subsequent visits extended gradually. “Early detection is critical to maintaining functional vision,” he warned. It is best to treat patients early on in order to obtain the best results. “If you wait, and you have a patient with a very low visual acuity, visual acuity will remain low. But if you start from a very high visual acuity, you may be able to maintain more or less the same level of visual function. This is important,” summarized Prof. Bandello.




28 June 2020 | Issue #2

Cornea and Ocular Surface in Children

The Rough with the Smooth by Sam McCommon


ne of the subspecialty symposia on day two of the 37th World Ophthalmology Congress (WOC2020 Virtual®) focused on the cornea and ocular surface in children. Treating children comes with a unique set of circumstances that must be considered in addition to the normal treatment of a condition. Below are two highlights from the discussion.

Allergic conjunctivitis The first topic tackled was allergic conjunctivitis (AC), covered in a presentation by Prof. Yair Morad of the Sackler Faculty of Medicine at Tel Aviv University in Israel. Prof. Morad discussed a range of treatment options, from managing common to extreme conditions. The condition leads to itchy, red eyes that many are unfortunately familiar with. AC is quite common, affecting 15% to 40% of the population affected. It’s seasonally exacerbated by things like pollen, though some 25% of sufferers are affected year round. It’s more common in children with an atopic background and is also more common in males. Primary treatments can be simple: avoiding allergens like pets, carpets, or pollinating trees, for example. Cold compresses and water-based lubricants can also help reduce symptoms. But,

as Prof. Morad noted, these ‘solutions’ often fail. He humorously compared treatments like topical antihistamines, mast cell stabilizing agents like cromolyn sodium, and non-steroidal anti-inflammatory drugs (NSAIDs) like ketorolac to lousy cars, with doctors offering them to patients before offering the comparative shiny Mercedes: multiple action drugs. Why not simply offer the higher quality product to begin with? Prof. Morad instead recommended multiple action drugs like nedocromil (Tilavist), azelastine (Optilast) or olopatadine (Patanol). In acute cases, he suggested using as mild a topical steroid as possible, like metholone — not prednisolone or dexamethasone. Another safe option is loteprednol, which is relatively safe for prolonged use. However, he stressed that steroids should only be used in the case of exacerbations. Steroids cannot be used forever and even they sometimes fail — so, Dr. Morad turned to what he dubbed “wonder drugs”. He therefore recommended 1% topical cyclosporine or tacrolimus — which he said has greater immunosuppression than cyclosporine, less stinging sensation, and no side effects. In the event these drugs aren’t tolerated, systemic steroids like prednisone at 1mg/kg can be used for

Seeing their smile when they see is all worth it.

alternate day treatment. Another option is a supra-tarsal injection of equal parts triamcinolone and tacrolimus, while continuing cyclosporine or tacrolimus treatment. He noted that patients experienced dramatic relief of symptoms within 1-5 days, with little need for repeated treatments. And if the case is truly difficult? Prof. Morad advised to turn to systemic cyclosporine.

Managing keratoplasty in children Prof. Nikolas Ziakas of the Aristotle University of Thessaloniki in Greece. discussed keratoplasty surgery in children — and all the special considerations one must take into account. These considerations include pre-, intra-, and postoperative complications as well as physiological differences between children and adults. Unsurprisingly, children are less cooperative and communicative than adults, which can lead to inaccurate visual acuity measurements and imprecise examinations. Physiologically, children have low scleral rigidity, thinner and more pliable corneas, smaller anterior segment dimensions, and a higher posterior vitreous pressure. Because of the lower scleral and corneal rigidity, Prof. Ziakas recommended oversizing the graft by 0.5-1 mm, particularly in the aphakic eye. This is in conjunction with choosing a corneal diameter of 5.5-7.0 mm. He noted that it’s especially important to oversize the graft when working with thin tissue, since compression of the tissue can compromise the wound. He also highlighted using the Price graftover-host technique to maintain positive pressure during penetrating keratoplasty. Postoperatively, children and infants require more control than adults. For example, the infant cornea heals much faster than the adult one, and sutures should be removed as soon as possible. Any microabscesses or neovascularization can indicate inflammation, which can lead to graft rejection.

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

10 out of 10 patients agree they wish they had not had traumatic ocular injury.

The ‘Traumatic’ in Ocular Injuries by Brooke Herron


orldwide, ocular trauma is an important (but perhaps lesser recognized) cause of blindness. Naturally, the initial injury itself (be it physical, postoperative or other) can be difficult to manage — however, it can also lead to other sight debilitating conditions such as traumatic cataract and glaucoma. Updated information on these injuries was presented during the Management of Anterior Segment Trauma: The Good, the Bad and the New session on the second day of the 37th World Ophthalmology Congress (WOC2020 Virtual®).

What’s the prognosis, doc? According to Dr. Ahmed Bardan from the University of Alexandria, Egypt, the initial visual acuity (VA) in patients with ocular injury significantly affects the final visual outcome. “There are other factors, like neglected injuries causing endophthalmitis; the presence of relative afferent pupillary defects (RAPD), which cause severe posterior segment and optic nerve damage; retinal detachment; and the size and location of the wound,” he said, adding that although those are the main factors, there are others including: lens injury, hyphema/vitreous hemorrhage and older age.

Further, Dr. Bardan detailed the prognostic tool used to classify ocular trauma and estimate visual outcomes: the Ocular Trauma Score (OTS). “The higher the score, the better the prognosis,” he explained, after going through the score’s different elements in detail. The zone of injury is another important aspect, said Dr. Bardan. “The more posterior the injury, the worse the outcome.”

Not your average glaucoma Traumatic glaucoma can look very different with a subtle or dramatic appearance, began Dr. Robert Chang from Stanford University, California in the United States. “It’s helpful to classify ocular trauma into two main categories: blunt and penetrating trauma,” he continued. “According to one study, blunt trauma causes glaucoma more frequently (19%) versus penetrating trauma at about 3%.” In addition, Dr. Chang said that it’s of significant importance to differentiate between angle recession and a cyclodialysis cleft: “A cleft may have low [intraocular] pressure initially, but the pressure can then spike to high after the hole closes.”

There are other reasons for high pressure, he continued. “For example, right after the injury you may see trabecular meshwork direct injury, leading to traumatic iritis or inflammation, lens dislocation, hyphema, and choroidal hemorrhage in the back of the eye. “Later, you may see the angle recession that develops or rare conditions like ghost cell glaucoma, hemolytic/ hemosideritic glaucoma, or even patients who already had cataract surgery and had their lens dislocated, or lens induced glaucoma from violating the lens capsule, leading to subsequent inflammation,” explained Dr. Chang.

Traumatic cataract is different, too The incidence of traumatic cataract is very common, said Dr. Alex Ng from Hong Kong Ophthalmic Associates. “Over half of serious injuries involve lens damage.” Dr. Ng noted that there are several controversies when it comes to treating traumatic cataract: “Mainly, it’s the timing of surgery. When we are approaching a cataract, sometimes we do it as early as possible, or sometimes we do it with other surgeries. The other controversy is whether we put in the IOL primarily or secondarily. “For the primary cataract removal, the advantage is that it prevents some cataract induced inflammation and glaucoma, especially when there’s lens material in the AC [anterior chamber],” explained Dr. Ng. He said early removal can also offer better visualization of the posterior segment. Secondary cataract removal also has benefits: being a hot versus quiet eye, better biometry, less inflammation, better surgical planning, among others. “The timing of surgery really depends on the presence of any other ocular injury,” he pointed out. The surgeon’s experience in dealing with traumatic cases is also critical. “Remember that traumatic cataract is not your daily day-in, day-out age-related cataract,” Dr. Ng emphasized.




28 June 2020 | Issue #2

New Advances in Vitreoretinal Surgery by Hazlin Hassan

“Advances in surgical systems including microincision vitrectomy surgery (MIVS), non-contact operating microscope and 3D headup, now allow surgeons to perform better vitrectomies for proliferative diabetic retinopathy (PDR).” Prof. Kazuaki Kadonosono Yokohama City University School of Medicine Yokohama, Japan


itreoretinal surgery has seen dramatic changes over the last 10 years with the emergence of new techniques, smaller gauge instrumentation, and better vitrectomy machines. During a surgical retina session on day two of the 37th World Ophthalmology Congress (WOC2020 Virtual®), an allstar cast featuring renowned surgeons from around the world discussed the latest cutting edge technologies in the surgical field of retina that allow even better surgical outcomes and fewer complications than ever before.

“Visualization is mandatory. We need to be able to see exactly what we are doing and be able to perform a dissection of this tissue from the retina surface to avoid the creation of retinal breaks which is a mandatory condition to avoid 100% failure and no light perception.” Prof. Marco Mura King Khaled Eye Specialist Hospital (KKESH) Riyadh, Saudi Arabia

When bigger Is not better For Prof. Marco Mura from King Khaled Eye Specialist Hospital, Saudi Arabia, he finds that the latest in smaller gauge vitrectomy probes are better, when it comes to treating retinopathy of prematurity (ROP). Here, the stakes are high. In stage 5 ROP, if a break develops, that’s 100% failure. “Visualization is mandatory. We need to be able to see exactly what we are doing and be able to perform a dissection of this tissue from the retina surface to avoid the creation of retinal breaks which is a mandatory condition to avoid 100% failure and no light perception,” Prof Mura cautioned. Improvements in technology including smaller gauge vitrectomy probes, new illumination techniques, and 3D digital visualization systems will help in the treatment of this complex disease with potentially better anatomical and functional results.

See it in 3D Advances in surgical systems including microincision vitrectomy surgery (MIVS), non-contact operating microscope and 3D head- up, now allow surgeons to perform better vitrectomies for proliferative diabetic retinopathy (PDR),

said Prof. Kazuaki Kadonosono from Yokohama City University School of Medicine, Japan. “3D vitrectomy offers advantages such as better depth of field, higher resolution, lower risk of phototoxicity, and opportunities for digital enhancement,” he explained. Surgical techniques such as bimanual procedures have also improved, resulting in decreasing surgical complications.

Surgeons and their need for speed “Why do we want to go faster?” asked Dr. David Chow from University of Toronto, Canada. “As we make quicker cuts, we take smaller bites of tissue, and we are inducing less traction.” One fast tool is Alcon’s ULTRAVIT® 10K bevel high speed vitrectomy probe which has a bevel tip design that allows the port to get closer to the retina, with less turbulence at 10,000 cpm and reduced backflow. Another device that Dr. Chow discussed is the Bi-Blade® dual port vitrectomy cutter from Bausch and Lomb. Its innovative dual blade design offers consistent flow rates, and reduced retinal traction at 15,000 cpm. Alcon is also releasing their version of a dual-blade cutter, the 20,000 cpm HYPERVIT® dual blade vitrectomy probe.

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

Taking OCTA to the Next Level

DICOM and EMR capability, results from multiple Canon imaging modalities can be stored, shared and analyzed as needed in your daily practice. The Retinal Expert (RX) software fully integrated with the Xephilio OCT-A1 does not only work well as a database, it also serves as a viewing station that allows access to all patient data for reviewing and reporting from remote locations while the database remains on the systems. The RX software is a very intuitive and user friendly software with extensive pre-settings for the scan protocols allowing efficient workflow and OCT user management.

The Canon Medical Xephilio OCT-A1 is powered by AI


ptical coherence tomography angiography (OCTA) has stepped into a new tomorrow with the entrance of Canon Medical Xephilio OCT-A1. The artificial intelligencepowered innovation is all about optimizing image quality, speed of acquisition with outstanding imaging capabilities, versatile reporting possibilities and even makes physical distancing safety a reality. The Canon Medical Xephilio OCT-A1 offers cutting edge imaging results with the Intelligent Denoise capability, Canon’s deep learning technology that offers a new quality of OCTA images. This is achieved within a single individual scan without the need to acquire and merge multiple images by delivering images with greatly reduced image noise, increased detail and improved visibility within just seconds. Combined with the Flow Fusion technology, you can also sub-divide complex examinations for difficult-toimage patients and overcome signal dropouts caused by vitreous artefacts.

of up to 1.6 µm enables detection and distinction of 10 layers of the retina, including Bruch’s membrane. Thanks to Canon’s recognized optical expertise, its excellent native optical resolution combined with the averaging multiple scans (up to 200) help achieve amazing detail resolution. Accurate scanning is also easy with the system’s integrated Scanning Laser Ophthalmoscope (SLO). The real-time retinal tracking not only provides precise monitoring of the examination; it also allows you to maintain the exact same scanning position automatically. As a result, the tracking reduces movement artefacts, providing consistent, high image quality. The software’s automatic selection of identical scan parameters for follow-up examinations makes for consistency and reliability in results. For reporting, the Canon Medical Xephilio OCT-A1 provides a full range of tools including an extensive normative database. Thanks to its extensive

A Canon Medical Xephilio OCT-A1 scan can be done in 2 seconds. This not only helps you save time and enhance work efficiency, but ultimately, the shorter examination time increases your patient’s comfort and well-being. Scan results can be ready in a matter of seconds. It’s not only its speed but also its outstanding image performance that impresses. The Canon Medical Xephilio OCT-A1’s outstanding digital resolution

Intelligent Denoise optimized scan

Most of all, the intelligent Canon Medical Xephilio OCT-A1 is easy to use with its three-click function to complete an examination. Just point, align and shoot. There is no need for any joysticks. It offers a complete range of intelligent functions to enable fully automated examinations, making it easy for delegation of scanning operations to nurses or assistants. In light of the new reality after COVID-19, keeping a safe physical distance is also now feasible with Canon Medical Xephilio OCT-A1 offering you multiple possibilities to operate the device in a safer, socially-distanced way. The OCT scanner can be operated easily from any PC, or tablet device over a network using a remote desktop solution (e.g. TeamViewer). The Canon Medical Xephilio OCT-A1 can be operated over the hospital network or via the Internet from another room in the hospital or even a different location.




28 June 2020 | Issue #2

risks. We are considering the treatment for patients who cannot be extended and who cannot come more frequently, and whose fellow eyes have reasonably good vision,” he continued.

Assessing the Options in nAMD Treatment

by Brooke Herron


nti–vascular endothelial growth factor (anti-VEGF) therapies dramatically changed the prognosis of neovascular age-related macular degeneration (nAMD), when before we only had photodynamic therapy (PDT), began Dr. Patricia Udaondo from the Hospital Universitario y Politécnico de La Fe in Valencia, Spain. Today, nAMD is often managed with intravitreal anti-VEGF injections. And as ground-breaking as these agents are, the treatment burden can be high for both patients and physicians — especially for those on fixed monthly dosing. Thanks to the high burden, regimens like treat-and-extend (T&E) are gaining steam: “T&E strikes a balance between the benefits of a fixed regimen and the desire for physicians to individualize based on specific response,” said Dr. Udaondo. “This reduces the cost of treatment and gets vision outcomes closer to that in clinical trials.” In addition, new treatments, like longerlasting anti-VEGFs and gene therapy are making waves. These updates and more were discussed during the Subspecialty Day: Management of Age-related Macular Degeneration session on the second day of the 37th World Ophthalmology Congress (WOC2020 Virtual®).

Bevacizumab isn’t going anywhere “Will bevacizumab still be used for management of wet AMD five years from now?” asked Dr. Baruch Kuppermann from the Gavin Herbert Eye Institute, University of California Irvine, USA. The answer is yes.

Although bevacizumab is off-label, it’s often used over approved anti-VEGFs due to its low cost and non-inferiority to other agents. According to Dr. Kuppermann, in 2018, the average wholesale cost for ranibizumab was $1950; aflibercept was $1850. Meanwhile, bevacizumab sits at $50 per dose. Also, Dr. Kupperman noted that biosimilars (in development for ranibizumab) won’t be able to compete with bevacizumab either, when it comes to cost and cost effectiveness. “We will continue to have bevacizumab as a strong weapon in our armamentarium in the fight against wet AMD for the foreseeable future,” he concluded.

Safety concerns rock the boat for brolucizumab Brolucizumab entered the market buoyed by results of efficacy and reduced injection frequency. Then the American Society of Retina Specialists (ASRS) alerted the ophthalmic community of 14 cases of retinal vasculitis. However, as serious these side effects are, physicians aren’t quite jumping ship yet. “Before the new safety concern, we had contemplated moving to brolucizumab as a first-line therapy,” said Dr. Srinivas Sadda, from the Doheny Eye Institute UCLA, California. He detailed several patient cases where brolucizumab resulted in better outcomes than other agents. “It appears to have superior drying and consequently, superior durability over other currently available agents. “Now in view of those concerns, we’re having extensive discussions with our patients so that they understand those

“If we’re able to predict who is going to get the inflammation, or if we’re able to get insight into why the inflammation is occurring and can manage it or prevent it, then that will obviously impact our utilization,” explained Dr. Sadda.

It’s all in the genes Gene therapy is showing promise for treating nAMD, said Dr. Allen Ho from Wills Eye Hospital, Pennsylvania, USA. During his presentation, Dr. Ho discussed phase I/II trial results for a new therapy from Regenxbio using subretinal delivery, dubbed as RGX-314. Results showed that RGX-314 was well-tolerated at all dose levels, reported Dr. Ho. In cohort 3, there was a longterm, durable treatment effect for over two years, resulting in improved VA and stable retinal thickness. It also significantly reduced the treatment burden. In cohort 5, 73% of patients remained anti-VEGF injection-free at 9 months. Could gene therapy rally to the frontline of nAMD treatment soon? We can’t predict the outcomes, but it certainly looks promising.

“T&E strikes a balance between the benefits of a fixed regimen and the desire for physicians to individualize based on specific response. This reduces the cost of treatment and gets vision outcomes closer to that in clinical trials.” Dr. Patricia Udaondo Hospital Universitario y Politécnico de La Fe Valencia, Spain

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

Corneal Surface Disorders Smoothing Things Over

by Sam McCommon

when amoeba of the acanthamoeba genus invade the cornea. The amoeba can be contracted in water, with hard water presenting a three times greater risk of exposure than soft water. Dr. Ahmad recommended that those with contact lenses should avoid wearing them while swimming and showering to reduce the risk of infection. The disease is notoriously difficult to cure, with a median treatment time of five to six months. It can lead to infection, inflammation, epithelial loss, IOP fluctuations and even cataracts. The main drug used to treat it is biguanide, which is sometimes paired with diamidine for a dual treatment. However, Dr. Ahmad noted that evidence for the effectiveness of a dual treatment is lacking, and that diamidine’s toxicity is a problem. Even with medical treatment, Dr. Ahmad said there is a 50% chance of poor outcomes, including poor vision and a further need for surgery.

There’s nothing corny about corneal health.


ay two of the 37th World Ophthalmology Congress (WOC2020 Virtual®) continues, and one of the morning’s live sessions tackled cornea diseases. Keratoconus was one of the major focuses, as was a more rare condition involving an amoebic infection in the cornea.

Looking for keratoconus clues Dr. Jesper Hjortdal from Aarhus University in Copenhagen, Denmark, presented an eye-opening view into potential signs of keratoconus. The etiology and onset of keratoconus has been mysterious for some time, although the medical community is aware that sex hormones play a role in maintaining the structure of the cornea. He shared data that indicated social demographic factors: of patients presenting with keratoconus, two-thirds were male while non-Europeans had a three times higher risk factor than Europeans. Single people had a 27% higher risk and those in the cities had a significantly lower risk than those living in the countryside.

Additionally, asthma and atopic dermatitis were associated with keratoconus but surprisingly diabetes was not associated, according to the study. He continued on to point out that he believes prolactin-induced protein (PIP) is a viable biomarker for keratoconus, and noted that PIP levels are regulated by androgens and estrogens. PIPs are found in many secretions in the body, including saliva, and can affect the corneal surface. Most specifically, he indicated that lower PIP levels than normal can be a biomarker for keratoconus. If so, this can be a landmark change in the way keratoconus is understood and predicted. Certainly, having many biomarkers would be ideal, but having a good measuring stick is a solid start.

Acanthamoeba keratitis Dr. Sajjad Ahmad, of Moorfields Eye Hospital in London, United Kingdom, took on a rare but dangerous condition: acanthamoeba keratitis (AK). As the name suggests, the condition occurs

Early diagnosis is crucial, as severe AK has a high level of vision morbidity. Dr. Ahmad recommends treating with antiamoebics before using topical steroids, and commented that a quarter of patients don’t need topical steroids, but around two-thirds will need systemic immune suppression. Keratoplasty is an option only when medical treatments have been optimized and still failed, emphasized Dr. Ahmad. In this circumstance, it’s a risky procedure, with a risk of recurrence, a failure to heal, secondary glaucoma or hypotony are all potential outcomes. Two-thirds of patients will require regrafts and three-quarters will require other surgery — all with vision outcomes ranging from 20/20 to blindness. Because it can be painful as well, non-steroidal anti-inflammatory drugs (NSAIDs) for chronic pain and sedatives for nighttime relief may be required. There’s even a mental health support group for the condition because it can affect one’s life so much. The condition certainly doesn’t sound pleasant, but it’s good to know that even for such a case treatments are available.




28 June 2020 | Issue #2

Imaging the Optic Nerve, Lamina Cribrosa and Retina in Glaucoma by Joanna Lee

Dr. Moraes also shared his study’s findings2 where he and his coinvestigators found a method to gauge the agreement between structural (optical coherence tomography [OCT]) and functional (visual field [VF]) glaucomatous damage.

The roles of OCT and OCTA

Screening for glaucoma is a difficult problem because it is asymptomatic, has low prevalence, is typically only slowly progressive, and has no agreed upon standard for diagnosis.” This statement from the Agency for Healthcare Research and Quality (AHRQ) provides an overview of the ongoing challenges in diagnosing the disease. Nevertheless, ongoing investigations are helping to shed more light on the parameters of its diagnoses.

Imaging in glaucoma In a WOC2020 Virtual® presentation titled Practical Recommendations for Imaging in Glaucoma, Dr. C. Gustavo De Moraes from Columbia University, New York, USA, mentioned among his many tips to always look at the global and local matrix when looking for progression as they complement each other. He also recommended to look at individual scans and compare them with the visual field (VF). To lower false positive rates, Dr. Moraes cited a study1 which suggested a rate progression of 0.9 μm/year would be useful to define progressive cases. As glaucoma occurs mostly in the superior and anterior poles of the disc, he also said it’s important to look for changes in these locations (on the topographical map).

In presenting Pearls and Pitfalls of Optical Coherence Tomography (OCT), Dr. Xiulan Zhang from Zhongshan Ophthalmic Center, China, highlighted a few factors which would affect the image quality when trying to determine the real “thinning of the retinal nerve fiber layer (RNFL) and ganglion cell-inner plexiform layer (GC-IPL). Some of the factors include signal quality, scan alignment, opacities, segmentation errors and aging. She also highlighted improvements which are needed in optical coherence tomography angiography (OCTA) imaging. “Going wider and deeper is needed in OCT and OCTA scanning of glaucoma subjects,” she said. Eyes with high myopia are difficult to diagnose, as expounded during a presentation on Myopia Optic Nerve Imaging for Myopic Glaucomatous Eyes. Dr. Kyung Rim Sung from the University of Ulsan College of Medicine at Asan Medical Center in Seoul, Korea, spoke on the possibilities of using OCT to diagnose and note the progression of the myopic glaucomatous optic disc. “Some of the myopic optic disc has deformation in its shape, having many variables; but when we look at the optic disc for glaucomatous change, we have to be careful of the neural retinal rim, RNFL and vessel position changes,” she explained. Using trend-based analysis of the GC-IPL change in thickness on the OCT, Prof. Jin Wook Jeoung from the Seoul National University Hospital in South Korea, in his presentation titled Progression Analysis in Glaucoma Using Macular OCT Scan found that the GC-

IPL thinning rate of the temporal sector was faster in the affected than in the unaffected hemifield. This suggests that glaucomatous damage may progress locally in a specific sequence. This type of trend-based analysis may be used for assessing glaucoma progression objectively and quantitatively. In another study, the integration of RNFL and GCIPL maps looks promising for detecting structural progression in patients with early glaucoma. Optic disc hemorrhages are usually overlooked in clinical examinations. Dr. Zeynep Ozturker from Baskent University in Turkey, in her presentation on Optic Nerve Hemorrhages in Glaucoma - What You Need to Know said that digital imaging devices are not capable of detecting disc hemorrhages (DHs). The presence of DHs is a risk factor for normal tension glaucoma (NTG) progression as well as primary openangle glaucoma (POAG) and they usually precede RNFL thinning. It can occur despite good intraocular pressure control. Disc photography, OCT and VF tests as a part of follow-ups, are vital for patients with DH.

Lest we forget: AI Finally, during the Artificial Intelligence and the Future of Imaging in Glaucoma presentation, Dr. Naama Hammel from Google shared on her team’s effort to develop and put in place validations of an algorithm to predict glaucoma.3 Although the model used fundus photography instead of OCT, her presentation provided insights into building models for deep learning. Her team, having worked on a previous model for diagnosing diabetic retinopathy, have found that high quality “ground truth data” is the “secret sauce” while validation and generalization is key in creating models the machines can learn.

References: 1

Saunders LJ, Medeiros FA, Weinreb RN, Zangwill LM. What rates of glaucoma progression are clinically significant? Expert Rev Ophthalmol. 2016; 11(3): 227–234.


Hood DC, Tsamis E, Bommakamti NK, et al. Structure-Function Agreement Is Better Than Commonly Thought in Eyes With Early Glaucoma. Invest Ophthalmol Vis Sci. 2019; 60(13): 4241–4248.


Phene S, Dunn RC, Hammel N, et al. Deep Learning and Glaucoma Specialists: The Relative Importance of Optic Disc Features to Predict Glaucoma Referral in Fundus Photographs. Ophthalmology. 2019;126(12):1627-1639.

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

Early Vitrectomy for Diabetic Retinopathy? by Sam McCommon


iabetic retinal disease was another topic covered on day two of the 37th World Ophthalmology Congress (WOC2020 Virtual®). As one of the leading causes of blindness, diabetic retinopathy (DR) is a major topic that will unfortunately continue to grow in importance concurrently with increasing rates of diabetes. Dr. Maria Berrocal from San Juan, Puerto Rico, presented a potential paradigm shift in the treatment of diabetic retinopathy: practicing early vitrectomy. As it stands, 60% of diabetics develop progressive diabetic retinopathy (PDR) and of those 50% will suffer severe vision loss. She noted that panretinal photocoagulation (PRP) reduces severe vision loss to 4%, but that despite PRP

5% of patients will still require vitrectomy.


perception after the treatment.

PRP has been considered the gold standard for DR treatment but is not ideal. Dr. Berrocal said that the treatment can lead to severe visual field defects and night vision loss. Furthermore, many eyes still progress to tractional retinal detachment (TRD).

Postoperative procedures necessary told a similar tale. Over eight years, 16% of the vitrectomized eyes in patients younger than age 50 needed additional laser treatment, 12% needed a reoperation, and 40% needed a cataract operation. In comparison, 72% of PRPtreated eyes needed laser surgery, 60% needed a vitrectomy, and 72% developed TRD, of which 16% was inoperable.

The crux of the presentation was Dr. Berrocal’s assertion that early vitrectomy is the best prevention compared to PRP.

A study of patients older than 50 bore similar results, with even fewer patients needing laser treatment or reoperation.

In an 8-year follow-up study comparing PRP and vitrectomy — in which one eye underwent PRP and the other vitrectomy — the outcomes clearly favored vitrectomy. Vitrectomized eyes had a mean postoperative visual acuity of 20/80, compared to 20/400 for PRP-treated eyes. Similarly, 88% of the vitrectomized eyes showed improvement in visual acuity in contrast to only 24% of the PRP-treated eyes. Twenty percent of eyes treated by PRP still had no light

Dr. Berrocal stressed the importance of understanding a patient’s needs, and just how vitrectomy can address them. Many working-age diabetics don’t have time to visit their ophthalmologist often, which treatments like ranibizumab require. What’s more, many diabetics are uninsured or underinsured, and may be burdened by the cost of treatment. Most importantly, she concludes, vitrectomy may be able to save many eyes – especially among young diabetics.

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: Be kind to your retina and your retina will be kind to you.





28 June 2020 | Issue #2

Reducing Rotation in Toric IOLs by Brooke Herron


oric intraocular lenses (IOLs) provide excellent visual acuity and high patient satisfaction by reducing or eliminating astigmatic error. However, residual error may happen and that impacts the expected clinical results, shared Prof. Boris Malyugin from the S. Fyodorov Eye Microsurgery Federal State Institution in Moscow, Russia. Residual error as a result of rotation can severely impact visual outcomes: A 30-degree rotation results in 100% cylinder power loss, while a 90-degree rotation doubles the astigmatism. “Eighty-five percent of postoperative rotation occurs within the first hour,” said Dr. David Chang, from the University of California, San Francisco, USA.

We Stand With The World of Ophthalmology Like tortoises, IOLs can sometimes rotate in the wrong direction. . .

during this time of challenge, and also of hope.

5. Leave the eye soft: “I don’t overinflate the bag while I’m inflating the anterior chamber.” 6. Tell patients to minimize activity: “I tell them not to do a lot of walking, to do a lot of sitting, I try to minimize their activity for the rest of that operative day.” C


Even with these pearls, sometimes rotation is unavoidable: “Rotating the IOL is something you’re going to have to do sooner or later if you do a lot of toric IOLs — but particularly if you’re going to do presbyopia correcting toric IOLs,” shared Dr. Chang. Y




Therefore, tips to optimize outcomes were shared by these experts and others, during a session titled Toric Implantation in Your Routine Practice on the second day of the 37th World Ophthalmology Congress (WOC2020 Virtual®).

Pearls for avoiding rotation Toric IOLs can rotate during surgery or postoperatively. To avoid this, Dr. Chang provided six pearls: 1. Use a non-dispersive OVD: “I don’t want the lens to be slippery.” 2. Remove OVD behind IOL: “Then I try to go behind the lens to evacuate the viscoelastic to improve contact between the posterior capsule and the lens.” 3. Digital alignment: “I use Callisto (Carl Zeiss Meditec, Jena, Germany) to digitally align, and that helps me avoid surgical misalignment.” 4. Nasal placement: “I tend to place the lens on the nasal part of the capsular bag, this is done anyway to center the visual axis of these diffractive lenses...”



Other tips and tricks “My personal opinion is that we probably use toric IOLs too little today as they are a great way to correct astigmatism,” said Dr. Anders Behndig from the Department of Clinical Sciences/Ophthalmology at Umeå University Hospital in Sweden. He also provided some tips regarding toric IOLs — for example, pure myopic astigmatism is better than mixed astigmatism: “You’re better off making the patient a little bit myopic, than a little bit hyperopic,” he explained. “There are also changes from with-therule-astigmatism (WTR) to against-therule-astigmatism (ATR) with increasing age.” Further, Prof. Malyugin noted that digital marking seems to be superior to manual marking when it comes to the proper alignment of the lens intraoperatively, and that certain surgical techniques can improve the stability and position of toric IOLs.

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:

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CAKE & PIE POST (WOC2020 Virtual® Edition) - DAY 2  

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