CAKE POST (APACRS 2022 Edition) - Issue 1

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ISSUE

06 | 12 | 22

cataract • anterior segment • kudos • enlightenment C A K E M A G A ZIN E ’ S D A ILY CO N GR E S S N E W S O N T H E A N T E R IO R S E G M E N T

HIGHLIGHTS

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Experts weigh in on levofloxacin 1.5% against ocular infection

a parade of IOL stars 06 It’s ... find out which one ‘shined’ the most!

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When Challenging Cases Make Surgeons Feel Like A

Squid Game Contestant

by Hazlin Hassan

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ven non K-drama watchers would have found it hard to miss the fanfare last year surrounding streaming sensation Squid Game, an unsettling Korean series about a group of people competing against each other in a series of challenges for prize money.

When a player loses, they die.

While many cataract surgeries can be fairly typical, surgeons are sometimes faced with cataracts that are challenging, much like the deadly challenges in Squid Game. On Day 1 of the 34th Annual Meeting of the Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS 2022), renowned experts at a session aptly titled Squid Game - Challenging Cases shared their top tips on how to manage and prevent surgical complications in order to ensure good outcomes.

Small pupils, big problem Professor Dr. Mohan Rajan of Rajan Eye Care Hospital, Chennai, India, shared some of his steps to success. In his opinion, a small pupil is the biggest problem. The complications of a small pupil include iris bleeding, iris prolapse, iridodialysis, zonular dialysis, difficulty in intraocular lens implantation and prolonged surgical time, among others.

His advice is to take appropriate preoperative protocols such as checking on the patient’s history of past and present use of alpha blockers. Tamsulosin and other alpha-blockers may impede pupil dilation and cause the “IFIS triad” (a flaccid and billowing iris, iris prolapse through the surgical incisions and progressive

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12 June 2022 | Issue #1

CAKE Magazine’s Daily Congress News on the Anterior Segment

>> Cont. from Page 1

intraoperative pupil constriction).

This triad can potentially result in complications, such as iris trauma and posterior capsule rupture.

Alpha-1 blockers are used for benign prostatic hyperplasia (BPH) and to treat urinary retention in women. It is also commonly used for kidney stone management. Tamsulosin is an Alpha-1A specific-blocker – the identical receptor found in the dilator muscle of the iris.

“Even short-term use (of tamsulosin) can lead to non-reversible iris dilation dysfunction in some patients,” he cautioned. He advises the use of intraoperative protocols such as intracameral phenocaine and intracameral epinephrine, and employing iris hooks during the procedure.

Professor Sang-Mok Lee of HanGil Eye Hospital, Incheon, South Korea, also discussed the management of small pupils in cataract surgery. “Small pupil is a well-known risk factor during cataract surgery,” he said during his presentation. Diverse strategies can be used to enlarge the small pupil depending on the cause of the small pupil, availability of instruments or devices, combined abnormality such as possible zonular weaknesses and the surgeon’s skill and preferences, he noted.

Prof. Lee also advises the use of intracameral epinephrine injection, along with pupillary membrane peeling and micro sphincterotomies. He also favors the use of iris retractors or hooks.

“Its advantage is that it can be moved to the CCC (continuous curvilinear capsulorhexis) margin to support zonules,” he said. One tip he shared was

All eyes were on Terry Kim, MD, professor of ophthalmology at the Duke University School of Medicine (USA) when he turned up at the Squid Game session dressed up as a guard from the famous Netflix series.

to direct the side incisions toward the edge of the pupil.

Another strategy is to use pupil expansion devices, such as the Malyugin Ring. “Recently, the development of diverse pupil expansion devices makes it easy to perform surgery with small pupils,” Prof. Lee added. An appropriate device can be chosen considering the strengths, weaknesses and availability of each device. Training in proper insertion and removal techniques is required to avoid complications. For small pupils with fibrotic pupillary membrane, membrane peeling or segmentation prior to installation of a device is recommended.

When zonules are weak Professor Byung-Yi Ko from Konyang University Hospital, Daejeon, South Korea, talked about cataract surgery in patients with zonular dialysis. Some intraoperative clues for the identification of zonular dialysis include trouble in

puncturing for capsulorhexis, difficulty in tearing, wrinkles during capsulotomy, and difficult nexus rotation after hydrodissection.

Some technical pearls he gave for treating weak zonules were not to try and grab pieces with the phaco tip, and to use the force of BSS (ophthalmic irrigation) on a cannula for cortex.

Surgeons should identify the zonulysis area, and carry out the corneal incision away from the zonulysis and capsulotomy initiation. Prof. Ko also advocates the use of iris retractors for zonulysis.

A capsular tension ring (CTR) would support localized zonular dehiscence and generalized zonular weakness, while preventing optic decentration and tilt of the IOL, minimize fibrosis and collapse of the capsular bag. However, contraindications for a CTR are anterior capsular tear and posterior capsular tear.

At the end of the day, the key to success is to be aware of the issues and be prepared for all eventualities.

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12 June 2022 | Issue #1

ZEISS Reflects on 175 Years of Innovation at APACRS 2022

by Matt Herman

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n a riveting lunch symposium on Day 1 of the 34th Annual Meeting of the Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS 2022) in Seoul, South Korea, speakers treated attendees to a tasty host of updates featuring technology from Carl Zeiss Meditec AG (Jena, Germany).

It was a feast for the stomach and for the mind at the APACRS 2022 lunch symposium, aptly titled Innovation @ Year 175 – Discover New Technologies in Refractive and Cataract Workflow, as three guest speakers discussed studies featuring up-and-comers in ZEISS’s innovation portfolio.

First on the menu was Dr. Fengju Zhang, who discussed preliminary results from a study conducted using the PRESBYON Laser Blended Vision for that white

rabbit of ophthalmology, presbyopia.

Initial results were promising, including 100% respondent satisfaction and 100% recommending the procedure to friends and family. In Dr. Zhang’s opinion, PRESBYOND is a critical part of the necessary variety of treatments for the broad spectrum of presbyopia patients for whom monovision is not an option.

Next up was Dr. Sri Ganesh, who talked about the ZEISS VISUMAX 800. He provided highlights aplenty about the VISUMAX 800, and there’s a lot to be excited about. What sets it apart from the crowd for Dr. Ganesh are the docking and centration aids and the new ZEISS Refractive Workplace, which all drastically reduce operation times and improve outcomes. He noted drastically improved outcomes for visual acuity (up to 3 months follow-up), predictability,

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and safety for presbyopia, myopia and astigmatism.

Last up was Dr. Oliver Findl, who discussed how the digital revolution, with the help of ZEISS tech, is making toric IOL workflow more efficient. Dr. Findl uses the ZEISS IOLMaster 700 in conjunction with the CSO MS-39 Tomography; for planning, he uses ZEISS’s EQ Workplace, and then for treatment after receiving the toric IOL, he uses ZEISS LUMERA 700 with CALLISTO eye.

So why digitize? Well, these smart devices streamline workflow by working with each other to keep patient data organized. You can now generate an email, Dr. Findl said, when it comes time to ordering the IOL – which makes life a lot easier. “You don’t have to do any transfer of data, which always has the trouble of making mistakes. And with time saved and less errors, it’s no wonder the digital age is coming to IOLs,” explained Dr. Findl.

CAKE Magazine’s Daily Congress News on the Anterior Segment

The Role of Levofloxacin 1.5% in Fighting Ocular Infection

by Hazlin Hassan

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n Day 1 of the 34th Annual Meeting of the Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS 2022), a lunch symposium entitled A New Dawn: Mastering Ocular Infection Control took a deep dive into the best practices in managing ocular infections and perioperative infection control.

Chaired by Professor Donald Tan of the Duke-NUS Medical School in Singapore, the expert speaker panel discussed real patient case studies to offer a highly practical perspective about choosing appropriate infection prevention and management strategies to optimize outcomes.

Bacterial keratitis Dr. Ruben Lim Bon Siong, associate professor at the Department of Ophthalmology and Visual Sciences, College of Medicine, University of the Philippines Manila, spoke about harnessing the power of 1.5% levofloxacin.

Bacterial keratitis, an infection of the cornea caused by bacteria, is a common clinical condition that may lead to visual impairment if untreated. Dr. Lim shared his clinical experience of treating corneal infection with high concentration levofloxacin 1.5% ophthalmic solution

in three patients. In all patients, the infection was completely resolved.

“Topical and intrastromal application of levofloxacin 1.5% was effective in treating cases of bacterial keratitis,” said Dr. Lim. In vitro studies on human corneal endothelial cells and keratocytes showed that levofloxacin was less cytotoxic than ofloxacin, ciprofloxacin, gatifloxacin and moxifloxacin, he added.

Rabbit corneas treated with levofloxacin 1.5% also showed no structural damage.

Human subjects treated for two weeks with levofloxacin 1.5% also revealed no epithelial or endothelial damage, or inflammatory changes. In rabbit keratitis models with levofloxacin-resistant staphylococcus aureus, levofloxacin 1.5% was more effective than fortified vancomycin for reducing colony counts. In terms of toxicity, gatifloxacin and ciprofloxacin have not been recommended for intrastromal injection due to the development of crystalline deposits.

Perioperative infection Dr. Joo Youn Oh, associate professor at the Seoul National University College of Medicine in South Korea, discussed

perioperative infection, and its management and prevention. She noted that the ocular surface is inhabited by microflora. The ocular microflora are the source of infection after ocular surgeries in most cases. Topical antibiotics remain a key to infection prophylaxis although the use of intracameral antibiotics is on the rise, she told delegates during the session.

“Levofloxacin 1.5% can provide the best prophylactic measure due to potent, broad-spectrum antibacterial activity, fast onset of action, high intraocular penetration and low ocular toxicity,” she explained. Comparing levofloxacin 1.5% versus 4th generation fluoroquinolones, preoperative eradication rate by levofloxacin 1.5% was 86.7% higher than 0.5% levofloxacin (60.8%), gatifloxacin or moxifloxacin (70-85%).

In terms of ocular penetration, levofloxacin 1.5% showed superior ocular penetration relative to gatifloxacin, moxifloxacin and besifloxacin in rabbit eyes. Levofloxacin 1.5% showed superior ocular penetration relative to gatifloxacin and moxifloxacin in patients undergoing cataract surgery.

As for ocular toxicity based on corneal epithelial cell cultures, levofloxacin retained higher corneal epithelial viability than moxifloxacin. Levofloxacin did not inhibit corneal wound healing, while moxifloxacin did. Both levofloxacin and moxifloxacin showed the same efficacy against gram-positive bacteria, pseudomonas and resistant strains.

Based on in-vitro studies, moxifloxacin and gatifloxacin are more potent than levofloxacin against gram-positive organisms. Levofloxacin, moxifloxacin and gatifloxacin have similar potencies against gram-negative bacteria.

Levofloxacin is more potent than moxifloxacin and gatifloxacin against pseudomonas.

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12 June 2022 | Issue #1

A Glimpse of What’s around the Bend in IOLs

Highlights from APACRS 2022

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is why, and Dr. Yoo thinks he has the answer: water. Clareon PanOptix has a 1.5% water content, compared with AcrySof PanOptix’s 0.5%.

So many intraocular lens options, so little time … at least that was the theme from a seven speaker supersymposium entitled On the Horizon: What’s New in IOLs? on Day 1 of the 34th Annual Meeting of the Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS 2022). The session was co-chaired by APACRS 2022 Program Director Dr. Graham Barrett from Australia and Dr. Hungwon Tchah from South Korea, with experts from around the world serving up a savory smorgasbord of state-of-the-art IOL pearls.

Dr. Yoo’s reasoning was that the higher water content in Clareon PanOptix and its specific optic design underlies the sought-after near vision improvement.

However, a note of caution: Smoother surfaces from the higher water content lead to contrast sensitivity with glare present in Clareon PanOptix. However, as was pointed out when taking questions, “[if] you have Clareon available, it’s a very easy choice.”

Dr. Chul Young Choi led the seveninning IOL extravaganza with a talk comparing multifocal IOLs, presenting his findings on many multifocal IOLs, including the ZEISS AT LISA tri family, Alcon’s AcrySof PanOptix, and Johnson & Johnson Vision’s TECNIS Synergy, and using a “mix & match” strategy.

Using a variety of laboratory and clinical tests, he compared the physical and optical characteristics of these IOLs. Conclusions varied across MTF curves, surface roughness, optical scattering, and ultraviolet light filtering IOLs, but laboratory and clinical results point to the same story: Always start with patient needs, and go from there.

Showdown in IOL town: AcrySof PanOptix vs. Clareon PanOptix and WATER! Next up is a battle for the ages in Dr. Young Sik Yoo’s comparison of AcrySof PanOptix and Clareon PanOptix (both products of Alcon). Clareon PanOptix is a first-choice IOL, but the real question

Dr. Lee emphasized speaking to the patient about their needs when choosing between these cutting-edge IOLs. Patients more suited to the Synergy were those who wanted good uncorrected distance visual acuity, understood the limitations and functions of the IOL, and wanted to avoid wearing glasses for near vision; while Symfony was better for distance and intermediate visual acuity in patients who didn’t mind wearing glasses for near vision.

Ultimately, both IOLs had comparable distance visual acuity, while Synergy was better for near, and Symfony better for optical quality. And of course, as she pointed out, belle-of-the-ball mix and match should never be counted out.

by Matt Herman

octors from the Asia-Pacific region and around the world show what’s on the horizon in a jampacked IOL expression session.

A multiplicity of multifocal IOLs

In her study, she focused on Johnson & Johnson Vision’s TECNIS EDoF IOLs: the Symfony ZXR00 and the Synergy ZFR00.

Presbyopia pandemonium!

Comparing IOLs for a familiar foe “Presbyopia is really the holy grail of ophthalmology,” renowned surgeon Dr. Mun Wai Lee mused after taking the stage for his presentation. Modern presbyopia IOLs might suggest that this holy grail has been found, but not so. With a worldwide adoption rate of a paltry 10%, Dr. Lee wanted to know why.

After comparing the trifocal AcrySof PanOptix, the EDoF AcrySof Vivity, and monofocal+ RayOne EMV (Rayner, West Sussex, United Kingdom) and considering their advantages and disadvantages, Dr. Lee’s conclusions were prominent throughout the day.

Know your patients and their goals and limitations, know your IOLs, and come up with a good decision tree based on what you have available. “The crusade goes on with presbyopia correction with intraocular lenses, and hopefully we will see more options available to us down the road,” he concluded.

Demystifying EDoF IOLs Dr. Ji Eun Lee wants the world to know about the newcomer to the IOL scene, extended depth-of-focus (EDoF) IOLs.

Chasing the white rabbit of binocular trifocality The math doesn’t add up — or shouldn’t add up — according to Dr. Gerd Auffarth’s presentation titled 1+1=3: Achieving Binocular Trifocality.

As all the doctors in the symposium noted, the IOL game is one of checks and balances – an advantage in one area creates a disadvantage in another area.

With trifocal IOLs, the disadvantages usually come at the expense of visual quality.

Existing approaches involved mix and match or some form of monovision, and Dr. Auffarth tried to find out if this is necessary. After doing an optical bench test, he conducted a clinical study to see how a novel approach from Artis Symbiose (Cristalens, France) held up.

So what did he find? As time went on, results were outstanding for visual acuity and halo and glare – even on elderly patients as old as 85 – truly phenomenal results that prove maybe 1+1 really can equal 3.

More mix and match Mania with EDoFs Dr. Hungwon Tchah knows that

CAKE Magazine’s Daily Congress News on the Anterior Segment

multifocal lenses have a problem … an intermediate problem. Because multifocal lenses split light into far and near ranges, the intermediate range becomes the forgotten middle child of the vision range.

EDoFs to the rescue, right?

concluded, “is that we need more data.”

Perhaps not, because as we know it’s a game of finite resources with IOLs, and with EDoFs near-vision becomes the sacrificial lamb. Enter Swiss Advanced Vision’s IOL, which uses its “Instant Focus” technology, its name for the pseudo non-diffracting bream principle (PNDB).

Hybrid monovision; if you’ve never heard of it, Dr. Kimiya Shimizu thinks you should. And this is exactly what his talk Hybrid Monovision (Monofocal & Multifocal IOLs) aimed to do.

We all know multifocal IOLs have their problems, leading to extensive explantation.

Patients using various combinations of SAV’s Eden and Lucidis IOLs were evaluated across a standard battery of visual acuity and QoL parameters. In the end, the results spoke for themselves: Eden is excellent for intermediate-tonear with good far vision outcomes, Lucidis was better for far vision with little impact on other ranges. But of course, mix and match was the real star.

“The only shortcomings,” Dr. Tchah

Enter hybrid monovision, which he defines as “exchanging the [multifocal] IOL for a monofocal IOL in the dominant eye.” In the end, after comparing hybrid monovision with other approaches like mini-monovision, hybrid monovision comes out on top for patients that aren’t overly concerned with intermediate vision. So if you have a patient dissatisfied with an existing IOL implantation, or is undergoing

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07/06/22

Can new kid on the block ‘Hybrid Monovision’ sink presbyopia?

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cataract surgery with presbyopia, hybrid monovision is well worth taking a look at.

This little IOL piggy went … on the back of ANOTHER IOL? The only thing better than one IOL? Well, many things, but one of them is two IOLs on top of another, according to Dr. Satish Srinivasan. He thinks Medicontur (Limas, France) is onto something with their 1stQ AddOn portfolio of IOLs. The case he highlighted was a 65-yearold female who experienced an unexpected myopic shift in the right eye due to capsular bag distension syndrome.

He decided on a piggyback IOL, and after showing a video of himself implanting a 1stQ AddOn, he went over the results, which were off-the-charts amazing. Not only did the patient end up with postop VA of 6/6, but Dr. Srinavasan also got a lovely handwritten thank you note. “It’s just wonderful,” the happy patient wrote, ending the day on a definite high note.

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