APAO Beijing - issue 1 by Media MICE

APAO Beijing 2010 Daily_Thursday-DL_0428 EWDaily_01-21 ASCRS NEWS_11x15-dl.qxd 9/15/10 5:21 AM Page 1

5th Anniversary Edition The News Magazine of APACRS and COS

Thursday, September 16, 2010

APAO Congress celebrates 25 years starting today by Matt Young EyeWorld Contributing Editor

The 25th Annual APAO Congress officially kicks off today with an assortment of activities to educate and delight. phthalmologists can look forward to a bevy of subspecialty day sessions today involving cataract and refractive surgery, glaucoma topics, and vitreo-retinal surgery, as well as APAO scientific sessions. The day winds down with the Presidential Dinner today at 6:30 pm, which concludes at 9:30 pm. Excluding today, the rest of the APAO congress also is jam packed with breakfast symposia, beginning at 8:00 am each day and concluding at 8:45 am, as well as scientific ses-

sions and live surgery throughout the day. Lunch symposia take place from 1 pm to 2 pm each day, including today. Be sure not to miss either the Opening Ceremony from 4:30 pm to 6 pm on Friday, September 17, or the Gala Dinner from 6:30 pm to 9:30 pm on Saturday, September 18. Stop in to peruse the Congress exhibition from Thursday through Sunday, 9 am to 5:30 pm, in Ballroom A, B, and C as well as Plenary Hall A and B. The 25th APAO Congress is a joint meeting of the APAO and AAO, and also is held in conjunction with the 15th Congress of the Chinese Ophthalmological Society. The APAO, meanwhile, marks its

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Congress President welcomes delegates by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer

ith over 3,000 years of history, Beijing is China's cultural and economic hub. It is for this reason, said Li Xiaoxin, M.D., current President of the Chinese Ophthalmological Society (COS), that the capital was chosen as the site of the 25th APAO/AAO Congress and the 15th Congress of the COS. “Here, we have massive scholastic, historic, cultural scenery, as well as warm and hospitable hosts,” she said in a welcome message delivered in Mandarin to participants of the two meetings. Mainland China is hosting the international ophthalmologic meeting for the first time. Dr. Li also

serves as Congress President. Meanwhile, with over 6,000 delegates, including 1,000 visitors from other countries, Dr. Li called the 15th Congress of the COS the “first and biggest meeting” to be held in China. She expressed “extreme joy” at welcoming “friends from afar.” “I believe at this distinguished meeting, there will be great opportunities to meet old friends and to make more new friends,” she said. Ophthalmologists from all over the world, she said, are here to share their skills and experiences, increase friendship, expand cooperation and promote the advancement of ophthalmology. “Ultimately,” she said, “the ben-

eficiaries are our patients.” Dr. Li thanked all the invited speakers, the members of the organizing committee and volunteers, and all the delegates for their “strong support” to make the meeting a success. She also expressed deep appreciation for the attention and support from the ophthalmic industry, saying their efforts will “inevitably promote greater ophthalmic development in China.” Inviting all the delegates to “enjoy this cordial, friendly meeting,” she expressed hope that this meeting, held during the “2010 Golden Autumn in Beijing,” would bring them many wonderful memories.

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1. TECNIS® Foldable Posterior Chamber Intraocular Lens [package insert]. Santa Ana, Calif: Abbott Medical Optics Inc. TECNIS, ProTEC and Tri-Fix are trademarks owned by or licensed to Abbott Laboratories, its subsidiaries or affiliates. ©2010 Abbott Medical Optics Inc., Santa Ana, CA 92705 www.AbbottMedicalOptics.com 2009.03.04-CT884-CHI

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EyeWorld Asia-Pacific Today / September 16, 2010

APAO - continued from page 1 50th anniversary this year Jialiang Zhao, M.D., vice president of APAO, is particularly excited that the APAO Congress takes place in China this year. “The APAO is held for the first time in Beijing in China,” he said in an interview with EyeWorld. “So this meeting I think is important for us.” Dr. Zhao has been practicing medicine in China since the 1970s and is enthusiastic both about the number of Chinese ophthalmologists attending APAO this year as well as the subject matters discussed. Dr. Zhao expects a great delegate turnout to attend the APAO Congress this year, with about 4,000 Chinese ophthalmologists in attendance out of an estimated 28,000 ophthalmologists nationwide. “We have a Chinese [language] program and also an English program to meet different ophthalmologists’ needs,” Dr. Zhao said of the APAO meeting. Personally, Dr. Zhao is enthusiastic about topics related to the prevention of blindness. “I’m very involved in the prevention of blindness,” Dr. Zhao said. “That’s my interest.” That’s also the interest of many non-Chinese ophthalmologists, who are travelling far and wide to be at APAO. Audrey R. Talley-Rostov, M.D., Northwest Eye Surgeons, Seattle, said she is excited about learning from colleagues across the globe at the APAO Congress, and also travelling to Kunming, China, as well as Shantou, China, afterwards to help educate local ophthalmologists, who will then go on to educate others and help perform more and better cataract surgeries. “It’s important to increase the amount and level of cataract surgery throughout China since cataract still a leading cause of blindness,” Dr. Talley-Rostov said. This isn’t Dr. Talley-Rostov’s first time to Asia, and it isn’t her first time training other ophthalmologists either. “In March of 2009, I spent a month helping to train cornea surgeons in southern India in modern corneal transplant techniques,” Dr. Talley-Rostov said. “India does about 10 times the amount of

cataract surgery that China does. India is basically ready for next level.” Still, she believes cataract sur-

gery is at the root of all blindness evil. “If you don’t have the infrastructure for cataract surgery, you’re

not going to be able to have it for corneal blindness,” Dr. TalleyRostov said.

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EyeWorld Asia-Pacific Today / September 16, 2010

The best of Beijing sightseeing by Faith Hayden EyeWorld Staff Writer

The Old Summer Palace Location: 28 Qinghua Xilu, Wudaokou Phone: (10) 6262-8501 Hours: Daily 7 AM to 7 PM

oday’s Beijing may be a bustling metropolis full of swank eateries and indulgent shops, but it’s also steeped in tradition, full of ancient Chinese architecture and educational museums on Chinese military and art. Below is a list of places to take in before heading home.

The original Summer Palace was laid out in the 12th century, and all that’s left of it is ruins of broken columns and pieces of marble. A number of ruins can be viewed at the Old Summer Palace, including Great Fountain Ruins and the old Garden of Yellow Flowers labyrinth. The palace grounds cover a wide area, so be prepared to do some walking.

Architectural Sights The Forbidden City Location: 4 Jingshan Qianjie Phone: (10) 6513-2255 Hours: Daily 8:30 AM to 5 PM Website: www.dpm.org.cn

Museums & Galleries Beijing Ancient Architecture Museum Location: Xiannong Altar, 21 Dongjing Lu, Chóngwén Phone: (10) 6304-5608 Hours: Tuesday through Sunday, 9 AM to 4 PM

The Forbidden City, or the Palace Museum, is so-called because it was completely off-limits to most of the world for 500 years. Now, though, it stands as the largest cluster of the most well-preserved ancient buildings in China. The former palace living quarters function as museums and include exhibits such as the hall of clocks, jade gallery, and silver and gold gallery. There are also several ornate buildings called “halls” that showcase traditional ancient Chinese architecture and décor. It’s important to note that you do not need an official guide to view the Forbidden City, despite some reports to the contrary. Photographs are not allowed unless you are given permission beforehand. Tiananmen Square Location: Just West of 3 3 East Chang’an Avenue Phone: (10) 6524-3322 Tiananmen Square isn’t only notable because it’s the world’s largest public square; it also provides quick access to many of Beijing’s most significant historical monuments. The square is located in the center of Beijing and has no exact address. It’s best to take the subway or walk to the square; taxis aren’t allowed to go near it. Monuments surrounding the square include: the Gate of Heavenly Peace, the Museum of Chinese History, the Museum of the Chinese Revolution, the Great Hall of the People, the Front Gate, the Chairman Mao Mausoleum, and the Monument to the People’s Heroes.

If you’re curious about Chinese architecture, then the Ancient Architecture Museum is an excellent choice. Exhibits include drawings, photos, material objects and elaborate scale models exploring ancient architecture development from mud houses to palace buildings. The Military Museum of the Chinese People’s Revolution Location: 9 Fuxing Road, Haidian District Phone: (10) 6681-7161 Hours: Daily 8 AM to 5 PM

Enjoy the sights, sounds, and smells of Wangfujing Street. At dusk the bright neon displays take control of the landscape. Enjoy retail therapy here, or something almost as good: window shopping. The Gate of Heavenly Peace Location: On the Chang’an Boulevard, west of Wangfujing This famous monument, which is widely used as a national symbol and harbors great political and historical significance, was erected during the Ming Dynasty in 1420. The Gate of Heavenly Peace is often referred to as the front entrance to the Forbidden City, so make sure to stop by on your way to the Palace Museum. Like other buildings of the empire, the gate has unique imperial roof decorations and is guarded by two lion statues on either side. Visitors are allowed to climb the gate for an excellent view of Tiananmen Square for a small fee.

Summer Palace Location: 19 Xinjian Gongmen, Yuquan Shan Phone: (10) 6288-1144 Hours: Daily 8:30 AM to 5 PM The Summer Palace is a gorgeous landscape featuring 2.9 square kilometers of temples, gardens, pavilions, lakes, and corridors. Most of the Summer Palace land is dominated by Longevity Hill, which harbors a number of magnificent buildings such as the CloudDispelling Hall, the Temple of Buddhist Virtue, and the Sea of Wisdom Temple. The palace is widely known to be the paramount example of Chinese landscaping and design in Beijing and is a must see.

The Military Museum is an essential stop for anyone with an interest in military history. Composed of two four-story wings adjacent to a seven-story main building, the museum contains mementos from the Chinese revolution, the second and third Chinese revolutionary wars, the founding of the Communist Party, and the establishment of the People’s Republic of China. Actual Cold Warera F-5 fighters, tanks, and HQ-2 (Red Flag-2) surface-to-air missiles are also featured in the museum. The National Art Museum of China Location: 1 Wusi Dajie, East District Phone: (10) 6400-6326 Hours: Daily 9 AM to 5 PM The National Art Museum has a truly impressive collection of Chinese art from 16th-century traditional paintings to modern-day pottery. Other exhibits include caricature art, lacquer art, toys and kites. English captions can be sporadic.

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EyeWorld Asia-Pacific Today / September 16, 2010

How best to educate budding ophthalmologists by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer

Dr. Abhay Vasavada

ince Charles Kelman introduced phacoemulsification in 1967, cataract surgery has moved forward to become a routine procedure for the experienced anterior segment ophthalmic surgeon. Over the years, the techniques and technologies that have advanced the procedure to this point have been frequently examined and discussed in fine detail; what may be overlooked are the astonishing parallel developments that take place, as it were, “behind the scenes.” More sophisticated cataract surgery also has given rise to more innovative training. In 2007, Henderson and Ali published a review of the literature

available up to that point examining the methods of teaching and assessing competence and skill in cataract surgery. They looked at the increasing emphasis on the requirement of wet lab facilities; methods to improve visualization of cadaver and animal eyes, as with the use of capsular dyes; and the use of virtual reality and three-dimensional animation in the training of ophthalmic surgeons. They stated that the proper assessment of surgical competency had become an important focus in training programs, a point that remains pertinent today as cataract continues to be the most common cause of preventable blindness throughout the world, the acknowledged “bread and butter” of ophthalmic surgery practice.

The camera eye One technological innovation that has become a staple for training programs and ophthalmology meetings around the world is the surgical video. While perhaps not quite as spectacular as technologies like virtual reality simulation, the surgical video remains an accessible and effective means of teaching cataract surgery. The surgical video has the advantage of capturing not just examples of the ideal deployment of refined techniques and technologies, but also examples of a surgeon’s lessthan-ideal experiences with very specific, sometimes unexpected situ-

ations that even the most skilled practitioner may occasionally encounter. It thus remains one of the most important sources of practical teaching points, helping make that crucial link between text-book theory and real-world practice. For educators, then, one of the basic questions is: “How to make and where to locate exciting videos for ophthalmic education?” The most obvious way is simply to keep the camera rolling, a dictum that is often repeated at the film festivals that have become a staple of the various ophthalmology meetings held around the world.

Diving for pearls The problem, however, remains: even as the maintenance of a complete video record of all your cases becomes more and more feasible, with the massive amount of material that is bound to accumulate, particularly in high volume practices such as are typical in the Asia-Pacific region, how do you know if you’ve found a real pearl, a video that will stimulate as well as educate the budding ophthalmic surgeon? Abhay Vasavada, M.D., Research Director for the Iladevi Cataract & IOL Research Centre and the Clinical Director and Principal Trainer for the Phacoemulsification program: National and International of the Raghudeep Eye Clinic in India, will explore this problem, presenting some examples of videos

25th APAO Congress draws crowds to register

from his own practice in a lecture at the symposium, “Demonstrating innovative technologies for ophthalmic education,” held in room 208A and 208B between 9 a.m. and 10:30 a.m. today. Dr. Vasavada will also be examining the various methods currently available for teaching cataract surgery in his related lecture, “How to teach cataract surgery innovatively,” to be presented at the following symposium in the same rooms between 11:00 a.m. and 12:30 p.m. today. In his lecture, Dr. Vasavada will emphasize the value of animations and simple sketches that explicitly demonstrate the technique, a wellstructured step-by-step curriculum for a trainee before beginning hands-on training, and instruction through the side assistant scope on the operating microscope or screen. He will also discuss the role of computer-based software to learn the surgical steps of rhexis and sculpting, and the evaluation forms that objectively and subjectively audit the surgical skill the trainee has acquired during the training process, such as the evaluation forms by the Arvind Eye Hospital, Madurai, India, and those established by a panel of surgeons at the Massachusetts Eye and Ear Infirmary: the Objective Assessment of Skills in Intraocular Surgery (OASIS) and the Global Rating Assessment of Skills in Intraocular Surgery (GRASIS).

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EyeWorld Asia-Pacific Today / September 16, 2010

The four C’s of sulcus IOL implantation by Matt Young EyeWorld Contributing Editor

It’s inevitable. Cases go wrong. Things head south. Sometimes, cataract surgeons are faced with complications like posterior capsular rupture. “It happens when you do enough surgery,” said Audrey R. Talley-Rostov, M.D., Northwest Eye Surgeons, Seattle. It’s also not the end of the world. The case goes on, and can go on successfully following the right

protocol related to sulcus implantation. Dr. Talley-Rostov is slated to speak today at the 25th APAO Congress sometime between 11 a.m. and 12:30 p.m. in Function Hall A on the topic of “IOL implantation in the sulcus – do’s and don’ts.” In fact, it’s more about the do’s, or as she says, about doing the “four C’s,” which refer to capsular evaluation, choosing the IOL, calculating

for the sulcus, and centering the optic. First, Dr. Talley-Rostov said, capsular evaluation is critical to determine how much capsulorhexis is left. “The posterior capsule has been violated,” Dr. Talley-Rostov said. “How much anterior capsule do I have available to me?” is an important question to ask, she said. Second, she said, it’s important

to choose an IOL for the appropriate sulcus placement. “You want something that’s going to be an IOL that’s a 3-piece IOL with a rounded optic, not a square-edged optic,” Dr. TalleyRostov said. “The ideal IOL is 13.5 mm in length. If you implant in the sulcus, you need something larger than 13 mm.” Haptics also should be angulat-

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Turnaround for refractive nightmares by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer

Dr. Amar Agarwal

ntrastromal ring segments can be used to treat mild to moderate myopia, and are useful for flattening the cone in cases of keratoconus. Complications with the procedure range from mild and clinically insignificant—such as tunnel deposits and channel haze—to serious enough to warrant explantation and further surgical intervention. Fortunately, current insertion techniques make the more serious complications—such as channel infections and corneal melts— unusual, and they are not generally associated with the procedure. Today, intrastromal ring segments can be inserted either through traditional mechanical techniques, or through the use of the femtosecond laser. The laser is used to create a channel of precise size and depth for the insertion of the intrastromal ring segment. In addition, unlike mechanical techniques, the femtosecond laser creates a continuous 360-degree chan-

nel, a difference that, as it turns out, is of crucial importance in certain situations. The problem is that, even with a femtosecond laser channel, difficulty can occur at any point during insertion; instead of following the channel, the ring segment can create a false plane. Further pushing at that point only leads to the creation of a false channel and the collapse of the surgically dissected channel, creating a situation that Amar Agarwal, MS, FRCS, said can be nothing short of a refractive nightmare.

Turning the tables To manage these situations, Dr. Agarwal described a technique conceived by Soosan Jacob, MS, FRCS, one of Dr. Agarwal’s colleagues at Dr. Agarwal’s Eye Hospital and Research Centre in Chennai, India. The turnaround technique takes advantage of the 360-degree continuity of the femtosecond laser channel. On encountering any difficulty during insertion, rather than trying to push it further, the segment is removed, turned around, and inserted in the opposite direction through the femtosecond laser channel. Forceps are used to advance the segment as far as the curvature of the channel allows, after which the second ring segment is used as an instrument to push the first segment further into the channel. The shape of the second segment, said Dr. Agarwal, makes it the perfect instrument for this

The creation of a false channel can be recognized by difficulty with insertion, radial folds, and a wave-like deformity at the advancing edge of the segment Source: Amar Agarwal, MS, FRCS

maneuver. A reverse Sinskey hook is then used to manipulate the second segment into the intended site of implantation.

Turnaround mechanics An examination of the mechanics of this intraoperative complication reveals why this technique works. The difficulty arises when the intrastromal ring segment enters a plane different from the one created surgically. The cleavage of this new plane, said Dr. Agarwal, can be recognized as progressively increasing difficulty in insertion of the segment. “A wave-like deformity along with folds radiating from the advancing edge of the segment is also seen on the cornea,” said Dr. Agarwal. Careful examination at this point reveals an internal lip in the corneal stroma where the false channel is initiated. The lip separates the

A second intrastromal ring segment can be the ideal instrument for pushing an intrastromal ring segment into place Source: Amar Agarwal, MS, FRCS

femtosecond laser channel from the false channel. More importantly, the lip acts as a guiding flap that confounds the surgeon’s efforts to redirect the segment into the surgical plane. Inserting the segment in the opposite direction using the turnaround technique allows it to slide over and flatten this lip, causing the false channel to collapse and opening the femtosecond laser channel, so that the segment can slide into the desired plane automatically. The technique, said Dr. Agarwal, allows the successful insertion of ring segments in situations which may otherwise lead surgeons to abandon the procedure altogether. Dr. Agarwal will be presenting the technique today at the 25th APAO Congress during the subspecialty day symposium on Refractive surgery for today, which takes place between 9 a.m. and 10:30 a.m. in Function Hall A.

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EyeWorld Asia-Pacific Today / September 16, 2010

Topical vs. intracameral antibiotics for infection control by Matt Young EyeWorld Contributing Editor

ince March 2006, when the Journal of Cataract & Refractive Surgery published a preliminary report on an ESCRS multicenter study of endophthalmitis prophylaxis after cataract surgery, debate has been fierce over the use of intracameral versus topical agents. That report found a very significantly beneficial effect of using intracameral cefuroxime over levofloxacin drops, finding the incidence of endophthalmitis to be almost five times as high in the levofloxacin group. But Francis S. Mah, M.D., comedical director, Charles T. Campbell Ophthalmic Microbiology Laboratory, University of Pittsburgh School of Medicine, Pittsburgh, continues to believe in the power of topical antibiotics for use as prophylaxis, and remains skeptical about intracameral agents for a variety of reasons. To come to his conclusions, he follows the timeline of bacterial infection. “There is a question as far as where is the bacteria coming from,” said Dr. Mah, who is slated to speak about “The role of preoperative antibiotics” at the 25th APAO Congress sometime between 9 a.m. and 10:30 a.m. in rooms 311A and 311B on Friday, September 17. “One thought is that during surgery, these bacteria are being placed inside the eye,” Dr. Mah said. “After the procedure, these bacteria would then go on to multiply. The problem with that theory

is that bacteria multiply quickly. We would expect endophthalmitis to occur within a day or two, not 4-7 days later. The replication of bacteria happens faster than that.” Historically, the peak incidence of endophthalmitis is between 4 and 7 days postoperatively, with recent evidence suggesting it’s more like 9 days after surgery, Dr. Mah said. Meanwhile, intracameral agents linger in the eye for about 2 hours. “The entire anterior chamber is replaced in about 100 minutes,” Dr. Mah said. “So for a normal eye, complete replacement occurs in less than two hours.” If that’s the case, then intracameral agents – which are used exclusively during surgery - simply aren’t around long enough in the eye to serve as effective prophylaxis against bacterial agents that build towards infection at between 4 and 9 days postoperatively, Dr. Mah said. If the peak incidence of infection were earlier, it would stand to reason that bacteria introduced intraoperatively often is the cause of infection and intracameral agents should stop that, Dr. Mah said. This isn’t the case, he said. Instead, Dr. Mah believes most infections result from bacteria located on the ocular surface. “Until the incision is healed, there’s always a spot these bacteria could enter,” Dr. Mah said. “There is evidence that clear corneal incisions [elevate] risk. India ink has been shown to traverse a clear corneal incision.”

Appropriate prophylaxis for these lid organisms is topical antibiotics, Dr. Mah said. “Use them preoperatively, within a couple hours of surgery,” Dr. Mah said. “Postoperatively, use them intensively for the first 24 hours. Then use them for a week until the incision is healed.”

Dr. Mah mentioned that he uses fourth-generation fluoroquinolones as his topical antibiotics of choice. He also suggested the use of povidone-iodine preoperatively is critical. Using his approach, Dr. Mah said he hasn’t “had a problem in more than 10 years.”

said. “So it’s sitting in the bag even though we know the bag is open. The IOL optic is fitting in the broken bag but supported enough because of the haptics in the sulcus.” In this case, adjustment in IOL calculation probably won’t be necessary. “If you’re able to do that, then the optic portion is going to be in about the same location as it would be if the whole thing were placed in the bag,” Dr. Talley-Rostov said. Instead, if the case involves an extension or rip in the circular cap-

sule, “then you want to lay the whole lens on top of the capsule,” Dr. Talley-Rostov said. “You’re going to have to adjust the calculation for the lens because it’s sitting in a different position. If you use the same IOL calculation for the lens in the bag…you’re going to end up with some myopia – more than you bargained for. Add a diopter to what you normally would have placed in the bag.” The last “C” involves centering the optic, and that involves examining the capsular extension. “Make sure the haptics are in an

area of maximum capsule support,” Dr. Talley-Rostov said. “Position the haptics 90 degrees away from where the extension is. Otherwise it could tilt and the optic won’t be centered. You might have to suture one or both haptics to the iris to be sure the optic stays centered.” To learn about the don’ts of sulcus IOL implantation, be sure to catch the rest of Dr. Talley-Rostov’s presentation today.

Two views of post-op endophthalmitis Source: Nick Mamalis, M.D.

The four C’s - continued from page 6 ed posteriorly, she said. The problem with single-piece IOLs in these situations is that they will “chase the iris,” potentially leading to chronic inflammation, uveitis and increased IOP. “Avoid that,” she said. Third, depending on how the IOL exactly is positioned, you may have to adjust the IOL calculation. For instance, in some cases of sulcus implantation, the anterior portion of the capsule will be intact. “Then you can actually prolapse part of the 3-piece IOL behind the [capsule] circle,” Dr. Talley-Rostov

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China National Convention Center BEIJING CHINA 2010

Saturday, September 18

Sunday, September 19

Maximizing Cataract Technologies for Today's Surgeon

Refractive Surgery - Driving Superior Patient Outcomes Function Hall B (Level 1)

Room: 309A (Level 3) 12:45 – 13:00 PM Registration and Reception 13:00 – 14:00 PM Program

12:45 – 13:00 PM Registration and Reception 13:00 – 14:00 PM Program

Moderators

Han Bor FAM, MD and Ke YAO, MD

Moderators

Michael C. KNORZ, MD and John CHANG, MD

Faculty

Y. Ralph CHU, MD Martin A. MAINSTER, MD George H. BEIKO, MD

Faculty

Zheng WANG, MD Tong SUN, MD Marguerite B. McDONALD, MD

Agenda

13:00

13:05

Welcome Note – Han Bor FAM, MD and Ke YAO, MD Spherical Aberration and Decentration of IOLs in the Market – Y. Ralph CHU, MD

13:15

Visual Function After Implantation of Aspheric Diffractive Multifocal IOLs – Ke YAO, MD

13:25