APAO Beijing - issue 3

APAO Beijing 2010 Daily_Saturday_0428 EWDaily_01-21 ASCRS NEWS_11x15-dl.qxd 9/17/10 6:29 AM Page 1

5th Anniversary Edition The News Magazine of APACRS and COS

Saturday, September 18, 2010

3-D ophthalmic surgery debuts in Asia

by Matt Young EyeWorld Contributing Editor

phthalmologists in Beijing on Friday witnessed something they probably never saw before: 3-D video surgery.

During the ASCRS-sponsored symposium at the 25th APAO Congress, David F. Chang, M.D., in private practice, Los Altos, Calif., packed lecture halls full of people wearing 3-D glasses, awaiting his surgical presentation titled, “The challenge of weak zonules.”

Earlier in the day, Dr. Chang told EyeWorld, “We finally got the 3-D equipment out of customs yes-

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continued on page 3

Opening ceremony kicks off with traditional Chinese music amid a fantastic audience reaction

All about the new COS president

By Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer

Kanxing Zhao, M.D., is the new COS president from 2010 to 2013

anxing Zhao, M.D., acquired his medical doctorate and Ph.D. degrees at Peking Medical University (now the Beijing University School of Medicine) in 1989. He is currently professor, chief physician, and

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tutor to Ph.D. students at Tianjin Medical University.

Apart from his clinical practice, Prof. Zhao is known for his substantial contributions to the development of ophthalmology. He is devoted to developing cooperation in ophthalmology and pushing exchange programs with the World Ophthalmology Congress (WOC), APAO and AAO. Over the past four decades, he has been an active clinician and teacher and an enthusiastic educator, as he has trained 34 Ph.D. students, dozens of master’s students, and hundreds of fellows.

Prof. Zhao has held a grant provided by the State Council of the People’s Republic of China since

1994. He has made significant contributions in the diagnosis and treatment of complex strabismus, vertical strabismus, and congenital nystagmus.

Together with Orbis International, Prof. Zhao conducted epidemiological studies on juvenile strabismus, amblyopia and ametropia that were completed in 2005.

However, many consider the greatest contribution of his research to be the discovery of the genetic background of a number of inherited eye disorders. He has contributed much to the understanding of the pathogenetic mechanism of retinitis pigmentosa.

In the last 16 years, Prof. Zhao has worked ceaselessly on the development and management of Tianjin Eye Hospital. Nevertheless, he continues to push both local and international scientific exchange.

Currently, Prof. Zhao chairs the Chinese Pediatric Ophthalmology and Strabismus Association and the Tianjin Ophthalmology Society. He was Vice President of the Chinese Ophthalmological Society (COS) from 2000 to 2007, and was selected as President-Elect in 2007. He was appointed editor in chief of the Chinese Journal of Ophthalmology in 2009, the first time a physician from outside the capital was chosen for the position.

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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 18, 2010

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Eliminate endophthalmitis with proper prophylaxis

by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer

ndophthalmitis, while rare, remains one of the most devastating potential complications of ophthalmic surgery. The AsiaPacific Association of Cataract & Refractive Surgeons (APACRS) took on the prevention of endophthalmitis in a symposium held Friday.

There are set guidelines that make recommendations for prophylaxis in all kinds of surgical procedures, said Francis Mah, M.D., University of Pittsburgh School of Medicine, Pittsburgh, Penn. In the guidelines is a stipulation that antibiotic prophylaxis is unnecessary unless (1) the procedure involves insertion or implantation of a prosthetic device, and (2) catastrophic morbidity and/or mortality can result from infection at the surgical site.

Ophthalmic surgery, said Dr. Mah, generally fulfills both criteria.

And yet, while prophylactic antisepsis with povidone iodine has been universally accepted as a precaution against endophthalmitis, it seems that some doctors remain unconvinced of the need for antibiotic prophylaxis.

In a survey of members of the American Society of Cataract & Refractive Surgery (ASCRS), 98% of respondents said they use postoperative topical antibiotics; however, only 88% of respondents said they

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Cesar Espiritu, M.D.

Mohan Rajan, M.D.

use preoperative topical antibiotics.

The implication, said Dr. Mah, is that ophthalmic surgeons consider postoperative treatment more important than prophylaxis.

The use of intracameral antibiotics for prophylaxis is even more controversial. Cesar Espiritu, M.D., American Eye Center, Manila, Philippines, examined the effect the results of the renowned ESCRS study on intracameral antibiotic prophylaxis for endophthalmitis prevention have had on clinical practice.

Looking at practice patterns in the UK, only 10% of surgeons surveyed used intracameral antibiotics—specifically cefuroxime—for prophylaxis before the results of the

study were published; after, the percentage rose to 55%.

Doctors in the US, however, have been more skeptical. In 2007, said Dr. Espiritu, more than 70% of surgeons surveyed said they did not use intracameral antibiotics.

However, 82% said they would be willing to use intracameral antibiotics if a reasonably priced, singledose preparation was made available.

In the Philippines, an estimated 30 to 40% of surgeons use intracameral antibiotics.

Amidst the skepticism, however, Dr. Espiritu said that various studies have shown that the use of intracameral antibiotics has resulted in

markedly reduced rates of endophthalmitis.

He concluded that although there is a significant amount of indirect and circumstantial evidence from clinical practice supporting the use of intracameral antibiotic prophylaxis, it is “hard to convince” surgeons to make the practice routine because cases are very rare to begin with.

Regardless of your views concerning the practicability of antibiotic prophylaxis, endophthalmitis is a medical emergency. Mohan Rajan, M.D., Rajan Eye Care, India, said that it is imperative to treat endophthalmitis once the diagnosis is made.

Specifically, Dr. Rajan discussed the role of vitreous surgery in endophthalmitis.

He described two vitreous surgery approaches: a “silver standard” procedure, comprising vitreous tap and the injection of intravitreal antibiotics to “buy time” while confirming diagnosis; and a “gold standard” procedure,” which is an immediate, complete, 3-port pars plana vitrectomy.

The silver standard vitreous tap, he said, should only be done if endophthalmitis is early, which is rarely the case upon presentation in his practice.

3-D ophthalmic surgery - continued from page 1

Ophthalmologists watch in 3-D delight

terday, and when I show a 3-D case in my keynote lecture, this will be the first-ever demonstration of 3-D teaching in Asia.”

Dr. Chang delivered on that promise shortly after noon on Friday, and the presentation certainly was unique in its three-dimensional effects.

Prior to his presentation, Roger F. Steinert, M.D., University of CaliforniaIrvine, Calif., presented Dr. Chang with a plaque for delivering this APAO Special Lecture.

Apart from the buzz surrounding the presentation, Dr. Chang also made some important points related to the use of capsular tension rings (CTRs).

He outlined a case in which a CTR was implanted, and then Dr. Chang realized there were very few zonules available.

Dr. Chang reminded the audience that a CTR works by redistributing the forces of surgery to all of the zonules available in a surgical case.

But in this case, the patient had only 6 clock hours of zonules available – far too few for the CTR to be effective, he said.

“I’m moving the entire bag, thanks to the CTR,” Dr. Chang said at one point. Three to four clock hours of zonular weakness would have been ok, but 6 clock hours definitely was not, he said.

“I can’t get the cortex out,” he said.

To successfully manage this case, Dr. Chang used a capsule retractor, which he said anchored the bag rather than redistribute forces to the rest of the zonules, and he was able to get the cortex out.

Spotlight on TASS Another tough issue – but one that needs to be understood – is that of toxic anterior segment syndrome (TASS).

TASS can occur in anterior segment surgery of any kind, said Liliana Werner, M.D., Ph.D., John A. Moran Eye Center, University of Utah, Utah, who also spoke at the ASCRS-sponsored symposium in Beijing.

The inflammatory process starts within 24 hours after surgery, she said. Hallmarks of TASS include diffuse corneal edema limbus to limbus and widespread endothelial damage.

There are many, many known causes of TASS, and these include instrument contamination, the use of detergents at the wrong concentration (and other surgical mistakes), glove powders, and others.

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EyeWorld Asia-Pacific Today / September 18, 2010

Four more for your China bucket list…

by Faith Hayden EyeWorld Staff Writer

eijing has plenty to see, do, and experience in and of itself, but if you have a few extra days to spare, take advantage of all China has to offer; you might not get another chance. Most of these suggestions are far afield, but all are easily accessible by planes, trains and automobiles. If you don’t make it as far as say, Shanghai, at the very least take the time to knock the Great Wall of China off your bucket list.

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The Great Wall of China The Great Wall, China’s most famous site, is a mandatory stop for anyone visiting the area. The wall spans an amazing 5,500 miles, stretching from Shanhaiguan in the East to Lop Nur in the West, loosely defining the southern edge of Inner Mongolia. You have to be careful when booking a tour of the Great Wall, however, as there are many scams on unsuspecting tourists.

Make sure you check all tour itineraries to ensure the tour isn’t going

to additional sites you have no interest in seeing. The Great Wall is the biggest tourist attraction in China so the best time to go is in the early morning hours on weekdays. Avoid visiting the wall on weekends at all cost.

Xi’an Xi’an is the capital city of the Shaanxi province, and about 700 miles southwest of Beijing. Xi’an is rich in culture and history and is one of the oldest cities in China.

There are many notable sights to see in Xi’an, as the city is full of ancient ruins, tombs, and historical monuments. The city itself is surrounded by the City Wall of Xi’an, which was re-constructed in the 14th century during the early Ming Dynasty. The army of Terracotta Warriors, located in the Mausoleum of Qin Shi Huang, is another very popular attraction. Other sites include the Giant Wild Goose Pagoda and Small Wild Goose Pagoda, remarkable towers that are more than 1,000 years old and have

survived massive earthquakes; various temples including the Xi Ming, the Wolong, and the Blue Dragon; the Qianling Mausoleum, a Tang Dynasty era tomb; the Shaanxi History Museum, which has a large collection of modern and ancient artifacts; and the Hanyang Tomb Museum, which was the first modern underground museum in China.

Qingdao If you’re hankering for a fresh breath of sea air after spending a few days in Beijing, consider visiting Qingdao, a port city 8 hours southeast by train. Known as “China’s Switzerland,” you may forget where you are while visiting Qingdao. The area was once a part of Germany and the architecture has heavy German influences.

Qingdao has a number of beaches to visit for those needing to watch the waves roll in. There are many other sites to see as well including Huashi Lou, a castle-like villa that once housed a Russian aristocrat; the Qingdao Sculpture Museum;

Tsingtao Brewery, which was originally founded by Germans and offers most exported beer from China; and Zhanshan Temple, Qingdao’s oldest Buddhist temple.

Shanghai Just 1.5 hours southeast of Beijing by plane, Shanghai is located at the mouth of the Yangtze River and is one of the most populous cities in the world. The city is known for its Art Deco architecture, and sets many worldwide fashion, entertainment and culture trends. There are tons of sites to see and things to experience in Shanghai, which makes it a huge tourist attraction.

Places of note in the city include the City God Temple, a lavish sanctuary to Shanghai’s three city gods; Art Scene China, a 1930s villa that houses contemporary Chinese art; the Dongjiadu Cathedral, Shanghai’s oldest church; and the Jade Buddha Temple, a place of worship that houses a 1.9 meter-high pale-green jade Buddha in its center.

Don’t miss out on a great China adventure

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EyeWorld Asia-Pacific Today / September 18, 2010

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A modern approach to allergies in Asia

By Matt Young EyeWorld Contributing Editor

sia needs a modern approach to allergic conjunctivitis, according to Quresh Maskati, MS, Maskati Eye Clinic, Mumbai, India.

“Most parts of Asia see severe forms of allergy all the time,” Dr. Maskati said.

Fortunately, he said, there are a variety of treatment options.

Identifying and diminishing exposure to offending antigens are possibilities, but they often are impractical, said Dr. Maskati during his presentation Friday at the 25th APAO Congress on “Medical and surgical management of allergic conjunctivitis.”

Cold compresses dramatically reduce the urge to itch, lessening the vicious rub-itch-rub-itch cycle, he said.

Tighter fitting sunglasses are beneficial, he said.

Improving hygiene is a mainstay of treatment. Advocating frequent hand washing and the avoidance of eye rubbing are important, particularly among patients in a lower socioeconomic status.

One particularly interesting approach Dr. Maskati mentioned is gradually desensitizing patients to antigens using a vaccine.

“The process involves making multiple scratch marks with various antigens on the body’s surface and identifying the offending antigen,” Dr. Maskati said. “Then the lab prepares a vaccine using gradually increasing doses of the antigen to be injected at regular intervals. The entire process takes about six months with injection given at fortnightly intervals.”

Some patients, after undergoing this vaccination process, have remarked that not only are their eyes better, but also their skin itching has disappeared, Dr. Maskati said.

Meanwhile, Dr. Maskati said, an itchy, burning eye often has a dry eye component. These patients may develop dry eye due to the toxicity of some drops or because of the allergy component itself over time.

“We need to be listening to patient symptoms and prescribing preservative-free tears in addition to the treatments we prescribe,” Dr. Maskati said.

Unfortunately, many physicians use mast cell stabilizers on an asneeded basis, and that’s the wrong approach, Dr. Maskati said. Many allergy patients can benefit from

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mast cell stabilizers even when there is no itching, he said.

“I normally put these drops in over two years, continuously,” Dr. Maskati said. “There are no side effects. Also it’s important to use anti-itching drops as required,” he said.

Still, he mentioned that dualaction drugs – both antihistamines and mast cell stabilizers – are ideal.

Dr. Maskati mentioned that ketotifen is a weak dual-action drug, while olapatadine is a potent dual action drop. He also mentioned that epinastine is a powerful yet safe dual action drug.

Steroids, he said, should be reserved for the most severe refractory cases.

“Always use them as supplemental therapy, not sole therapy,” Dr. Maskati said.

He suggested using them as pulsed therapy, hourly for 3-7 days.

But it’s a slippery slope once patients are started on steroids. They often begin to self-medicate with topical steroids, and that leads to problems, he said.

Surgical options are reserved for refractory cases of mainly palpebral spring catarrh with minimal or no bulbar involvement, Dr. Maskati said. It’s important to excise the papillae and free the conjunctival graft from the unaffected bulbar conjunctiva, he said.

When this was done in 20 eyes, relief was seen in 16, he said.

Further, there are no serious complications of this surgical approach, he said. Suture granuloma was seen in 2 eyes of the 20.

sun; bright lights; pollens, and other causes.

It’s a bilateral condition in 95% of cases, Dr. Heng said.

Symptoms include itching, redness, burning, tearing, and mucus discharge. Signs also include diffuse hyperemia, tarsal papillae, and other factors.

Cobblestone papillae sometimes appears later in the disease, which is really papillae fusing together, he said.

Flattened papillae also may form, and also take a long time to disappear.

Complications of VKC are varied, and include corneal pannus/scarring, keratoconus, mechanical ptosis, steroid-induced glaucoma and amblyopia.

Like Dr. Maskati, Dr. Heng believes avoiding allergens is difficult.

He also believes that washing the hands, face and hair is important – especially before bed.

“Periodically vacuum the carpets, beds and wash curtains,” to keep allergens at bay, he said.

As for treatment, Dr. Heng men-

tioned cold compresses, artificial tears, prophylactic drops before allergen exposure, dual-action agents and steroids.

Unfortunately, cyclosprorin A may cause a burning sensation and affect compliance in this population, Dr. Heng said.

Further, commercial formulations of cyclosporin A actually are too weak for this condition, Dr. Heng said.

Tacrolimus, alternatively, is effective in suppressing the inflammatory reaction in VKC. “It’s a potent immunosuppressive agent,” Dr. Heng said. “It stabilizes the mast cells.”

Surgery for VKC includes superficial keratectomy and debridement for plaques, cryotherapy, and other options.

Co-management with an allergist/dermatologist should be considered, he said.

At the end of the day, “VKC typically affects young males in warmer climates,” Dr. Heng noted.

“Most outgrow the condition by puberty. Education plays a major role in management.”

Focus on VKC Meanwhile, Wee-Jin Heng, M.D., The Eye Institute, Tan Tock Seng Hospital, Singapore, focused on the diagnosis and treatment of vernal keratoconjunctivitis (VKC), which he said is often associated with atopic disease.

For example, he said, it’s associated with asthma in 27% of cases, allergic rhinitis in 20% and eczema in 10%.

“It’s more complicated than just an IgE mediated disease,” said Dr. Heng, who gave a presentation titled “Vernal keratoconjunctivitis” at the 25th APAO Congress on Friday.

These patients also have a genetic predisposition, he said.

Triggers of the disease are many, and include wind; hot, dry climates;

Allergic conjunctivitis Source: ORA, North Andover, Mass.

Vernal keratoconjunctivitis Source: ORA, North Andover, Mass.

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EyeWorld Asia-Pacific Today / September 18, 2010

Corneal collagen crosslinking development continues

by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer

ollagen crosslinking is one of the more exciting developments in ophthalmic surgery in recent years. The procedure represents a shift in clinical practice that is virtually paradigmatic—the move from old school medical practice that involves, generally, either pharmaceutical or surgical intervention, to direct biomechanical manipulation of tissue.

The procedure was the focus of a scientific symposium held Friday.

What exactly is crosslinking?

Theo Seiler, M.D., Institut für Refraktive und OphthalmoChirurgie, Zurich, Switzerland, described it as a nuance in chemical structure that affects the behavior of a given material. Using the example of a solid ball and an oil made from the same substance, he said

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that crosslinking would be the differentiating factor between the two otherwise identical materials.

It isn’t an entirely new concept.

Crosslinking, said Dr. Seiler, has been used in activities as varied as the tanning of leather, the manufacture of plastics, and the hardening of polymers for dental applications.

It is the latter application, he said, that inspired corneal collagen crosslinking.

Several approaches to crosslinking were examined. Sugars, for instance, seemed to provide the best stiffening effect (explaining why diabetic patients don’t get keratoconus, said Dr. Seiler), but took over 20 days to complete.

The current method—photopolymerization using riboflavin and ultraviolet-A (UVA) irradiation—was deemed most practical.

New friends and old ...

The procedure, said Dr. Seiler was developed for two main indications: (1) to stop the progression of keratoconus and (2) to stop corneal melting; however, over the years, a third indication has begun to emerge: collagen cross-leaking, it seems, may be used to treat corneal infections.

As a relatively new procedure, the applications are still being explored. Ronald Krueger, M.D., Cole Eye Institute, Cleveland, Ohio, USA, has been working on combining collagen crosslinking with topoguided PRK. The rationale being that collagen crosslinking could help “fix” the result of a refractive procedure, particularly in “weak corneas” with or at risk for keratoectasia.

While studies are ongoing, Dr. Krueger concluded that topo-guided

PRK followed by crosslinking appears to be safe and effective and halts keratoectasia; in addition, combining the two procedures appears to be useful in reducing spherical and cylindrical aberrations.

Another approach currently being explored is combining the procedure with the use of intrastromal corneal ring segments (ICRS).

These are two different approaches to biomechanically changing the shape of the cornea, said Glaucom Reggiani Mello, M.D., Cole Eye Institute. He said that combining the two procedures may have a synergistic effect, and ultimately help avoid or delay the need for corneal transplantation.

The problem with the use of ICRS, said Dr. Mello, is that the effect can be unpredictable, due at

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EyeWorld Asia-Pacific Today / September 18, 2010

least in part to the wide range of presentations of corneal weakness.

The advent of the femtosecond laser has increased safety and predictability, but it remains a fact that ICRS do not change the underlying condition—i.e., the weakness of the cornea.

The presence of the ICRS, then, may not be enough to keep the cornea in the desired shape. As with the previous PRK - crosslinking combo, crosslinking is expected to “lock” the cornea in this desired shape, and may lead to better longterm results.

Many questions remain regarding the best way to perform collagen crosslinking. One such question is whether to leave the epithelium on or off.

The problem, said Colin Chan, M.D., Vision Eye Institute and University of Sydney, Australia, can be broken down into a question of safety versus efficacy: leaving the epithelium on, he said, increases safety at the expense of efficacy; leaving it off increases efficacy, but at the expense of increasing the risk for complications.

While the evidence showing the efficacy of leaving the epithelium off is “solid,” he said that data for leaving the epithelium on is “rather sparse,” and that most of the data for this version of the procedure come from animal studies.

As a result, it is difficult to make a conclusion based on current evidence. A better way to state the problem, he said, is how do we refine the procedure to maximize

... at the 25th APAO Congress

efficacy while minimizing risk?

Just what sort of complications are we looking at with the procedure? First, asked Laurence Sullivan, M.D., Royal Victorian Eye and Ear Hospital and Centre for Research, Australia, what exactly is it we’re doing with corneal crosslinking? Dr. Seiler has made it clear what the procedure aims to do, but is that the entire picture?

To begin with, said Dr. Sullivan, what crosslinking does is it is removing epithelium and killing cells. This, of course, is a rough approximation, but demonstrates the kind of theoretical damage the procedure can do.

In theory, he said, complications related to the epithelial defect and ultraviolet light irradiation can occur. These include non-healing

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defects, infections, and, for the UVA irradiation, a neurotrophic cornea.

In practice, the complications that have been reported include microbial keratitis, sterile infiltrates, iritis, stromal haze, and endothelial infarction. Postoperative pain can be significant. However, he considers this, along with deep microstriae and stromal haze—which actually may indicate that the procedure is working and tend to be non-clinically significant and self-limiting— side effects of the procedure, rather than true complications.

Collagen crosslinking, after all, induces significant changes in corneal physiology, and “plenty can go wrong,” he said. Fortunately, he said, serious problems are rare.

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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, PhD

Moderators

Michael C. KNORZ, MD and John CHANG, MD

Faculty

Y. Ralph CHU, MD Martin A. MAINSTER, MD, PhD, FRCOphth.

George H. BEIKO, BM, BCh, FRCSC

Faculty

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

Agenda

Agenda

13:00

13:00

13:05

Welcome Note – Han Bor FAM, MD and Ke YAO, MD, PhD 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, PhD

13:25

IOL Materials and the Many Myths of Blue-Blocking – Martin A. MAINSTER, MD, PhD, FRCOphth.

13:35

Optical Synergy: Tecnis Acrylic 1 Piece IOLs – George H. BEIKO, BM, BCh, FRCSC

13:45

Signature: Dual Pump and Ellips When You Should Use It – Han Bor FAM, MD

13:55 14:00

13:05

Welcome Note – Michael C. KNORZ, MD and John CHANG, MD Comparison of Biomechanical Influences of Corneal Flaps Created Using Intralase and Hansatome – Zheng WANG, MD, PhD

13:15

Advancement in Femtosecond Lasers – John CHANG, MD

13:25

Bridging It All Together: Presbyopic Treatment – Michael C. KNORZ, MD

13:35

Wavefront-Guided Treatment For Superior Patient Outcomes – Tong SUN, MD, PhD

13:45

Patient Satisfaction and Outcomes with iLasik – Marguerite B. McDONALD, MD, FACS

13:55

Questions and Answers – Panel Discussion

14:00

Closing

Questions and Answers – Panel Discussion Closing