APAO Beijing - issue 4 by Media MICE

APAO Beijing 2010 Daily_Sunday_0428 EWDaily_01-21 ASCRS NEWS_11x15-dl.qxd 9/18/10 6:25 AM Page 1

5th Anniversary Edition The News Magazine of APACRS and COS

Sunday, September 19, 2010

Momentarily starstruck at APAO by Matt Young EyeWorld Contributing Editor

great moment of levity descended upon the 25th APAO Congress on Saturday as Amar Agarwal, MS, FRCS, launched his presentation on “Flap Wars.” Paying homage to the Star Wars movies, Dr. Agarwal, Dr. Agarwal’s Eye Hospital, Chennai, India, played his Flap Wars video, which began in the spirit of that famous 1977 movie opening, with story text scrolling into a starry galaxy. Dr. Agarwal’s story, however, was slightly different:

In the present year, the kingdom of Refraction is waging a bitter war. The microkeratomes are still causing discontent with

flap related problems. Luke Femtowalker and the other Jedi knights are trying to quell the troubles using the power of their light sabre but things still are not going absolutely smoothly……… Amar Agarwalker – make that Agarwal – suggested that flap-making had a set of problems 20 years ago, and although refractive surgery has made great strides in improving, flaps continue to get into trouble today. Flap striae is one area of continuing concern, although it can be treated with hydration and stretching, he said.

George Lucas would have been proud of Dr. Amar Agarwal’s presentation delivered Saturday

continued on page 3

APAO celebrates 50 years; honors distinguished ophthalmologists By Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer

he APAO celebrated its golden jubilee with a gala dinner held Saturday at the Beijing Beichan International Convention Center. Aside from being provided with a truly sumptuous meal, delegates were treated to “smart” Hua Dan, an energetic Chinese opera performance featuring lively young female characters. At the dinner, the APAO also honored the organization's most distinguished members, among them Professor He Shouzhi, M.D. A clinical professor of ophthalmology in China, Prof. He holds several distinguished positions in

He Shouzhi, M.D.

various ophthalmologic organizations, including Executive Member of the Chinese Ophthalmic Association, Chairman of the Chinese Cataract Society, Chairman of the Beijing Ophthalmic Association, and member of the Board of Officers of the Asia-Pacific Association of Cataract & Refractive Surgeons. In China, Prof. He was among the pioneers of modern cataract microsurgery techniques, spearheading the development of ECCE and phacoemulsification in the country, part of his efforts in the prevention and eradication of blindness. Around the world, he is recognized

as a key player in the promotion of continuing medical education, especially in the development of new techniques for cataract surgery. In recognition of his contributions to the control of blindness and to ophthalmic science in general, Prof. He has received numerous awards, including the APACRS Gold Medal in 2005 and the AAO's Golden Apple Award for Ophthalmic Education in 2007. At the dinner, Prof. He was presented with the 2010 Outstanding Achievement Award of the COS, the Society's highest honor, for his significant contributions to the development of cataract surgery in China.

APAO Beijing 2010 Daily_Sunday_0428 EWDaily_01-21 ASCRS NEWS_11x15-dl.qxd 9/18/10 6:26 AM Page 2

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APAO Beijing 2010 Daily_Sunday_0428 EWDaily_01-21 ASCRS NEWS_11x15-dl.qxd 9/18/10 6:27 AM Page 3

EyeWorld Asia-Pacific Today / September 19, 2010

Momentarily starstruck - continued from page 1 Epithelial ingrowth is problematic, and the flap may need lifting either partly or fully to clear it up. Current femtosecond technology sometimes has problems with uneven raster lines, he said. Flap dissection also can be difficult after femtosecond flap creation. “Be very careful; a torn flap edge can occur,” Dr. Agarwal said. Buttonholes continue to be possible with the femtosecond lasers too, Dr. Agarwal said. “Bubbles bursting into the anterior chamber can occur,” Dr. Agarwal said. “You can wind up with a buttonhole.” Suction can be lost midway through LASIK procedures, although this isn’t such a big problem with newer machines, he said. Decentered flaps continue to remain as problems, he said. Transient light sensitivity also can occur, although it’s not too much of a problem, he said. “The moral of the story is, 20 years back we had problems, 20 years since we still have problems,” Dr. Agarwal said. “The surgeon behind the machine can make a lot of difference.” Speaking on a related topic at the 25th APAO Congress, Helen K. Wu, M.D., New England Eye Center at Tufts Medical Center, Boston, spoke on the issue of lifting the flap or performing surface ablation insofar as a LASIK retreatment. She explained that the rate of retreatment after LASIK varies from less than 5% to 30% for residual refractive error. There are many benefits of flap lifting, she said. “It’s easy to perform up to a year or more depending on the healing at the edge of the flap,” she said, although it may be more difficult to do if a femtosecond flap was created. There’s also a lower risk of infection after a flap lift. A flap lift is well tolerated by patients and is more comfortable than surface ablation, she said. The drawbacks of flap lifting also are many, she said. There’s a higher risk of epithelial ingrowth and possible need for multiple scraping procedures. The incidence of dry eye is increased. Tearing the flap is possible. There’s an increased risk for striae. Previous RK or AK incisions may open, she said. Further, the incidence of epithelial ingrowth is 0-2% in primary flap lift cases, but it goes up to 24% in

The femtosecond laser is compared to a Star Wars light sabre...but it still needs tweaking

secondary flap lift treatments, she said. Epithelial ingrowth is concerning, she said, because left untreated, it can cause stromal scarring, flap melt, or induced astigmatism (as it grows toward the center of the visual axis). To avoid epithelial ingrowth, she said, irrigate well and score the flap edge with a sharp instrument. Carefully inspect the flap edge prior to releasing the patient to go home. Understand that placing a bandage contact lens may increase the risk of epithelial ingrowth, she said. Contraindications for flap lifting include tears in the flap or buttonholes, and incomplete flaps, she said. Moving onto advantages of surface ablation, Dr. Wu mentioned it does not decrease the stromal bed thickness. It’s also easy to perform, smoothes out fine superficial striae, is the preferable technique in patients with RK or AK prior to LASIK, and is preferred in patients with anterior basement membrane dystrophy. Striae is not a trivial issue, Dr. Wu said. Flap microstriae can be seen in retroillumination, and surface ablation really can improve quality of vision by smoothing out these striae, she said. The problems with surface ablation include the increased risk of haze (and therefore a loss of BCVA), a need for mitomycin C, potential flap interface inflammation, discomfort, and the increased risk for infection. The bottom line: “LASIK enhancements may be accomplished successfully with either lift-

ing of the flap or with surface ablation,” Dr. Wu said. But she said, “In the first one to three years, lifting the flap to retreat is the easiest for both the patient and the surgeon.” Meanwhile, Kimiya Shimizu, M.D., Department of Ophthalmology, Kitasato University School of Medicine, Kanagawa, Japan, suggested that LASIK has two major problems. First, there’s the problem of long-term refractive instability. Second, it can lead to a decrease in quality of vision. In a study of 44 eyes with 8 years of follow-up, 9% of high

myopic eyes lost 1 D of BCVA. Both high and low myopes also were found to be undercorrected after 8 years. “The regression rate is about 15% of corrected refraction 8 years postoperatively,” he said. In another study of 47 eyes of 28 patients, higher-order aberrations significantly increased even after wavefront-guided LASIK. Contrast sensitivity also decreased after wavefront-guided LASIK. Other problems of LASIK include dry eye, epithelial ingrowth, diffuse lamellar keratitis, and flap infection, he said.

Vice President of the APAO Council

Jialiang Zhao, M.D. Professor at Peking Union Medical College Hospital and Past President of the Chinese Ophthalmological Society (COS) will continue to serve as regional Vice President on the Asia-Pacific Academy of Ophthalmology (APAO) Council for 2010-2011.

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EyeWorld Asia-Pacific Today / September 19, 2010

The best and worst of cataract surgery discussed at APAO By Matt Young EyeWorld Contributing Editor

Ralph Chu, M.D.

Yao Ke, M.D.

he best – and worst – of cataract technologies were discussed Saturday as part of a high-impact EyeWorld Corporate Events session at the 25th APAO Congress. Martin A. Mainster, Ph.D., M.D., University of Kansas School of Medicine, Prairie Village, Kansas, argued that the use of IOL chromophores in IOLs is not evidencedbased medicine. “Perhaps the greatest single weakness of the phototoxicity-AMD hypothesis is that 10 of the 12 major epidemiological studies that examined it found no link between environmental light and AMD,” Dr. Mainster said. However, there’s a lot of evidence suggesting blue-blocking IOLs actually disturb patients severely, and more than just visually, Dr. Mainster said. “Loss of the blue light needed for retinal ganglion photoreceptors can cause circadian disruption identical to chronic jet lag,” Dr. Mainster said. Circadian disruption also occurs in blindness, shift work, aging, many systemic diseases and most forms of cancer, he said. In fact, violet and blue light pro-

Listening intently at EyeWorld Corporate Events

Martin Mainster, Ph.D., M.D.

vide 83% of circadian photoreception, Dr. Mainster said. “Health risks are correlated with the degree and duration of circadian disruption,” Dr. Mainster said. “Agerelated losses in retinal illumination are most prominent in the violet and blue part of the spectrum producing progressive decreases in circadian and scotopic photoreception so yellow lenses selectively degrade dim light and circadian photoreception.” Alternatively, he said, cataract surgery with a colorless UV-only blocking IOL decreases insomnia and increases daytime alertness. “All cataract surgery improves circadian photoreception, but colorless UV-blocking IOLs provide much better performance than yellow blue-blocking IOLs,” Dr. Mainster said. George H. Beiko, FRCSC, University of Toronto, Canada, agreed that it’s important for ophthalmologists to focus not just on patient vision, but also their mood. “We tend to look at our patients’ vision and use that as a guide to measure how successful surgery is,” Dr. Beiko said. “It’s not just about their vision - it’s also

George H. Beiko, FRCSC

about their mood. By blocking blue light, we’re actually increasing their amount of poor sleep and how depressed they are.” Dr. Beiko also suggested that physicians take for granted that as people get older, depression is a part of life. “But maybe it’s not part of life; maybe it’s a part of aging that with cataract surgery we can reverse,” Dr. Beiko said. Dr. Beiko advised it’s important to ask patients not only how they’re seeing after cataract surgery, but also “How is your life changing?” Yao Ke, M.D., Eye Center, Zhejiang University School of Medicine, China, meanwhile, discussed what he considers to be an excellent IOL: the Tecnis ZM900 lens (AMO, Santa Ana, Calif.), which is a silicone multifocal posterior chamber IOL. “Two years ago we began to use this,” and with stunning results, he said. Patients had better monocular and binocular near visual acuity. They increased their binocular accommodative amplitude by about 2.6 D. They also experienced decreased spherical aberration, he said. In 100 eyes of 50 patients, Dr. Yao found that they experienced the same good contrast sensitivity of a monofocal IOL but lower glare sensitivity at low and middle spatial frequencies. The lens also helped improve near stereoacuity. The use of AMO’s acrylic lens material also provides full transmission of healthy blue light, better chromatic aberration reduction, and better material transparency, he said. “Blue light is proved to be essential for optimal scotopic vision,” he said, adding that blue

Han Bor Fam, M.D.

light provides 35% of scotopic sensitivity. The acrylic ZMA00 (which also is a Tecnis multifocal posterior chamber IOL) has been found to provide excellent contrast sensitivity and also enhance binocular accommodative amplitude by nearly 3 D. Dr. Beiko, meanwhile, said he likes the Tecnis 1-piece ZCB00 lens (AMO). It provides good night vision, good day vision, yields no PCO or glistenings, and enhances patient safety, he said. “Glistenings occur in 60% of AcrySof [Alcon, Fort Worth, Texas] lenses after 1-5 years,” Dr. Beiko said. “One percent of patients have severe glistening. That’s a huge number of patients.” Glistenings also continue to increase with time, he said – up to 10 years according to research. Given that the age of cataract surgery is decreasing – now averaging 62 – people are living 20 years after their procedure. That means long-term glistenings will be constant problems for them, he said. For one, he said, contrast sensitivity decreases as glistenings increase. “Vision can drop by 1 to 2 lines of visual acuity,” he said. Other advantages of the ZCB00 lens include the fact that implantation is smooth, and surgeons report no damage of the IOL optic or haptic during implantation. “Synergy is defined as the value and performance of any elements that, when compounded, will be greater than the sum of the separate individual parts,” Dr. Beiko said. “If by synergy we mean individual elements combine to give a great effect, the Tecnis 1-piece IOL has achieved this.”

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EyeWorld Asia-Pacific Today / September 19, 2010 5

Project Vision: full speed ahead by David F. Chang M.D.

members regularly travel to the rural charity eye centers to train and supervise the local doctors on site. Eventually, the plan is to train surgeons who have become adept at manual, sutureless ECCE in phaco. Phaco would then be offered to those patients who prefer and can afford this higher cost approach. Following the successful cost recovery formula pioneered at Aravind

and Tilganga eye hospitals, this additional revenue could subsidize other needed ophthalmic medical and surgical services. Editor’s note: Dr. Chang is an adjunct clinical professor at the Chinese University in Hong Kong, and is on the international advisory board of Project Vision.

China National Convention Center Supported by a grant from Abbott Medical Optics, Inc. Drs. Lam and Chang observing surgery at a rural Project Vision charity eye hospital

t is well known among ophthalmologists that cataracts are the leading cause of blindness in the developing world. Professor Dennis S. C. Lam, chairman of the Chinese University in Hong Kong’s Department of Ophthalmology, founded Project Vision to address this daunting challenge in China. Project Vision uses the existing county hospital infrastructure to create rural charity eye centers. Local ophthalmologists are trained in manual, sutureless, modified small incision ECCE, and provided with the necessary diagnostic and surgical equipment. One floor of a local county hospital is then transformed into an eye clinic with an adjoining operating room. Successful pilot projects in Southern China have demonstrated that such newly trained cataract surgeons are able to perform high volume, manual, sutureless ECCE with excellent outcomes. The reduced surgical fee is affordable to low income patients, but with sufficient volume results in a surplus of revenue that makes these charity eye centers financially sustainable. In 2010, Project Vision is operating 16 charity eye centers in 5 provinces. Over 50,000 cataract surgeries have been performed so far and an additional 100,000 cases are projected by the end of 2011. Using this scalable model, Project Vision has the audacious goal of eventually opening 100 rural charity eye centers throughout the country. While the initial centers have been capitalized through private philanthropy, the Central Chinese Government is providing partial financial support amounting $18 million (US) toward Project Vision’s current campaign to

eradicate cataract blindness in Yunnan province. This campaign will include establishing 20 new charity eye centers and performing 200,000 free cataract operations to the indigent over a period of just 3 years. This collaboration also paves the way for continued government funding of future phases of Project Vision’s expansion. Private philanthropy, primarily from Hong Kong, has accounted for the remainder of Project Vision’s funding to date.

Project Vision surgical training The cataract surgical training is conducted onsite at the charity centers by traveling Project Vision faculty ophthalmologists using standardized protocols. This is supplemented by additional training at one of three regional Project Vision teaching hospitals, which are located in the major cities of Shantou, Beijing, and Kunming, with a fourth under construction in Haikou. These anchor teaching hospitals routinely perform phaco with foldable IOLs along with the full range of ophthalmic tertiary subspecialty care. However, in contrast to other academic centers, they are also very focused on training and supporting ophthalmologists who staff surrounding Project Vision rural charity eye centers. Based on demographic considerations, Project Vision selects the sites for these rural centers, which in most cases are geographically linked to these central anchor hubs. Of course, China’s overall population is of such scale that each rural eye center will serve a local population of 2-3 million within 1-3 hours driving distance. In addition to teaching at the anchor hospital, Project Vision faculty

BEIJING CHINA 2010

Sunday, September 19 Refractive Surgery Driving Superior Patient Outcomes Function Hall B (Level 1) 12:45 – 13:00 PM 13:00 – 14:00 PM

Registration and Reception Program

Moderators Faculty

Michael C. KNORZ, MD and John CHANG, MD Zheng WANG, MD, PhD Tong SUN, MD, PhD Marguerite B. McDONALD, MD, FACS

Agenda 13:00

Welcome Note – Michael C. KNORZ, MD and John CHANG, MD