CAKE & PIE POST (C&PE 2021 Edition) - ISSUE 2

The CAKE & PIE Revolution has Begun and it’s...

Bananas!

by Andrew Sweeney

Do not adjust your television set, computer monitor or smartphone … normal programming will not resume — and welcome to the colorful world of Media MICE. The revolution has begun, comrades: banana costumes will become mandatory ophthalmic daily wear and everyone has to try Media MICE CEO Matt Young’s cooking (at least once). The CAKE & PIE Expo (C&PE) 2021 has arrived, and the ophthalmic conference arena will never be the same again.

So, glory to the revolution and welcome one and all to the Expo’s first day, featuring the absolute best and brightest in our awesome industry. The entire Media MICE team has labored in the foundries and factories to mine for nuggets of creative genius (or insanity, it’s all a matter of perspective) for you all to enjoy. You will find all your usual favorites, including the auditorium’s superlative symposiums (on two tracks) and positively perfect exhibitor booths — with a dash of our very own quirky take on things.

Log-in to the virtual lobby to take stock of the menagerie of the medically mesmerizing exhibits, starting with a cheeky little offering you’ll find at the bottom right of your screen called Humorous Scientific Posters. [Editor’s Note: You may or may not take these posters seriously, they’re of the humorous kind after all.] Featuring some of the (ahem) leading and totally backed up by, well, research, this isn’t something you’ll want to miss. It even features a reference to my favorite medical malady, syphilis [Editor’s note: Oh god, no not again…]

But that’s not all! No, no, no. We have far

more, including previous copies of CAKE, PIE and COOKIE magazines for you to peruse and download; our awesome Show Dailies – CAKE & PIE POST – made possible by our friends at OCULUS, Allergan, Quantel Medical; Media MICE TV; and much, much more. Make sure you check all of these cool functions out, and swing by our social media pages (i.e. LinkedIn and Facebook) to really spread the love. We’re all very sensitive people, after all.

Of course, the main events of the show on Day One, the brightest stars in the sky as it were, were the scientific sessions. With a veritable cosmic smorgasbord of content on offer, beginning with a discussion on What’s Cooking in Cataract? and ending with tasty retina recipes from the Special Session: Retinawesome. There was also a smattering of COVID-19’s effect on clinics, a pinch of posterior segment insights, and a heavy drizzling of the very best cuttingedge innovation in ophthalmology.

We also want to draw your attention to the debut of the Subthreshold Ophthalmic Laser Society (SOLS) which officially launched at C&PE: Welcome to the madness! They have fully joined the revolution, and we hope you will too. So, make sure to tune back in on Saturday, June 19. The Expo floor opens at 2 Pm, Singapore time (UTC/GMT+8). Come one, come all — and get ready for Day Two of the greatest ophthalmic expo on earth.

The revolution will be televised, and the leader will be bananas.

What’s Cooking in Cataract?

by Brooke Herron

As the title suggests, this session featured the latest and greatest buns from the metaphorical cataract oven. With renowned ophthalmologists from around the world, we sample topics like FLACS innovation, prolene flange sutures for complex cases, and making phaco fly (literally). Buckle up, CAKErs, it’s time to see what’s cooking in cataract…

Femto cataract surgery is improving

This was the topic covered by CAKE magazine advisory board member, Dr. Harvey Uy, from the Peregrine Eye and Laser Institute in the Philippines. He shared that femtosecond laser assisted cataract surgery (or FLACS) was introduced about 10 years ago to assist with the essential steps of cataract surgery: anterior capsulorhexis, lens fragmentation and clear corneal incision.

So, what’s new in FLACS capsulotomy?

Dr. Uy shared that he’s excited because the FLACS laser can now create toric IOL alignment marks (called anterior refractive capsulorhexis marks) on the anterior capsule. “We’re also exploring the ability of free floating laser cut capsulotomy buttons to protect the corneal endothelium in eyes with endothelial dystrophy.”

Next, he covered lens laser fragmentation, which has the goal of softening the lens to facilitate nuclear disassembly, before moving on to clear corneal incisions.

“The clear corneal incisions made by the FLACS laser allow access to the interior of the eye for surgery. When you use a FLACS laser, it will consistently create a nice, multiplanar incision which seals shut at the end

of the surgery more often than not,” explained Dr. Uy.

Another development is the new software and equipment that helps surgeons improve refractive outcomes after cataract surgery. “We recognize that astigmatism is a major cause of unhappiness after cataract surgery and about one-third to half of the population will have significant astigmatism — which if not corrected, results in degradation of vision, especially if you put in a premium IOL,” he said.

Yippie Aye Yay: Flanged prolene solutions for complex cataract surgeries

We’ve got to give credit where it’s due, and Dr. Cathleen McCabe, a cataract specialist from Sarasota, Florida, USA, came to the CAKE & PIE Expo (C&PE) dressed to impress in western wear and with a themed presentation. (That’s a big yeehaw, partner.)

Her presentation focused on the advantages of using 5-0 and 6-0 prolene sutures in cataract surgeries. She discussed various ways prolene sutures are used, like the belt loop technique. Overall, she said that, “5-0 and 6-0 prolene with a flange for scleral fixation allows for the original IOL to be fixated securely — and this is particularly important in premium lenses where patients may want to retain that lens.

“It also can support a secondary IOL and it’s minimally disruptive to the conjunctiva, especially in cases where you’re trying to preserve it, like prior to trabeculotomy,” she continued. “Small incisions are possible,

too. Plus, you may avoid anterior vitrectomy because no IOL exchange is needed in some cases.

“It’s also useful for other problems, such as iridodialysis or severely loose zonules at the time of original cataract extraction. It’s a low tech solution, it’s accessible to everyone. And burying the flange into the superficial sclera is key to preventing erosion and more serious complications,” concluded Dr. McCabe.

Make my phaco fly

Dr. Florian Kretz, the CEO, shareholder and founder of Precise Vision Augenärzte in Rheine, Germany, took this “flying phaco” down two routes: tips and tricks — and actually traveling with the machine. Below, we look at the clever way he (literally) flies with phaco...

“Making my phaco fly has a special meaning for me: By really flying with a highly transportable phaco machine that fits in a pilot’s suitcase. It’s fun to have a portable phaco machine because of all the options it offers you — I even carry it on board as hand luggage,” shared Dr. Kretz. For these procedures, he uses the Oertli CataRhex (Berneck, Switzerland).

Dr. Kretz, along with his surgical team, performed 100 surgeries in three locations in three days, using one little phaco machine,” added Dr. Kretz.

Political Posterior Segment Surgery, Cool Cataracts & Pellet Perforations

by Andrew Sweeney

We’ve all had challenging days at work: One of those days that tests your abilities and forces you to rise to the occasion. Writers might find themselves interviewing someone who offers answers as readily as a Scotsman gives up his irn bru (I am speaking from experience, I will never give my bru up). Meanwhile, doctors may have to deal with difficult patients, IT systems may fail, and the list goes on.

But have you ever had to flatten the retina of a serving prime minister of a major nuclear power? What about performing eye operations during a natural disaster like a hurricane? Or handling the stresses of a particularly difficult cataract surgery? Can you imagine what it must be like to treat multiple patients who were shot in the face with pellet guns during violent protests?

Wonder no more, by viewing Tricky Procedures: Wars, Storms and Celebrities… Oh My! one of the first symposiums to take place at the CAKE & PIE Expo (C&PE) 2021. With three doctors from three continents, the symposium was a fascinating insight into some of the more unusual situations ophthalmologists may find themselves in.

Time to flatten the PM’s retina

The first speaker was Dr. Richard Packard, a senior consultant at Arnott Eye Associates, Cavendish Medical (London, United Kingdom). He described his experience of flattening the retina of former British Prime Minister Margaret Thatcher, while she was still in power in 1983. The formidable politician

complained of flashes and floaters in her eye for three days, and Dr. Packard diagnosed her with a u-shaped retinal tear with subretinal fluid.

Beginning with a series of argon laser burns around the tear, Dr. Packard then operated for an hour using a radial suckle to seal the retinal tear while the prime minister’s bodyguards were right next door. The story broke, the doctor found himself on the front pages, and Thatcher’s outcome was “good with unaided vision of 6/6+”. Dr. Packard was pleased with the outcome, and especially so after finding himself in Britain’s premier satirical magazine Private Eye!

Cataract: Keep calm and operate on

Cataract surgery might be one of the more common ophthalmologic procedures, but that doesn’t mean it isn’t stressful. Dr. William Trattler, an ophthalmologist at the Center for Excellence in Eye Care (Miami, Florida), offered his most valuable tips on staying cool with cataracts — including taking inspiration from sports stars, like NBA basketball players.

Dr. Trattler recommends that you maintain focus, be confident, control your emotions — and most importantly enjoy what you’re doing! Practicing mindfulness can be very helpful, as well as understanding that you should be pursuing excellence, not perfection.

Dr. Trattler also described how both he and his father treated patients during Hurricane Andrew in 1992, a deadly hurricane that blasted its way through Florida. In one case, they effectively managed a corneal laceration on just auxiliary power, without running water or air-conditioning, and successfully treated the injury. Kudos!

No one wants a pellet to the eye

If you know your politics, then you’ll know that Kashmir is one of the more troubled regions in the world. Prof. Dr. S. Natarajan, the chairman and managing director at Aditya Jyot Eye Hospital (Mumbai, India), reported on a study of 777 patients with pellet gun-related ocular injuries that occurred during widespread violence in the region in 2016. Nearly 98% of patients were male, and half were younger than 30.

Just over 60% of patients underwent a slit lamp examination, which found that corneal abrasion or lamellar laceration was present in 1% of patients, traumatic contact was found in 26%, and hyphema was found in 26%. Most injuries (93%) were monocular, while only 5% were binocular. Prof. Dr. Natarajan warns against the severe impacts of pellet gun injuries, and that while visual acuity outcomes may be poor, surgery should still be considered.

A Pinch of Posterior Segment Insight Spices up this PIE Just Right

by Sam McCommon

No first day of any ophthalmic conference is complete without delving into posterior segment complications, and we wouldn’t let you down. So, we were treated to three fantastic back-of-the-eye talks that both open the door for further questions and provide valuable takeaways.

Retinal findings in COVID-19, and post-COVID subretinal abscess

Since the beginning of the pandemic, questions about just how COVID-19 affects the eyes have been flying around the medical world. Can the virus infect the eyes? Can the virus spread via tear shedding? Does it infect corneal tissue? Can it lead to retinopathy?

While we’ve got more answers now than we did last year, there are still plenty of questions up in the air. Prof. Gemmy Cheung, head and senior consultant of the Medical Retina Department at Singapore National Eye Centre (SNEC), and advisory board member of PIE magazine, turned our attention to the retinal effects of COVID-19 — and, in contrast to Prof. Cheung, they’re often not pretty.

Early findings reported cotton wool spots, microhemorrhages and optical coherence tomography (OCT) hyperreflectivity in healthcare workers who had contracted COVID-19. But much more data has been released since then — though we’re still not entirely sure what to make of it all.

As Prof. Cheung pointed out, some 203 articles on PubMed appear when you search for the terms “Retina” and “COVID” or “Sars-CoV-2.” Of those, however, not all contain adequate data, so Prof. Cheung summarized the highlights of 26 of them for our viewing pleasure.

Of the cases with controls, there was a significantly higher rate of cotton wool spots than hemorrhages — and while the retinal hemorrhage rate was higher in COVID-19 patients than controls, it wasn’t statistically significant.

However, a paper by Prof. Cheung and her colleagues noticed a significant trend in microvasculature and tortuous veins in the eyes of COVID-19 patients — including relatively young, healthy patients with mild infections. In other patients with more severe cases that required treatment, ocular effects could be attributed to treatments rather than the virus.

Other OCT scans are striking: Some comparisons between COVID-19 patients and controls published by the Canadian Journal of Ophthalmology clearly indicate something terrible has happened to the eyes of the patients. They look completely different from the controls, and Prof. Cheung noted that if she had seen them with no context, she would have assumed they belonged to patients with poorly controlled diabetes. Even patients with mild symptoms still can experience retinal problems.

Dr. Alay Banker, director of Banker’s Retina Clinic & Laser Centre in

Ahmedabad, India, continued the COVID-19 discussion with a particularly interesting case involving a fungal infection following COVID-19 infection. The findings suggested an infection by Bipolaris fungus — a fungus associated with numerous other conditions not limited to the eye. The takeaway here is that doctors should make sure to conduct follow-ups with their COVID-19 patients and keep an open mind when it comes to infections — because sometimes the cause of the infection can be surprising, like it unfortunately was in this case.

There’s clearly much more to be learned — and you’d better believe we’re going to continue to cover this topic.

The Goldilocks zone of retinal fluid

Prof. Mark Gillies, with the University of Sydney and general Australian extraordinaire, challenged a conventional theory in treating wet or advanced neovascular age-related macular degeneration (nAMD). Essentially, when it comes to treat-and-extend (T&E) or pro re nata (PRN) regimens, the theory so far has been this: All fluid in the retina should be treated.

Prof. Gillies suggests this assumption is flawed, and we should reconsider it. This is potentially big news, and we’re all ears.

He shared a study that followed macular atrophy (MA) within five years of treatment, where 10% of patients had MA within one year of treatment, 42% at five years and 49% at nine years. After five years, the numbers stabilized. Dry lesions were the main risk factor for MA — specifically, the driest lesions were four times more likely to develop MA than active lesions.

So, low levels of fluid and disease activity are the strongest predictor of MA. Contrary to the goals of T&E and PRN, it may be beneficial to allow some fluid to protect against atrophy.

Not all fluid is made the same, however. Subretinal fluid appears to be well tolerated, whereas intraretinal fluid was associated with significantly worse outcomes. This is a very interesting takeaway, and will make for a great deeper investigation.

The Pandemic’s Impact on Ophthalmology in Southeast Asia

by Chris Higginson

practice in the Philippines, which has had over 1.34 million cases.

No doubt, ophthalmology has felt the effects from the worldwide pandemic. During this session from the ASEAN Ophthalmology Society (AOS), we explore the impact in Southeast Asia.

In Indonesia

Dr. Rina Ladistia Nora spoke about a study of COVID-19 on dry eye she recently headed, as well as the effect COVID-19 in Indonesia, which has suffered almost 2 million cases and 54,000 deaths.

Early in the pandemic, the Indonesian Ophthalmologists Association’s (IOA) Young Ophthalmologists division became active, with a newsletter and its first online conference, held in April 2020. In addition, the IOA provided guidelines on infection prevention and how to redesign contact areas to reduce risk, as well as best practices for telemedicine.

Dr. Nora’s study on dry eye, which compared COVID-19 positive patients to negative ones, found that subjective ocular surface complaints are more prevalent in COVID-19 positive patients. Further, there is no relationship between subjective ocular surface complaints and objective parameters of dry eye. Additional research is required to prove the presence of inflammation in the eye.

In Malaysia

Next, Dr. Miswan Muiz Mahyudin gave a Malaysian perspective on ophthalmology during the pandemic, which has resulted in 670,000 cases and over 4,000 deaths.

COVID-19 had a particularly bad effect on eye care in Malaysia as all government hospital eye clinics initially closed for 6-8 weeks. When they reopened, consultation numbers were restricted to 20% capacity and the clinics were open fewer days during the week. In addition, one of the major hospitals was converted entirely into a COVID-19 hospital.

When physicians could see patients, there was a lack of government guidance regarding what procedures should be done and how patients should be tested prior to treatment — this resulted in confusion and more cases in hospitals. Today, most healthcare workers are vaccinated, but there’s a spike in “half-managed” cases, where care was interrupted by the lockdown, and mild cases are beginning to show up in moderate/severe states due to poor general care.

In the Philippines

Then Dr. Jessica Abaño shared how the pandemic has affected ophthalmology

During the initial lockdown in early 2020, all eye care was suspended and many ophthalmologists were sent by the government to work in COVID-19 wards. Since then, things have improved, and the Philippine Academy of Ophthalmology (PAO) has been extremely active. They have provided physicians with goggles, slit lamp screens and other necessary equipment such as the PPE; given clear advice on how to reduce infection risk; and even produced a series of webinars on telemedicine training and education. They also have an active Facebook page, where they communicate directly with the public, as well as ophthalmologists. In addition, the PAO hosted a virtual exhibition in November 2020.

Now things are improving, they are doing more webinars, advising physicians on how to safely reopen their surgeries, and how to adjust to the new normal.

In Thailand

Lastly, Dr. Pimkwan Jaru-Ampornpan spoke about the COVID-19 and ophthalmology practice in Thailand, where there have been around 170,000 cases resulting in over 1,100 deaths.

During each outbreak, surgeons have been advised to wear masks with eye protection; postpone elective surgeries and non-urgent OPD cases; and ensure all patients are screened prior to surgery or admission. In March 2020, the Royal College of Ophthalmologists of Thailand (RCOPT) sent guidelines to physicians, instructing them to use slit lamp shields; to avoid using air-puff tonometry and immersion A-scan biometry;and practice general social distancing measures. The advice was effective and surveys show over 90% of Thai ophthalmologists were aware and followed this advice.

Today, Thailand has been hit with a third wave of COVID-19 and hospitals are reaching their capacity. However, vaccination is underway, and hospitals are slowly resuming care for nonCOVID-19 patients, including those who need eye care.

SOLS New Society Dedicated to Subthreshold

Laser Launched at C&PE

Do you know what the best thing is about joining a new club or society? Sure, there’s discussion and debate to look forward to, and maybe even some cool activities to take part in (like the CAKE and PIE Expo). Above everything else though, is belonging to something and feeling like part of a family…

“Consider yourself at home. Consider yourself one of the family. It’s clear we’re going to get along.”

Now, we’re not suggesting that they should adopt the Oliver Twist musical number as their society anthem (or maybe we are), but congratulations to the Subthreshold Ophthalmic Laser Society (SOLS) on their launch! The organization’s debut event, a symposium on Do We Still Need Subthreshold Laser for Macular Diseases? was one of the standout events of the Expo’s first day. If you’re fascinated by all things laser, as well as ophthalmology, then this is the society for you.

Moderated by Drs. Kenneth Fong (Oasis Eye Specialists, Kuala Lumpur, Malaysia) and Victor Chong (Royal Free Hospital, London, England), the symposium began with Dr. Chong outlining his hopes for the society’s work. He said he hopes it will help change perceptions about how laser technology works and clear up misunderstandings. He added this is particularly important to improve awareness about best practices.

What is SOLS?

The first presenter, Dr. Lihteh Wu of the Asociados de Mácula Vitreo y Retina de Costa Rica in San Jose, gave an introduction to subthreshold

by Andrew Sweeney

lasers. He described their raison d’etre as eliminating iatrogenic damage from conventional macular photocoagulation. He also described the perfect subthreshold laser as being strong in three aspects: yellow wavelength, multispot technology and low duty cycle.

Moving on to treatment guidelines

Dr. Wu said that large 160 µm spot sizes are used to increase the treatment area and ensure dense delivery of laser impact. He said that during subliminal laser treatment, no visible reduction should be observed and that there is no need to change power with different degrees of edema. The laser settings should be set at 160 µm spot size with a duty cycle of 5% and an exposure time of 0.2 seconds.

What conditions are best suited for laser?

Dr. Jay Chhablani at UPMC Pittsburgh (Pennsylvania) presented on central serous chorioretinopathy (CSR) and subthreshold lasers. He described the condition as a major vision threat to middle-aged men, with symptoms including blurred vision, positive scotoma and micropsia. Dr. Chhablani recommends using subthreshold lasers in early cases without previous treatment or where subfoveal leaks are present.

He discussed a case study of a 49-year-old man who was diagnosed with CSR with a central black spot in the left eye. After subthreshold laser was applied to the patient, he returned for a check-up after two months. His best corrected visual acuity (BCVA) in the left eye had improved from 20/25 to 20/20, and intraocular pressure (IOP) decreased from 19 to 15 mmHg, along with the alleviation of acute symptoms.

The last presenter was Dr. Alejandro Filloy Rius of the Rovira i Virgili University (Tarragona, Spain). He focused on using subliminal laser for diabetic macular edema (DME), stating that in most cases a “weak laser treatment’ is all that’s required.” The key to deciding between a weak or strong treatment process is guided by balancing the degree of the edema with cost.

Dr. Filloy Rius also elaborated on his treatment guidelines for DME, which should be optical coherence tomography (OCT) guided with a 5% duty cycle, 300-400 mw power titration, and 160 µm spots. He argued that patient selection is key and that “surface area and density are the cornerstones to a successful treatment.” He added that one should audit results as with any surgical procedure.

Settin’ up the Kitchen How to Build and Grow a Solid Ophthalmic Clinic

by Joanna Lee

In a session focusing on ophthalmology center and/or hospital group management supported by Ophthalmology Innovation Summit (OIS), four doctors from four different countries divulged their personal challenges unique to their market and environment, and offered tips in pioneering and the running of their own practices.

Perspectives from Malaysia

The Malaysian perspective came from Dr. Kenneth Fong, who is the managing director of OasisEye Specialists in Kuala Lumpur. Taking a look at a relatively new private eyecare set-up, Dr. Fong offered his pragmatic insight into starting up a center, from considering the practice’s SWOT analysis, financing obstacles, obtaining licenses, staffing, infrastructure, equipment and location.

However, when it comes to attracting the best talent, Dr. Fong said the key is having a group of doctors who share the same core values and work well together. “I think the character and ethics of the doctor is more important than their actual surgical ability,” he said, adding that each doctor must be financially committed to the center and should be given different leadership roles.

Besides handling the nitty-gritties of daily operations, like leaky pipes and the possibility of power and IT failures, keeping costs low is a challenge for new set-ups. Thus, he shared a few practical tips in negotiating and buying equipment or supplies and going paperless.

Outlooks from Indonesia

Dr. Sjakon Tahija is the only doctor among his business-oriented family in Indonesia. He and his family acquired 20% of shares in the Jakarta Eye Center (JEC) eye hospital in 1990. He left JEC in 2004 to establish the KMN chain of eye clinics (now with five branches in Jakarta), with the vision to have the highest standards of medical outcomes and customer care. His target market

is Indonesians who go overseas for eye care.

In its early days, KMN faced a shortage of capable ophthalmologists and governmental regulations which only allowed general anesthesia in fullfledged hospitals. Dr. Tahija mitigated these issues by inviting Dr. Abhay Vasavada to transfer his expertise to KMN doctors, while sending their doctors to other countries to train in various subspecialties. They also partnered with South Jakarta Clinic hospitals for general anesthesia needs and had an Australian anesthesiologist train them in local anesthesia.

To manage their competition overseas, KMN worked hard to focus on giving top quality medical service to their target market from the upper economic segment, right down to training their security guards to smile to appear friendlier. They also offered free flow ice cream and coffee.

When patient numbers dropped 80% during the COVID-19 pandemic and discount vouchers were given, KMN finally found its new market — the very patients who would normally only go overseas for medical eye care began to come in to experience KMN’s eye care service for the first time.

China’s first private eye hospital

Branding, human resources and finances are common challenges in setting up a private hospital, said Dr. He Wei who set up He Eye Specialist Hospital, China’s first private eye hospital in 1995. Now, the He Vision Group (HVG) is integrating medical eye care, education and training with its own university of 15,000

students and the China National Training Center for the Prevention of Blindness, plus industrialization (producing own ophthalmic and surgical supplies) and R&D in China.

To address the lack of staff expertise in eye care, he gradually built networks with medical institutions in seven provinces, 35 eye hospitals and 60 vision centers. Dr. He said his PhD topic in molecular pathology also afforded him a base to branch into intelligent medicine and big data, which led to the establishment of a National Eye Gene Bank, stem cell research, and now, traditional herbs for eye care. He credits the financial support from the government in helping him to expand these ideas.

Meanwhile in India

Observing his dog’s glittering retina during childhood sparked his love for ophthalmology for Dr. S. Natarajan as he relayed his journey from the early days up to the birth of Aditya Jyot Eye Hospital in 1990. “The inability of the hospital where I was working to install the required state-of-the-art eye surgery equipment was responsible for my decision to start an exclusive vitreoretinal center at Dadar, Mumbai, a very expensive city,” he said. His mentor Dr. S.S. Badrinath inaugurated the Aditya Jyot Eye Hospital, which began in the ground floor of a flat.

The practice then expanded into a LASIK center. “Perseverance, better financial planning and sheer hard work gave me the means to open a bigger, better eye hospital in central Mumbai at Wadala,” he said. In 2004, he initiated the Aditya Jyot Eye Bank and the following year, he set up the Aditya Jyot Foundation for Twinkling Little Eyes, its name given by the legendary Dr. A.P.J. Abdul Kalam, who inspired this very initiative. He ended his session by sharing about the importance of thinking positively and emphasizing the power of thoughts to help influence challenging circumstances for the better.

What about our future?

years old

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Problem Solving in Clinics, Business and Life

by Sam McCommon

And … we’re off! Day One of the CAKE & PIE Expo (C&PE) kicked off with a fantastic discussion about problem solving in clinics, business and life. This fairly free-form set of presentations allowed speakers to talk about what practices, tools or ideas had been most valuable for them lately — and, in good fashion, the ideas ranged far and wide.

Retinawesome’s rise to fame

Dr. Hudson Nakamura launched the talk by discussing Retinawesome — an online webinar born of necessity. PIE magazine has frequently covered Retinawesome’s meetings, including this writer, so we’re well aware of its value.

To give a brief summary, Retinawesome features some of the most fascinating and difficult cases out there. Ophthalmologists — usually, but not always retinal specialists — share their unique cases, and these are followed by a lively and insightful discussion panel. The wit and banter is one of the features of Retinawesome, and it’s certainly something we look forward to.

One of the key developments Dr. Nakamura highlighted — and which often features in videos shared on Retinawesome — is the amazing leap forward surgical imaging has taken. High-definition, 4K video and 3D imaging make surgeries like vitrectomy more straightforward than ever, and easier to share with colleagues for discussion. If you’re looking for enlightenment and entertainment in the ophthalmic world, don’t miss out on Retinawesome.

Clinical and community ophthalmology responds to COVID-19

Of course, the pandemic has presented a systematic challenge to ophthalmology as well as, well … everything. Dr. G.V. Rao, of the Arunodaya Deseret Eye Hospital (Gurugram, Haryana, India) and Arunodaya Charitable Trust (New Delhi, India) shared his experience and insights.

For a bit of context, the Arunodaya Charitable Trust (ACT) is a heavyweight in the field. It’s treated upwards of 13 million underprivileged patients since its inception in 1990, and has performed nearly 50,000 vision-saving surgeries. With three clinics in the Delhi area, it’s served a vital role providing vision care for those who couldn’t otherwise afford it.

India’s experience with COVID-19, including the second wave it’s currently experiencing, have strained its ophthalmic services. This strain is multifactorial: It includes financial strain for both clinic and patient, clinical strain in managing treatment during a pandemic, and personal strain in the form of mental health and morale crises among practitioners.

But ophthalmologists have risen to the occasion, and have learned many lessons. In the end, we’ll likely see a more robust system. This includes improved practices with fiscal planning and preparation, better training of staff, improved patient education, and improved communication practices between doctor and patient. Even with a cloud like COVID-19, there’s a silver lining.

Can fish swim in the rain? Creativity and bias in ophthalmology

Dr. Luis Diaz-Santana, of Cambridge Consultants, led us through an excellent talk about the value of creativity in ophthalmology — and in any practice, really. The question above came from his daughter, to which he flatly responded, “no.” This dispelled the previous, biased idea she’d held that fish could swim in the rain.

Now, such an anecdote may leave a person scratching their head, but he’s got a great point: The biases we hold become less and less obvious to ourselves as we get older, but we all hold them. And in any innovative field, approaching a topic with as little bias as possible is vital to develop a full understanding of a topic.

Among the many examples he gives — really, we’ll do a full article on these — he discusses the way spying on Soviet satellites and the Cold War led to the rise of many modern treatments in ophthalmology. The combination of astronomers and ophthalmologists may seem a bit off, but they both essentially focus on seeing things as accurately as possible.

For Dr. Diaz-Santana, creativity involves having as many viewpoints as possible on a topic and involving people from different disciplines. We look forward to exploring this in more detail later.

Kung Fu Panda, Zen, and the art of ophthalmology

This is another topic that certainly deserves its own article — but for now we encourage you to check out Prof. Dr. S. Natarajan’s discussion on the lessons ophthalmologists can learn from Kung Fu Panda. He goes into the philosophy of questions like skill mastery, self knowledge, personal growth and being your best self — all through the lens of what’s ostensibly a kid’s movie. We highly recommend you watch his presentation for the in-depth philosophical session.

Houston, we have liftoff!

Serving Up Innovation with Adaptica

Part of the He Vision Group, Adaptica (Padua, Italy) develops and manufactures simple, smart, AI-based and mobile devices to detect refractive errors and visual defects and correct vision problems in people worldwide. Below, we explore how these devices do just that...

Let’s meet the product portfolio

Vasileios Skountis runs the international sales operations for Adaptica. During his presentation, he provided a comprehensive introduction to the company’s innovative product portfolio and discussed the benefits of using artificial intelligence (AI) enabled devices in ophthalmic and optometric practice.

2WIN

This binocular and mobile vision screening device is particularly applicable now — in the continuing time of COVID-19. That’s because it can be operated at a safe distance of 1 meter, and the operator is never in direct contact with the patient. It’s fast, noninvasive and is ideal for uncooperative patients, including infants. Further, it can measure objective refraction of both eyes simultaneously with a range of +15D to -15D — the widest range currently available. It also has various applications for further diagnosis, like the CR-App for corneal reflex, the LCApp for new glasses centering, and more.

Kaleidos

The first and unique binocular vision screener, this device measures the refraction of both eyes and can detect other ocular impairments. A big benefit of Kaleidos is that it functions as a dark room, so it can be operated in any light conditions. It measures the same range of vision of 2WIN, as well as phorias and tropias in prismatic diopters.

Kaleidos Plus

As the name suggests, this unique AI-

by Brooke Herron

based device goes one step further and can take a complete binocular measurement of objective refraction, amblyogenic factor screening and anterior segment anomalies screening in just three seconds and with no need for cycloplegic drops.

Real life applications

Ziming Liu is the product manager for Shenyang eyeROBO Intellectual Technology. During his talk, he discussed 2WIN-S (2WIN + Kaleidos) applications in China. He shared that the target users for 2WIN-S include opticians and optometrist (to help with practice efficiency); ophthalmologists (who work with children or need fast reports for adults); pediatricians; those on mission trips; in ERs (to check visual response in trauma); corporate clinics and schools (to enable mass screenings.

“In May 2021, a mass screening was launched in Beijing where more than 5,000 students have already been examined,” he said. “With three devices, more than 600 students can be screened each day.”

In addition, with the combined software system developed by eyeROBO, 2WIN-S can upload data rapidly and conduct real-time analysis. (EyeROBO is an AI platform based on Adaptica’s cloud.) Ziming Liu concluded that “as one of the effective screening methods for myopia prevention in China, we recommend promoting and using these devices.”

Dr. Eric Pazo,clinical research manager at He Vision Group and a lecturer at He University, China, also looked at using the 2WIN-S in school-aged children. He shared results comparing measurements between cycloplegic retinoscopy and 2WIN-S: Spherical equivalent, J0 and

J45 agreement in this study had high correlation.

The final presenter was CAKE magazine’s advisory board member, Dr. Harvey Uy, the medical director at the Peregrine Eye and Laser Institute in the Philippines. He showcased how these devices help optimize workflow and time in the clinic.

He delved into infrared photorefraction or photoretinoscopy, which marries infrared light and internal computer interpretation (AI) and works by projecting infrared light through the patient’s pupil and onto the retina. “Using the photoretinoscope, we can then estimate different types of error and do both eyes at the same time,” explained Dr. Uy, adding that there is also good specificity and sensitivity for detecting amblyopia, which is comparable to other existing instruments. “It is also quite accurate in measuring vertical and horizontal strabismus,” he continued.

“The Kaleidos has greatly enhanced our practice efficiency because instead of taking several minutes to use the autorefractometer, it only takes a few seconds to get a reading. It also has a small footprint and is portable — plus patients like it. It’s now an essential part of our practice,” he concluded.

COVID-19

Effects on Ophthalmology in India

by Joanna Lee

Distributed care is what could help with the challenges that India’s 30,000 ophthalmologists will face post COVID-19, said Founder and Chair of the LV Prasad Eye Institute in Hyderabad, Dr. Gullapalli N. Rao. He shared his thoughts on the impact of COVID-19 on ophthalmic practice in Arunodaya Deseret Eye Hospital’s first session on the first day of CAKE & PIE Expo (C&PE) titled, COVID-19, Mucormycosis (Black fungus) and Other Pandemic Issues Affecting Ophthalmology Practice

Various issues have arisen thanks to the virus.The pandemic has resulted in a lack of follow-up care for eye patients and has increased the number of backlogged cases. There has also been a disruption in screening programs, eye camps and mobile programs. These issues, combined with the complexities of treating patients amid travel restrictions, disruptions in education and loss of human resources, and the decrease of quality care for patients will also affect the sustainability of practice, he said.

Solutions for troubled times

Looking at solutions, Dr. Rao advocated for a distributed model of care with the best talent, leveraging the best technologies with a touch of “human tenderness” (3T Model) which could be dispersed across all areas of India.

Education and exposure to rural eye health and spreading talent to teaching, research, technology and other areas would help with the challenges, he said. Dr. Rao called for more vision centers to replace eye camps, more rural secondary centers for smaller tertiary centers, and a migration of professionals to spread the reach of care throughout the country.

Speaking of access, Dr. Arun Sethi shared the success story behind the Arunodaya Charitable Trust (ACT), a nonprofit charitable organization established in 1990 that has since served 14 million patients at the Trust’s base hospital, Arunodaya Deseret Eye Hospital (ADEH) in Gurugram, Haryana, India. As the hospital’s medical director with a passion for community ophthalmology, Dr. Sethi discussed ACT’s village outreach program, eye camps, school screening programs and satellite centers, as well as the mobile ophthalmic units utilized in an effort to “reach the unreached,” even through the pandemic.

Battle plans for the pandemic

In mitigating the pandemic, Dr. Aditya Sethi, also from the Arunodaya Deseret Eye Hospital (ADEH), provided a glimpse into an exemplary hospital “battle plan” which demonstrated how they initiated measures for employee safety, patient safety and housekeeping rules.

To cover all the bases, the hospital held trainings for employees and patients on safety precautions while at the hospital and while at home. Their plan left no stone unturned, as they detailed steps for daily screening, identified the levels of risks for different staff groups, created protocols for sick employees — right down to determining admission criteria and health requirements for the safe return to work for staff who have recovered from COVID-19. Dr. Aditya reminded the audience that “it’s a good idea to have a well-ventilated room (to work in).”

Economic impacts

Health economist Dr. Denny John from the Department of Public Health at Amrita Institute of Medical Sciences & Research Centre, Kochi, Kerala, India, shared his study’s findings about the economic impact of COVID-19 on the disadvantaged in both the state and the country.

India’s economy is expected to contract by 12% in Q1 of 2022. Healthcare in India has the lowest insurance coverage and is still being financed out of pocket by the poor who are mostly daily wage earners. The study aimed to estimate economic burden and productivity loss using disability-adjusted life years (DALYs), years of potential productive life lost (YPPLL) and cost of productivity lost (CPL). Initial findings of his study showed that the 55-70 age group were the highest affected group; this group made up 39.99% of cases and deaths, while the DALYs lost were at 70.92 per million population in the 60-65 age group. The paper will be published in the BMJ Open Ophthalmology Journal

A fungus among us

Editor’s Note:

For more on these talks, check out this session (and others) on demand following the CAKE & PIE Expo.

Finally, Dr. Parul Lokwani from ADEH presented on mucormycosis or Rhino Orbital-Cerebral Mucormycosis (ROCM) cases, which she observed have been on the rise during the second wave of COVID-19 in India. She said secondary infections have been reportedly common in hospitalized, severely ill COVID-19 patients, before discussion of diagnosis, treatment and prevention of this fungal disease.

Cutting-edge Practices in Ophthalmology

ADEH Family of Clinicians Share Surgical Pearls

by Sam McCommon

Abevy of ophthalmologists manage the Arunodaya Deseret Eye Hospital (ADEH), with whom we’re in regular contact and whose company we quite enjoy. The name “Sethi” is essentially synonymous with this organization, which is based in Gurugram, Haryana, India.

Their team presented some wonderful talks on cutting-edge ophthalmic practices, which we think you’ll enjoy, too. What’s covered here can only be a fraction of what’s in the video, so we recommend you watch the full session as well.

Refractive surprises after IOL implantation

Dr. Reena Sethi kicked off the session with a discussion of refractive surprises — and how doctors can determine how to prevent these nasty surprises, as well as how to respond to them.

First, doctors need to look for outlying cases that are known to pose refractive risks after cataract surgery. Extreme hyperopes and myopes; those with dense, white or brunescent cataracts; radial keratotomy (RK); photorefractive keratectomy (PRK); penetrating

keratoplasty (PK); and LASIK patients all pose a higher risk of refractive problems after IOL implantation than a “standard” patient. Sometimes, however, surprises can happen with no warning whatsoever — and doctors need to be prepared for that as well.

As Dr. Reena Sethi said, doctors need to be able to explain just what went wrong. Was it the biometry? Was the wrong formula used or was there a data entry error? Was the wrong IOL used, or was it placed incorrectly — either upside down or not in the bag? Was there a posterior segment anomaly?

One way to prevent these nasty surprises is to make absolutely sure biometry is correctly done — and then done again. Dr. Reena Sethi pointed out that many mistakes in biometry come from contact, which can lead to big changes. A 0.5 mm depression on the cornea, for example, can lead to an error or -1.25 D. Similarly, a measurement that’s 0.5 mm off-axis can create a +1.25 D error. In non-contact methods, a cataract’s density can reduce the sound-to-noise ratio and thus reliability.

To guarantee the best results, Dr. Reena Sethi suggests measuring both eyes, and measuring twice — especially if

the axial difference between the eyes is greater than 0.3 mm or if consecutive measurements differ by 0.2 mm or more. Using two different biometric techniques can help reduce risks as well.

In the event of surprises, a doctor will need to help the patient manage said surprise. There are many options available, including glasses, contact lenses, LASIK, piggyback IOLs, IOL repositioning or an IOL exchange.

Special “tricks” for pediatric eyes

Dr. Aditya Sethi shared some pearls of wisdom from the field of pediatric ophthalmology — specifically in the case of pediatric cataracts. Treating children is different from treating adults, as most doctors well know, and there are many factors to take into account. For example, is the cataract visually significant, and will surgery actually improve vision? When is the best time to conduct the surgery? Inquiring minds will be able to come up with plenty of their own questions.

Simply put, there are four steps that go into dealing with pediatric cataract. First is proper evaluation; second is meticulous surgery, bearing in mind pediatric necessities; third is correct follow-up; and fourth is amblyopia therapy.

For Dr. Aditya Sethi, a visually significant cataract has several features — for example, it’s larger than 3 mm and is in the central visual axis. Additionally, if the retinal details cannot be seen, strabismus is present, or there’s no central fixation after 8 weeks, the cataract is significant.

Unilateral and bilateral cataracts each present their own set of challenges — we recommend watching Dr. Aditya Sethi’s session for a full explanation.

A good takeaway is Dr. Aditya Sethi’s “Rule of 7,” which helps determine when and how to target pediatric patients. For example, if a patient’s age added with their target hyperopia equals 7, you’re good to go. Alternatively, their age plus their refractive error — for example, 2 years of age and +5.0 D — means it’s time to act when the formula produces 7.

Recipes for Results in Cataract and Refractive Surgery

by Brooke Herron

Getting the best outcomes isn’t always simple — thankfully, we have leading experts to share their recipes for the best results (get ‘em while they’re hot!).

When SMILE becomes a frown: Managing complications in SMILE

“During the stage of laser delivery, you can have problems such as black spots and suction loss; and during the stage of lenticule dissection you can have issues such as the lenticule getting stuck on the cap, the lenticule being torn, cap tears, as well as the inability to find the lenticule itself,” said Dr. Sheetal Brar, a senior consultant at Nethradhama Superspeciality Eye Hospital in Bangalore, India, and a well-recognized expert on all things SMILE (small incision lenticule extraction).

To prevent and manage black spots, Dr. Brar suggests minimally using topical anesthesia; immediately docking after eye preparation; wiping the cornea and contact glass with a moist sponge before redocking. “You can also break the suction manually if you see there are

IOL selection in postrefractive surgery eyes

Dr. William Trattler from the Center for Excellence in Eye Care in Miami, Florida, covered the hurdles surgeons face when performing cataract surgery on patients with previous refractive surgery like LASIK or PRK.

multiple areas of black spots involving the center or visual axis,” she said.

Another important complication is suction loss. “Whenever you have suction loss and the lenticule cut has progressed to more than 10%, you will have to convert to femto-LASIK. Whereas, if your lenticule cut is less than 10%, then you can proceed with SMILE,” she explained, adding that you can proceed with SMILE if the suction loss occurs during the side, cap or cap side cut.

Dr. Brar further discussed lenticulerelated complications and their solutions (check out her presentation on demand for these important tips!).

Pearls and tricks of the flanged IOL sutureless fixation

Next, Dr. Matias Iglicki from University of Buenos Aires in Argentina, shared results from a paper he co-authored as part of the International Retina Group titled, Results in comparison between 30-gauge ultra-thin wall and 27-gauge needle in sutureless intraocular lens flanged technique in diabetic patients: 24 month follow-up study. During his presentation, he showed several surgical techniques.

“If we use a 30G with a thin wall, the inner diameter is 0.14 mm where the haptic is 0.15 mm, so it won’t fit, but an ultra thin wall (UTW) needle has 0.20 mm and then it fits properly,” he shared. “This is why the ultra-thin needle is the best needle for this surgery.”

In conclusion, Dr. Iglicki said that sutureless IOL flanged technique using 30G UTW needle is more predictable and results in less complications in aphakic diabetic patients compared to 27G technique.

“It should be simple, we have great formulas, new IOLs,” said Dr. Trattler of the challenges involved with post-LASIK patients. “First, how can we predict the patient is going to have a good BCVA postoperative outcome? Surprisingly enough, hidden in those topographies there can be some level of irregularity in the cornea shape from previous LASIK. We want to find out who is a good candidate for a presbyopic IOL, and how to enhance patients who end up unhappy despite using the latest IOL formulas.

“Understand that in patients with a history of laser vision correction, we have a lot of ways to make patients see very well with cataract surgery; however, even with our best efforts, patients could still end up over- or undercorrected,” continued Dr. Trattler. He explained that for patients that end up off-target, potential solutions include glasses or contact lenses; PRK over the LASIK flap; lifting the flap depending on the situation; as well as a piggyback IOL or IOL exchange.

Pseudoexfoliation: No wiggle, no cry

The last speaker was Canada-based ophthalmologist and professor Dr. George Beiko who presented on pseudoexfoliation syndrome, including clinical and pathological findings.

“When assessing a pseudoexfoliation patient for cataract surgery, it’s important to look for the wiggle or phacodonesis. If none is present, then we can be confident that we can proceed with our standard approach with minimal risk of complications,” said Dr. Beiko.

Unfortunately, we don’t have enough room to cover all of the important information covered by the experts in these presentations — so, make sure to check them out on demand following the expo!

Indeed, Retinas are Awesome

Ophthalmologists — particularly those specializing in the posterior segment — can certainly agree on one thing: retinas are awesome. Hence the name of this special segment and organization dedicated to just that — Retinawesome — which featured surgical techniques, tips and more.

When the nucleus drops

Wondering how to remove a dropped nucleus that’s gone subretinal? That was the topic covered by Dr. Athanasius Nikolakopoulos (Greece), who shared that in this case,the nucleus was sucked through a huge tear in the retina, which was smaller than the nucleus and made it very hard to get through without destroying it.

The trick to removing it is not to touch anything on the nucleus when it’s sitting on top of the retina or you will damage it, so it must be lifted. In addition, because the patient was quite old, the nucleus could not be crushed or broken, so he used endo-fragmentation to break it up, which was successful. Fortunately, no damage was done by the small pieces of nucleus as they broke apart and bounced off the retina.

by Chris Higginson

Tackle that macular hole

Dr. Vaibhav Sethi (India) discussed how he treated a macular hole with epiretinal membrane (ERM). The operation started problematically; this was due to the ERM, so there wasn’t much effective stain. This unfortunately led Dr. Sethi to scratch too much at the ILM (internal limiting membrane). This created a macular plate, but luckily it was quite a distance from the fovea.

Thus, he had to change plans. Dr. Sethi then used the pinch and peel technique, which he has used before, to remove the ILM, but it came off at the ERM. He intended to use the flap technique to cover the macular hole but was unable to, so he dried and drained the posterior pole as much as possible and put in gas. Happily, there was a closure and the patient achieved BCVA 20/100. His takeaway message is “stick to what works best in your hands.”

Inverted flap and stuff

Dr. Hudson Nakamura (Brazil) spoke about using the inverted ILM flap and stuff in technique for traumatic macular hole with PVR (proliferative

vitreoretinopathy) retinal detachment. He started with a complete air and fluid exchange and injected blue dye, which tinted the ILM. Then he peeled up the ILM from the fovea side, close to the hole, but not up to it. He did this from both sides, leaving a small amount attached around the hole, so it is kept in place. He then stuffed the ILM into the hole.

To repair the retinal detachment, he completed 2-3 rows of burn with the endolaser, followed by direct exchange of PFC (perfluorocarbon) for silicone oil.

Myopes with macular holes and more Dr. Waiching Lam (Hong Kong) spoke about treating a macular hole in a myopic patient with associated retinal detachment. After peeling the vitreous membrane, he stained the ILM and peeled the membrane manually with a diamond dusted scraper from around the macular hole, which he then used to cover the hole, without needing to stuff it.

Instead of draining through the macular hole, he drained through a small hole he created in an extra foveal location. This was done because often when the drain is through the macular hole, there’s a risk of subretinal fluid enlarging the hole, meaning the recovery is slower, or it doesn’t close at all. Creating a small extra foveal hole allows the surgeon to flatten the attachment by manipulating the macular hole.

Chronic and traumatic macular holes

During his presentation, Dr. Saad Waheeb (Saudi Arabia) spoke on treating a chronic, traumatic large macular hole. After performing a vitrectomy and staining the ILM with dye, he then used the pinch and peel technique to begin taking off the ILM. He avoided peeling the whole ILM (in case it didn’t work), and returned and got a free flap to cover the hole later. He used the “envelope” technique, where he removed the ILM from different sides, covering the hole like an envelope, with one layer on top of the other. After four weeks the hole was closed, and the patient had a VA of 20/50.

C&PE Welcomes the Israeli Ophthalmic Innovation Group

The Israeli Ophthalmic Innovation Group is the largest community on LinkedIn for companies operating in the ophthalmic space in Israel. Including more than 30 companies, the group aims to cover true innovation in eye care. And at Media MICE (and the CAKE & PIE Expo), this is exactly the type of organization that we can get on board with.

The group has a wide range of areas of focus: from cornea to retina, and stem cells to digital health. They include companies who have FDA approved and CE marked products, as well as those that are in the concept stage. According to Nahum Ferera, CEO and co-founder of EyeYon Medical, regardless of the

company’s stage, they all contribute to creating cutting-edge technologies for real unmet clinical needs.

Representatives from the following companies: EyeYon Medical, Weizmann Institute of Science, BioProtect Ltd, Meir Medical Center, CorNeat Vision and Star Tree Ventures Ltd are present at C&PE.

“We decided to join the CAKE & PIE Expo as we find Media MICE a real partner in telling our story to the world and helping us to improve patients’ lives all around the world,” said Mr. Ferera, who specializes in leading medical device projects from idea to a successful product. He also has extensive experience in c-level management, ophthalmic medical devices, business development, clinical trials, regulation and intellectual property.