CAKE Magazine Issue 05: The ebook version ('The Art Issue', ASCRS 2020 Virtual Edition) by Media MICE

THE WORLD’S SECOND FUNKY OPHTHALMOLOGY MAGAZINE

05 THE ART ISSUE May 2020

cakemagazine.org

Cover Story

Ophthalmologist’s

OPUS The Art of Patient Counseling

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IN THIS ISSUE...

Matt Young CEO & Publisher

Robert Anderson Media Director

Hannah Nguyen Production & Circulation Manager

Gloria D. Gamat Chief Editor

Brooke Herron Editor

Mark Hillen Editor-At-Large

Ruchi Mahajan Ranga Project Manager Writers

Andrew Sweeney April Ingram Chow Ee-Tan Joanna Lee Hazlin Hassan Konstantin Yakimchuk Khor Hui-Min Olawale Salami Sam McCommon Tan Sher Lynn

Cataract

05 08

Ophthalmic Inserts, Promising Alternatives to Eye Drops?

Anterior Segment

11 13

Ophthalmologists Face ‘Grim Sight’ Amid the Coronavirus Pandemic The Critical Conundrum: Managing Ocular Surgery Patients on Antithrombotics

The Lowdown on Managing Ocular Trauma

Experts’ Take on Preventing CME after Lens-Based Surgery

Cover Story

Ophthalmologist’s Opus: The Art of Patient Counseling

Maricel Salvador Graphic Designer

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SOCIETY FRIENDS

All India Ophthalmological Society

Kudos

23 25

Bernie Ursell: A Passion for Eye Care Education Dr. Ian Yeo: On a Mission to Train Rural Ophthalmologists

Enlightenment

Conference Highlights

27 30

Apart but United: Fighting the Coronavirus Pandemic International Companies ‘Eye’ the Indian Market

Young Ophthalmologists’ Toolkit for Surviving the COVID-19 Pandemic Lockdown

36 38

Refractive Round-up: SMILE Stays Strong

Managing an Unhappy Pseudophakic Patient Latest Refractive Innovations In the Spotlight

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LETTER TO READERS

! Gut Sehen ist Alles

impinging upon his worldview; no rosetinted spectacles for him. Leibl’s other motto was: “Gut sehen ist alles”, meaning “good vision is everything”. I quite agree. It’s an axiom — you strive to achieve this for your patients, and it’s even more important to them. I’ve been fortunate (so far) to have had vision that has been better than 20/20 all my life, perhaps on a par with Leibl’s visual acuity. But I’m beginning to experience presbyopia, and I really do not like it.

ave you heard of the German portrait artist Wilhelm Leibl? Until I saw his work in the Kunsthaus Zürich in mid-December, I had no idea who this guy was. It turns out he was from Cologne, born in 1844, a rich boy — Daddy was the director of the Cathedral Choir, and his work became progressively more photorealistic with each year. There was a quote attributed to him: “In each century, there are perhaps only six people who can see well; the others beautifully, and that means falsely.” I guess he was an emmetrope then. I like to think Leibl was being literal in that statement — that he was musing on how improbable it is to get perfect vision. How common is it that someone has a cornea without astigmatism, an axial length that avoids myopia and hyperopia, or an optic nerve untainted by elevated intraocular pressure? Everything’s on a bell curve — including ocular anatomy — and the chances of all those bell curves aligning to give p-e-r-f-e-c-t vision must be fantastically rare. He died at 56 years of age, so he was likely spared the harsh realities of age-related retinal diseases and cataract (but probably not presbyopia). Would Leibl have known of the work of the fellow German speaker Ernst Fuchs, born six years later (albeit 900km to the east in Vienna)? Of course, he could have been speaking figuratively. Perhaps Leibl was also immune to emotions

However, these annoyances are obliterated when I read about what low vision is really like for people — and the impact of something that improves their vision (even slightly) can bring. It’s magical. So, in addition to being artists, perhaps ophthalmologists are magicians? Let’s think about it... your sleight of hand brings outcomes that outstand? Maybe. I’ve heard it so many times from cataract surgeons: “You implant a multifocal IOL, and you get a patient seeing 20/20.” You think you’ve performed a miracle — something magical — and yet the patient isn’t happy. There are many potential reasons why: sometimes they can’t neuroadapt; some can’t tolerate glares and/or halos that can be a consequence of multifocal IOL design. It’s all an optical trade-off, after all. Some actually like a bit of myopia; and some only remember that they like close-up embroidery after surgery (and not in the half-an-hour or so of chair time you had with them discussing their lifestyle and distance preferences).

they want to ply their trade successfully, they need people to be compliant, to play along, and to look where the magician wants them to look — not where they should be looking. Most magic is actually psychological analysis. Patient selection, if you like. You don’t want a person complaining when you’ve really performed something incredible, something that has taken years of training and thousands of hours to perfect. It’s not you, it’s them. So, avoid them in the first place. And if you can’t avoid them, under-promise and overdeliver. I don’t want to be the “Santa doesn’t exist guy”, but what people describe as “magic” or “magical” isn’t something that breaks the laws of physics. It’s an experience, not a reality. But to give someone that experience? Boy, that’s a lot of work. The amount of practice needed to reliably pull off a “dumb” card trick is phenomenal. I’m sure you can relate. But it is worth remembering that for most people, what you do is magic. You might feel like you’re working your ass off operating on lists of patients that are as long as the Great Wall of China. I know from my own grandparents, seeing clearly without cataracts was something spectacular. And from my cousins, the delight of being spectacle-free after LASIK was something they’ve described as “the best thing they’ve done”. But they didn’t do it — it was surgeons like you who did! So, raise a glass and give yourself a toast... and maybe add some new skills to your LinkedIn profile: artist and magician.

Having that “magic touch” has a little bit more to it than “simply” applying great surgical skill and superb attention to detail throughout the process! Most magicians aim to surprise and delight, and they deploy everything from distraction, sleight of hand — and most importantly — psychology to direct (or misdirect people) to get the outcome they want. However, they’re not dumb. Skeptics and shrewd operators exist in the audience. And if

Dr. Mark Hillen

Director of Communications ELZA Institute, Zurich, Switzerland Editor-At-Large | CAKE Magazine

| May 2020

ADVISORY BOARD MEMBERS

Dr. Jodhbir S. Mehta

Dr. William B. Trattler

Dr. Chelvin Sng

Dr. Harvey S. Uy

Dr. Mehta is head of Cornea External Disease and senior consultant in the Refractive Service at Singapore National Eye Centre (SNEC), deputy executive director at Singapore Eye Research Institute (SERI), as well as a professor at DukeNational University of Singapore. With a main interest in corneal transplantation, he completed a corneal external disease and refractive fellowship at Moorfields Eye Hospital in London and at SNEC. He has co-authored nearly 20 textbooks and 333 citations, and holds 16 patents, six of which have been licensed. A seasoned committee organizer, Dr. Mehta

will be part of the World Corneal Organizing Committee in 2020, as well as the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS), Singapore, in the same year. He has won several awards from the American Academy of Ophthalmology (AAO) and the Association for Research in Vision and Ophthalmology (ARVO), among others, the latest of which was from the American Society of Cataract and Refractive Surgeon (ASCRS) in 2018. Dr. Mehta is also a favorite keynote speaker and presenter in several international conferences. jodmehta@gmail.com

Dr. Trattler is a refractive, corneal and cataract eye surgeon at the Center For Excellence In Eye Care in Miami, Florida, USA. He performs a wide variety of cataract and refractive surgeries, including PRK; all laser LASIK; no injection, suture-less cataract surgery; as well as laser cataract surgery. He has been an investigator for next generation technologies (like the Tetraflex accommodating intraocular lens) and procedures like corneal collagen crosslinking (CXL). His involvement in the FDA-approval study for CXL led to its approval in 2016. In addition to his private practice, Dr. Trattler is on the Volunteer

Faculty at the Florida International University Wertheim College of Medicine, as well as the University of Miami’s Bascom Palmer Eye Institute. He is board certified by the American Board of Ophthalmology and has been an author of several articles and abstracts. In 2016, Dr. Trattler received the Catalyst Award in Advancing Diversity in Leadership from the Ophthalmic World Leaders (OWL), an association of interdisciplinary ophthalmic professionals dedicated to driving innovation and patient care by advancing diversity in leadership. wtrattler@gmail.com

Dr. Sng is a consultant at the National University Hospital (NUH) and assistant professor at National University of Singapore (NUS). She is also an honorary consultant at Moorfields Eye Hospital, London, and adjunct clinic investigator at SERI. A pioneer of minimally invasive glaucoma surgery (MIGS), Dr. Sng was the first surgeon in Asia to perform XEN, InnFocus Microshunt and iStent Inject implantation. A co-author of “The Ophthalmology Examinations Review”, Dr. Sng has also written several book chapters and publications in various international journals. She has received international grants and awards for her research accomplishments

from the American Academy of Ophthalmology and the Australian and New Zealand Glaucoma Interest Group. Proficient in conventional glaucoma surgery and trained in complex cataract surgery, Dr. Sng co-invented a new glaucoma drainage device, which was patented in 2015. She has been invited as a reviewer for several international ophthalmic publications, and as a speaker in various international lectures and conventions. When not working, Dr. Sng can be found volunteering in medical missions in India and across Southeast Asia. chelvin@gmail.com

Dr. Uy currently serves as associate clinical professor at the University of the PhilippinesPhilippine General Hospital, consultant for Retina and Uveitis Services at St. Luke’s Medical Center, as well as medical director at Peregrine Eye and Laser Institute in the Philippines. Previously, he was a clinical fellow in Medical and Surgical Retina at St. Luke’s Medical Center, Philippines, and in Ocular Immunology and Uveitis at the Massachusetts Eye and Ear Infirmary at Harvard Medical School. In 2015, he co-invented the Modular Intraocular Lens Designs, Tools and Methods,

which was patented with the United States Patent Office. Dr. Uy is a recipient of numerous awards and honors, including the Immunology Award, presented by the Ocular Immunology Service from the Massachusetts Eye and Ear Infirmary, Harvard Medical School (1998), and the Senior Achievement Award from the AsiaPacific Academy of Ophthalmology (2017). He has also published more than 32 international peer-reviewed journals and 30 book chapters, and is a prominent speaker, presenting in various national and international conferences. harveyuy@yahoo.com

| May 2020

ATARACT INTRACANALICULAR INSERT

Ophthalmic Inserts

Promising Alternatives to Eye Drops? by Konstantin Yakimchuk

n ophthalmology, corticosteroids are widely used for postoperative control of pain and inflammation. While steroid-based supportive therapy aims to diminish ocular inflammation, it is potentially followed by a plethora of secondary complications including elevated intraocular pressure, glaucoma, slow tissue regeneration, pain and impaired vision.1 However, traditional eye drops may no longer satisfy ophthalmologists, since only a very small volume is actually delivered to the internal eye tissues — even if application recommendations are precisely followed.2 Moreover, liquid drainage through the nasolacrimal channel, reduced corneal permeability and blinking are natural barriers which diminish the efficiency of standard eye drops.3 Besides, eye drops are directly diluted by the tear film. Thus, novel methods of drug delivery to the intraocular tissues are, indeed, needed. One such technique has been described by Brooks et. al., from the Duke University Eye Center in Durham, North Carolina and University of Illinois at Chicago, Illinois, U.S., in the recent issue of Clinical Ophthalmology.4

Application of Intracanalicular SustainedRelease Dexamethasone A comprehensive review by Brooks et. al. described the applications of

For some patients, eye drops aren’t an option.

intracanalicular sustained-release dexamethasone (Dextenza, Ocular Therapeutix, Bedford, Maine, U.S.) to reduce postoperative ocular inflammation and pain. The review strongly advocates punctal plugs as an effective method to deliver therapeutic agents; while the dexamethasone intracanalicular insert might replace eye drops in near future due to clear advantages, such as continuous drug administration into the eyes.5 This method has been already approved by the Federal Drug Administration (FDA), especially for the suppression of postoperative inflammation. Dexamethasone has been efficiently used to inhibit postoperative inflammation and pain after ocular surgery.6 Moreover, it is well tolerated by ocular tissues.

To obtain an expert’s opinion on Dr. Brooks’ review, Dr. Harvey Uy, clinical associate professor of ophthalmology, University of the Philippines and medical director at Peregrine Eye and Laser Institute in Makati, the Philippines, was invited to comment on the study. According to Dr. Uy, therapeutic management after cataract surgery is primarily based on the proper control of postoperative surgery. Currently, the standard care approach implements the installation of topical drops with antibiotics and corticosteroids. Although this approach proved to be highly effective, poor compliance may cause complications and insufficient outcomes.

| May 2020

ATARACT INTRACANALICULAR INSERT

Novel Techniques in the Management of Poor Compliance Longer-acting transzonular triamcinolone-moxifloxacin suspension (Dropless, Imprimis Pharmaceuticals, San Diego, California, U.S.) is one of the most effective methods to diminish the troubles with poor compliance. As Dr. Uy stated, he and his colleagues “have used this method satisfactorily for several years now in selective fashion for patients who are unable to apply postoperative drops and for patients with concomitant macular edema amenable to corticosteroid therapy.” Are there any contraindications to transzonular triamcinolone-moxifloxacin suspension? According to the expert, limitations of this method include transient postoperative errors, contraindication for eyes with zonular weakness, and the necessity of extra intraocular maneuvers. Another technique uses sustainedrelease dexamethasone punctual plug implants (Dextenza, Ocular Therapeutix, Bedford, Maryland, U.S.). Dr. Uy noted that: “the authors of this article have extensively reviewed the literature and correctly conclude that this method achieves adequate postoperative control with no significant safety issues.” Importantly, this novel technique is easy to operate and the probability of making an error is rather low.

Preclinical Studies and Implementations in Clinical Practice Did preclinical studies evaluate the safety of intracanalicular plugs? For decades, animal models remain a vital tool for testing novel therapeutic approaches in ophthalmology. In particular, no effects on intraocular pressure or local toxicity were observed when dexamethasone was released into the dog canaliculi using intracanalicular depots.7 Moreover, urine and blood samples obtained from dogs treated with dexamethasone depots were analyzed for possible toxic effects of this type of corticosteroid delivery.8 Notably, no adverse effects

were detected in dexamethasonetreated dogs when compared to placebo. Has this technique been already implemented in clinical practice? Several clinical studies have been performed. In particular, a recent randomized study applied this technique for cataract surgery. According to the study description, dexamethasone was inserted into the inferior canaliculus during operation.9 Continuous release of dexamethasone abolished ocular pain and eliminated anterior chamber cells after one week of treatment. Also, a recent study by Tyson et. al. has evaluated the efficacy of intracanalicular corticosteroid inserts for the suppression of inflammation following cataract surgery. The results demonstrated significant inhibition of inflammation and no difference in the adverse effects when compared to control treatment.10 Moreover, the patients themselves strongly advocate for the intracanalicular corticosteroid insert. When the patients who received the dexamethasone intracanalicular insert following cataract surgery were questioned regarding their experience about the method, the majority of the patients characterized their experience with the technique as “very convenient” and were willing to recommend it to relatives and friends.11

Safety and Limitations of Intracanalicular Corticosteroid Insert In addition to the limitations of the method, are corticosteroids completely safe? Immunosuppressive functions of steroids are well known. In line with this, physicians should be careful prescribing these drugs for patients

| May 2020

with acute ocular infections, since corticosteroids may suppress both antimicrobial immune response and the mechanisms of wound healing. Both viral and fungal infections might be aggravated.12 Furthermore, treatment with topical steroids was associated with symptoms of ocular surface disease and active disease progression.13 Are there any disadvantages of intracanalicular corticosteroid insert? Dr. Uy emphasized: “The main disadvantage of this approach is cost effectiveness, as the cost of a branded bottle of steroid drops is only a fraction of the cost of the intracanalicular plug. When finances permit, the sustained release approach provides improved patient compliance with no safety concerns.” However, when available resources of the healthcare system are restricted, eye drops or the transzonular technique would be more costeffective, even considering their limitations. Perhaps the best solution would be to prescribe the insert for patients who fail to reliably introduce eye drops and maintain follow up visits, and where there is a lack of additional care and hypersensitivity to postoperative therapeutic drugs. In particular, intracanalicular corticosteroid inserts might be applied for retinal, corneal, glaucoma and other types of surgeries, which may potentially be associated in problems with accessing the palpebral fissure to apply eye drops. According to Brooks and co-authors, the described drug delivery technique might significantly overcome weaknesses of current delivery systems in ophthalmology, while effectively reducing the post-surgical inflammatory process. The authors suggested that intracanalicular delivery might significantly abate both the disadvantages of topical eye drops and the toxicity of preservative components in topical medicines.

To support this statement, Dr. Uy pointed out that “the introduction of the dexamethasone implant is a very welcome addition to the eye surgeon’s toolkit.” Moreover, additional studies are required to fully estimate the potential therapeutic advantages of this method.

P, Pleyer U. Dexamethasone Intraocular Suspension: A Long-Acting Therapeutic for Treating Inflammation Associated with Cataract Surgery. J Ocul Pharmacol Ther. 2019;35(10):525-534. 7

Renfro L, Snow JS. Ocular effects of topical and systemic steroids. Dermatol Clin. 1992;10:505-512.

Driscoll A, Blizzard C. Toxicity and Pharmacokinetics of Sustained-Release Dexamethasone in Beagle Dogs. Adv Ther. 2016:33(1);58-67.

Walters T, et al. Sustained-release dexamethasone for the treatment of ocular inflammation and pain after cataract surgery. J Cataract Refract Surg. 2015;41(10): 20492059.

References: 1

Chang DT, et al. Intracameral dexamethasone reduces inflammation on the first postoperative day after cataract surgery in eyes with and without glaucoma. Clin Ophthalmol. 2009;3:345-355. Hermann MM, Ustundag C, Diestelhorst M. Electronic compliance monitoring of topical treatment after ophthalmic surgery. Int Ophthalmol. 2020;30(4):385-390.

Gaudana R, Ananthula HK, Parenky A, Mitra AK. Ocular drug delivery. AAPS. 2010;12(3):348360.

Brooks CC, Jabbehdari S, Gupta PK. Dexamethasone 0.4mg Sustained-Release Intracanalicular Insert in the Management of Ocular Inflammation and Pain Following Ophthalmic Surgery: Design, Development and Place in Therapy. Clin Ophthalmol. 2020;14:89-94.

Chen H. Recent developments in ocular drug delivery. J Drug Target. 2015;23(7-8):597-604.

Grzybowski A, Brockmann T, Kanclerz

CASIA2 A3 ëpîΩ_Resized-02-29-20.pdf

Tyson SL, Bafna S, Gira JP, et al. Multicenter randomized phase 3 study of a sustainedrelease intracanalicular dexamethasone insert for treatment of ocular inflammation and pain after cataract surgery. J Cataract Refract Surg. 2019;45(2):204-212.

Gira, J. P. et al. Evaluating the patient experience after implantation of a 0.4 mg sustained release dexamethasone intracanalicular insert (Dextenza): results of a qualitative survey. Patient Prefer Adherence. 2017;11:487-494.

Srinivasan M, Mascarenhas J, Rajaraman R, et al. Corticosteroids for bacterial keratitis: the Steroids for Corneal Ulcers Trial (SCUT). Arch Ophthalmol. 2012;130(2):143-150.

Cho CH, Lee SB. Clinical analysis of microbiologically proven fungal keratitis according to prior topical steroid use: a retrospective study in South Korea. BMC Ophthalmol. 2019;19(1):207.

2/29/20

Contributing Doctor Dr. Harvey S. Uy is a clinical associate professor of ophthalmology, University of the Philippines, and medical director, Peregrine Eye and Laser Institute in Makati, the Philippines. He completed fellowships at St. Luke’s Medical Center and the Massachusetts Eye and Ear Infirmary and has been a pioneer in femtosecond cataract surgery, accommodation restoration by lens softening, modular intraocular lenses, and intravitreal drugs. He has published over 50 peer reviewed articles and is on the editorial board of American Journal of Ophthalmology Case Reports. He is a former president of the Philippine Academy of Ophthalmology and current council member of the Asia Pacific Vitreo-retina Society. He received the Jose Rizal Research Award from the Philippine Medical Association, the Xavier School Exemplary Alumni Award, and Achievement Awards from the American and Asia Pacific Academies of Ophthalmology. Dr. Uy has also delivered more than 400 scientific lectures worldwide. harveyuy@yahoo.com

11:55 PM

| May 2020

ATARACT POSTOPERATIVE COMPLICATIONS Before performing surgery — or stunts — assessing risks is crucial.

Experts’ Take

On Preventing CME after Lens-Based Surgery by Joanna Lee

ver the years, sight-threatening postoperative cataract surgery complications like cystoid macular edema (CME) and endophthalmitis have been minimized. This is largely due to the efficacy of topical nonsteroidal anti-inflammatory drugs (NSAIDs), which help manage intra- and postoperative inflammation. Robust evidence has shown that these medications, along with precise surgical skills and practical measures, have helped doctors mitigate the risk factors that allow these conditions to develop.1

Look out for High-Risk Patients

To minimize the chances of developing postoperative CME, assessing the risk factors is a critical first step. According to Dr. Alay Banker from Banker’s Retina Clinic and Laser Centre in Ahmedabad, India, patients with pre-existing conditions (like diabetes and uveitis) would be susceptible to CME.

“If they have any co-existing ocular conditions such as uveitis, diabetic macular edema (DME), or retinal vascular conditions, doctors should make sure the patient is disease-free before cataract surger, or their blood sugar level should be absolutely under control for at least three months prior to cataract surgery,” he shared. There is evidence to support this concern over diabetics, according to Dr. Mae-Lynn Bastion from the National University of Malaysia Hospital. She cited a retrospective study of 82,000 eyes which quantified how patients face an ascending risk of postcataract surgery CME as their diabetic retinopathy progresses.2 Additionally, she said: “There is a subtle difference between a patient with CME and the ones with DME.” To discern between the two, Dr. Bastion said CME cases would show cystoid changes, while DME patients would have hard exudation and subretinal fluids.

| May 2020

Besides those with diabetes and uveitis, patients who previously had a posterior capsular tear during surgery are also at risk. “Postoperatively, if there is prolonged persistent inflammation and if near vision or if reading vision doesn’t improve, I would order a macular optical coherence tomography (OCT),” explained Dr. Bastion. “Certain drugs, such as those from the prostaglandin analog (PGA) group do have side effects, which can add to the risk. So, I usually would avoid them after surgery, especially if the capsular bag is compromised,” she added. Ensuring that eyelids are free from blepharitis and other conditions is also imperative to minimize the risk of CME or endophthalmitis.3

Utilize NSAID Eye Drops for CME Prevention

Consultant ophthalmologist and eye surgeon Dr. Yee Fong Choong, from the International Specialist Eye Centre

in Kuala Lumpur, Malaysia, said: “To me, the most important things are to perform safe surgeries and to use preventative nonsteroidal antiinflammatory eye drops for all patients, particularly those with diabetes.” In the same vein, according to Dr. Banker, some patients tend to use topical NSAIDs months prior to the cataract surgery. “More so if the patient has had postoperative CME in the other eye, say a few months ago,” he said. “I think it is good to start the NSAIDs on this eye one month prior to the cataract surgery.” However, Dr. Banker cautioned that if used long-term, NSAIDs could cause corneal toxicity. So, for patients with DME, Dr. Banker said a preoperative anti-VEGF injection could be used instead.

Always Plan Ahead Before the Surgery

Dr. Banker also advised to develop a plan ahead of the surgery. “See the patient, see what type of cataract he has, and find out what steps you would take. In your pre-plan, have your necessary tools ready, such as iris dilator (just in case), and know what type of viscoelastic agents you are going to use,” he said. Adequate preparation allows for better control during surgery; it can also make the process go quicker, thus lowering the risk of CME and endophthalmitis.

here, there might be other problems, like the patient may not know how to put in the eye drops or some may even go home without the eye drops,” she explained.

Get Your Postoperative Antibiotics Ready

At the end of the surgery, several options are available as prevention measures. “Postoperatively, I put in a drop or two of iodine at the end of the surgery. Some use intracameral vancomycin4 at the end of the surgery. That is not recommended as patients can develop hemorrhagic occlusal retinal vasculitis (HORV),” said Dr. Banker. He also prefers to use optical steroid antibiotics instead of systemic antibiotic drops, as the latter has less ocular penetration.

doesn’t contain anything toxic in the preservative. It’s been safely used for the eye with high effectiveness,” he explained. The incidence of endophthalmitis varies around the world, averaging between 1 in 800 and 1 in 1,200, meaning that endophthalmitis occurs in about 0.1% of cataract surgeries. Dr. Choong has only experienced one endophthalmitis case out of the 15,000 surgeries he’s performed over the past 24 years. “The trick is to reduce that risk,” shared Dr. Choong. “Most of the bacteria is exogenous, coming from the patients themselves.” According to Dr. Banker, in developing countries, people tend to re-use instruments. “That’s a major issue. Ideally, you cannot do that, but in cases where cost-cutting measures are necessary, you have to make sure you have good sterilization standards,” he said.

Besides using intracameral cefuroxime in her clinic (under national clinical practice guidelines), Dr. Bastion also mentioned using moxifloxacin. “Ever since we started this, the rate of endophthalmitis has dropped,” she confirmed.

Educating patients to come back for follow-ups, to practice good hygiene, and avoid dust are but some of the steps that help mitigate the possibilities of infection following surgery.

As for Dr. Choong, he said he usually uses amoxicillin. “For ease of use, we usually draw the antibiotic straight from the bottle. This particular antibiotic

“At the end of the day, it’s about risk reduction — as we can’t completely eliminate the risks. So, we do what we can,” Dr. Choong concluded.

Dr. Choong added that a non-traumatic, quick and short duration of surgery — preferably between 5 and 10 minutes — would help mitigate the patient’s risk of contracting CME. “Well, it’s not exactly like ‘Speedy Gonzales,’ as that would likely cause more complications, but you need not have unnecessary delays,” explained Dr. Bastion regarding shorter surgical durations. One of the ways Dr. Bastion reduces delays is by getting medication — the steroids and antibiotics — ready in the OR. “The moment the surgery is over, the patient’s eye drops are opened and administered right away. If you delay

Have the patient’s eye drops ready to administer directly following surgery to help avoid postoperative problems.

| May 2020

ATARACT POSTOPERATIVE COMPLICATIONS

Contributing Doctors Dr. Mae-Lynn Catherine Bastion received her medical degree from the University of Sydney, Australia, with first class honors in 1999. In 2003, she completed her fellowship with the Royal College of Surgeons and Physicians of Glasgow, U.K., and in 2004 completed her Doctor of Ophthalmology postgraduate studies in Ophthalmology with UKM (National University of Malaysia). Appointed as a member of the Academy of Medicine of Malaysia (AMM) in 2006, she received the AMM Fellowship in 2016. In 2007, she completed her clinical fellowship in vitreoretinal surgery under Associate Professor Dr. Lim Tock Han and three other vitreoretinal surgeons at The Eye Institute, Tan Tock Seng Hospital, Singapore. Following that, she returned to UKM and served as head of vitreoretinal services. She was appointed a professor of ophthalmology (vitreo-retina) at UKM in 2014, and continues to mentor and teach postgraduates and undergraduates while maintaining a private practice at the UKM Specialist Centre. mae-lynn@ppukm.ukm.edu.my

Dr. Yee Fong Choong is a consultant ophthalmic surgeon with sub-specialist interest in cataract, children’s eye diseases and squint. An ASEAN Scholar and a recipient of the prestigious British High Commissioner’s Award to study medicine in the United Kingdom, he graduated with Bachelor of Medicine and Surgery (MBChB) from the University of Leeds. He was conferred Fellow of the Royal College of Ophthalmologists (FRCOphth), London, and was awarded the Certificate of Completion of Specialist Training (CCST) upon finishing the higher specialist training in the U.K. He has extensive work experience at various leading institutions in the U.K. and has subspecialty training in pediatric ophthalmology and strabismus at London’s Great Ormond Street Hospital for Children and King’s College University Hospital. Prior to his return to Malaysia, he was a consultant ophthalmic surgeon at the University Hospital of Wales Cardiff, U.K. As a keen medical researcher, he has published more than 30 scientific articles in international medical journals and has given more than 40 lectures and presentations at international ophthalmic meetings. He is a panelist in several consultative bodies in the Ministry of Health advising the government on health policies relating to ophthalmology. yeefongchoong@gmail.com

References: 1

Hoffman RS, Braga-Mele R, Donaldson K, et. al. ASCRS Cataract Clinical Committee and the American Glaucoma Society. J Cataract Refract Surg. 2016;42(9):1368-1379.

Chu CJ, Johnston RL, Buscombe C, Sallam A B, Mohamed Q, Yang YC. (2016). Risk Factors and Incidence of Macular Edema after Cataract Surgery: A Database Study of 81984 Eyes. Ophthalmology. 2016;123(2):316-323.

Murthy R. (2017). Lid conditions affecting cataract surgery. J Clin Ophthalmol Res. 2017;5:65-66.

George NK, Stewart MW. The Routine Use of Intracameral Antibiotics to Prevent Endophthalmitis After Cataract Surgery: How Good is the Evidence? Ophthalmol Ther. 2018;7(2):233-245.

Dr. Alay S. Banker is the director of Banker’s Retina Clinic, Ahmedabad, Gujarat and chief of Gujarat Telemedicine ROP Project (Honorary Services) in India. After completing his MS from Gujarat University where he won the Gold Medal, he did a vitreoretinal fellowship at Medical Research Foundation, Sankara Nethralaya, Chennai. He then served as a clinical instructor and fellow of vitreo-retina and uveitis at University of California, San Diego, U.S. Some of his achievements include the International Scholar Award and International Education Award from American Academy of Ophthalmology (AAO), Senior Honor Award and Honor Award from American Society of Retina Specialists (ASRS), APAO Achievement Award 2014, the Late Dr. Piyush Patel Award for Social Service from Ahmedabad Medical Association, Gold Medal from All India community Ophthalmology Society for Community project on ROP, and Dr. R. N. Mathur Oration from Gujarat State Ophthalmological Society, 2012. He has also won many Best Paper and Best Poster awards at AAO, USI, VRSI, state meetings and AIOS. He is among a select few to be invited as a faculty to both the uveitis and retina subspecialty meetings by AAO and to the Vail Vitrectomy Meeting. He is a member of the International Uveitis Society Group (IUSG) and the Chief Liaison leader for AsiaPacific Region to the International Affairs Committee of ASRS. Dr. Banker has published 48 papers in international and national peer-reviewed journals and has written eight book chapters. He has given over 500 guest speaker presentations and over 100 instruction courses at national and international conferences. alay.banker@gmail.com

INDUSTRY UPDATE

Julius Müller-Albinus Joins Geuder AG

arlier this year, Julius MüllerAlbinus joined Geuder AG as head of innovation management and strategy. In this role, Mr. Müller-Albinus is responsible for establishing sustainable innovation processes, realizing management projects to foster innovation, and expanding strategic partnerships — with the overarching objective of not

only shaping the company’s future, but also contributing to the further development of ophthalmic surgery.

with comprehensive expertise in actively positioning the company and expanding our market position,” said CEO Volker Geuder.

Mr. Müller-Albinus has years of experience in leading medical technology companies. “He has profound market, product and user knowledge in the field of ophthalmic surgery, and he will support us

“The innovation management will identify, assess and implement opportunities, even more so against the backdrop of changed regulatory requirements,” shared Mr. MüllerAlbinus.

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NTERIOR SEGMENT COVID-19 SPECIAL REPORT

Ophthalmologists Face ‘Grim Sight’

Amid the Coronavirus Pandemic by Sam McCommon

t’s no secret that the coronavirus pandemic has affected every single sector of the economy, and mostly for the worse. This includes the medical field — and ophthalmology. While hospitals and other clinics are feeling overwhelmed, ophthalmologists are feeling a different sort of pinch. To discuss the effects of the coronavirus on ophthalmic clinical practice, we spoke with Dr. Sudhir Singh from Rajasthan, India, and Dr. William Trattler, from Miami, Florida.

COVID-19’s Impact on Ophthalmic Business All over the world, the pandemic has had a major impact on businesses, with customers and patients opting to stay away from clinics and all elective surgeries cancelled. According to Dr. Trattler, “We have scaled down our 15 ophthalmology

and three optometry practices to just a few doctors, seeing only urgent and emergency patients. We have halted all elective surgery. Those (doctors) seeing patients are wearing PPE,” he shared. “It has been a dramatic shift in our practice in just a week, but something that we needed to do to try to keep as many people home as possible to limit the spread of COVID-19.” In India, it’s no different. “The coronavirus has impacted business very badly in India also,” shared Dr. Singh. “Elective surgeries were suspended as of two weeks ago and will remain suspended until April 15, 2020, as India is under lockdown. Only emergency services are open in eye hospitals.” Dr. Singh also pointed out that expenses have not dropped. Doctors still have plenty of bills to pay. “There is no business, but expenses like staff salaries, house taxes/rents, electricity

bills, every month installments (EMI), annual maintenance contract (AMC) fees and other expenses are on as usual,” he said.

Understanding Patients’ Behavior Of course, people everywhere are anxious and scared — and many are wary of even leaving the house, much less venturing out for treatment. Dr. Trattler confirmed this sentiment among his patients. “Patients are concerned, and even if we were to allow non-urgent patients to come for their visit — most, if not all, would prefer staying at home right now.” The anxiety is universal. “Patients are concerned about falling ill due to corona infections,” said Dr. Singh. “They are following the measures taken by our government, like cooperating in our three-week

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NTERIOR SEGMENT COVID-19 SPECIAL REPORT national lockdown by staying at home and practicing social distancing and good hygiene.”

COVID-19’s Toll on the Ophthalmic Industry Imagining the world after the coronavirus pandemic is like trying to guess what’s in a snow globe just after it’s been shaken. Some time will need to pass before the picture becomes clearer. What is clear now, however, is that there will most certainly be longterm effects from the pandemic over the coming months and years. “The foremost effect is on the country’s economy,” said Dr. Singh. “It is going to be affected very badly. It will have a cascading effect on the industry, employment, salaries and patients’ paying capacity. So a patient may change their health priorities in the form of delaying elective procedures, and going for economical procedures rather than expensive procedures.” Dr. Trattler also shared his uncertainty: “It is so hard to know at this time,” he said. “I am hopeful things will get back to normal once a therapy is confirmed, or the crisis ends. I am unsure if this will be weeks or months. My main concern is that even when there is news that the crisis is over, there will still be patients who are concerned and not willing to go out.” The future of the economy will play a huge role in the future of the ophthalmic industry, as well as all others. But in this industry, they’ll affect those who have committed the most financially. In Dr. Singh’s words: “These (economic) factors will affect those who have invested in expensive technologies and big eye hospital setups more.“ It wasn’t all roses in Dr. Singh’s neck of the woods before the virus spread to India, either. “The industry was already suffering from the worldwide economic slowdown and all businesses were facing various problems. The coronavirus pandemic is a terrible blow to an already sick industry,” he said.

optimism for the future. “The Indian government has handled the situation quite well and taken all stringent measures, such as putting our 1.3 billion population under national lockdown. We have suspended all modes of international, national, state and city passenger transportation to contain the corona pandemic,” he noted. He continued: “Despite all this, the next three weeks are going to be very crucial for India. The impact on the Indian economy will be decided by how this coronavirus pandemic is going to affect the Indian population. So far, there has been a fear of a further slowdown in the industry but there is no panic. Each and every sector is following the directions and initiatives taken by our government.”

Contributing Doctors Dr. Sudhir Singh is a world-renowned ophthalmologist. He completed his MBBS and SMS, M. S. Ophthalmology from Medical College Jaipur and he was trained in pediatric ophthalmology and strabismus by Orbis International. Dr. Singh has been an invited speaker and performed live surgeries at various national and international conferences. He has intratunnel phacofracture (MSICS technique), SquintMaster software and many other innovations to his credit and more than 30 national and international publications to his name. Dr. Singh is an ophthalmologist, a medical writer, a reviewer of national and international journals and an instruction course evaluator AIOS. He also is a computer programmer and has designed and developed ophthalmology software and websites. Dr. Singh is currently the senior consultant and head of the department at JW Global Hospital Research Centre, Mount Abu. drsudhirsingh@gmail.com

A Silver Lining to the Coronavirus Crisis Despite the dread and gloom that has filled the news, a silver lining remains to this cloud. For many, there’s been a re-evaluation of priorities — as well as more time to spend with those closest to them. “This coronavirus pandemic will teach many positive lessons to each individual, family, society and nation,” said Dr. Singh. “It will change the perceptions of all aforementioned. The individuals will re-think about the priorities regarding personal life, family life and professional life, and will adjust time spent on each judiciously. They will also learn to differentiate between minimum basic life requirements and luxuries. They will also learn to accept the things they can’t change, and they will have the courage to change the things they can. Finally, families will learn to give quality time to each other,” he shared.

A lot will change in the next several months, and especially in the near future. Dr. Singh does hold out cautious

Dr. Trattler echoed Dr. Singh’s views on family. “The one positive aspect of this situation has been more family time,” he observed. “People are connecting with friends, and most are spending more time than ever with their families. So, there is often a silver lining — and hopefully spending time with family can help reduce stress levels,” he concluded.

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Dr. William B. Trattler is a refractive, corneal and cataract eye surgeon at the Center For Excellence In Eye Care in Miami, Florida, USA. He performs a wide variety of cataract and refractive surgeries, including PRK; all laser LASIK; no injection, suture-less cataract surgery; as well as laser cataract surgery. He has been an investigator for next-generation technologies (like the Tetraflex accommodating intraocular lens) and procedures like corneal collagen crosslinking (CXL). His involvement in the FDA-approval study for CXL led to its approval in 2016. In addition to his private practice, Dr. Trattler is on the Volunteer Faculty at the Florida International University Wertheim College of Medicine, as well as the University of Miami’s Bascom Palmer Eye Institute. He is board certified by the American Board of Ophthalmology and has been an author of several articles and abstracts. In 2016, Dr. Trattler received the Catalyst Award in Advancing Diversity in Leadership from the Ophthalmic World Leaders (OWL), an association of interdisciplinary ophthalmic professionals dedicated to driving innovation and patient care by advancing diversity in leadership. wtrattler@gmail.com

Editor’s Note: A version of this article was first published online at cakemagazine.org — where we continue to publish digital content.

NTERIOR SEGMENT OCULAR SURGERY RISK FACTORS

The Critical Conundrum Managing Ocular Surgery Patients on Antithrombotics by April Ingram

s we enjoy increased life expectancy and the baby boomer generation continues to age, the proportion of global citizens over the age of 65 is growing faster than the overall population — with worldwide estimates reaching two billion by 2050. Meanwhile, millions of ocular surgeries are performed each year in this subgroup of patients, with cataract extraction topping the list. One challenge faced by surgeons is that these patients are becoming increasingly elderly, and most are receiving care for significant comorbidities or prevention of future medical events. Many are already on antithrombotic agents to reduce the risk of thromboembolic and atherothrombotic events, especially in those with atrial fibrillation, recent stroke or myocardial infarction.

The Role and Effects of Aspirin in the Elderly Preventatively speaking, a recent survey conducted in the United States found that 52% of individuals between 45 and 75 years were taking aspirin for primary prevention of cardiovascular events.1 “It’s just aspirin... No big deal. What harm could it cause?” A 2019 study in JAMA by Zheng et. al., found that although daily aspirin use was associated with an 11% lower risk of cardiovascular events, 1 in 200 people (with no known history of cardiovascular disease) would experience a major bleed.2 So, yes — taking aspirin is a big deal. Although antithrombotic drugs, like aspirin, are unquestionably effective in

reducing the risk of cardiac events, these drugs may also predispose patients to hemorrhagic complications during ocular surgery. In 2011, Oh and colleagues published a study on antiplatelet use in patients undergoing vitreoretinal surgery. And while only 14.6% of patients were on antiplatelet therapy in 1993, the number rose to nearly a third (32.3%) by 2008 — a trend that’s likely to continue into the current decade.3 Discontinuation of antithrombotic treatment in the perioperative period might seem like a valid solution. However, this decision can spike the patient’s risk of a thromboembolic event with potentially catastrophic consequences.

Understanding the Guidelines for Risk Management In a recent issue of Eye, Drs. Makuloluwa, Tiew and Briggs from St. Paul’s Eye Unit, Royal Liverpool University Hospital, U.K., dissected current literature to better understand how ophthalmic surgeons are approaching these complex cases. This paper provides a thorough overview of antiplatelet and anticoagulant agents and mechanism of action, and reviews current guidelines of management in the peri-operative period.4

After establishing the drug therapy that these patients may be receiving, Makuloluwa and co-authors conveniently detailed the implications of each agent on various methods of anesthesia and ocular procedures. Interestingly, although published guidelines exist that make recommendations for risk assessment and management of patients on antithrombotic medications undergoing surgery, a survey of U.K. ophthalmologists reportedly found that 40% were unaware that such guidelines existed. Let’s be clear: Even though they were not aware of the guidelines per se, the vast majority were very comfortable with antiplatelet management of their patients — although variability in management, especially pertaining to patients on warfarin or direct oral anticoagulants (DOACs) existed.

A Clear Pathway for Managing Patients on Antithrombotic Agents According to Dr. Chelvin Sng from the National University Hospital in Singapore, “clear guidelines in the perioperative management of ophthalmic patients on antithrombotic

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NTERIOR SEGMENT OCULAR SURGERY RISK FACTORS agents are certainly welcome and should be applied discriminately to each individual patient.” Based on the extensive literature search and analysis of available data, Makuloluwa et. al., have kindly, and likely painstakingly, completed the hard work for us. They’ve developed a proposed pathway for the perioperative management of patients on antithrombotic agents — specific to ophthalmic patients and procedures. Surgical procedures have been categorized into low-risk (e.g., subTenon cataract, strabismus, corneal or lid lesion removal) and high-risk (e.g., any vitreoretinal procedure, glaucoma surgery, per-retro bulbar anesthesia, temporal artery biopsy or more extensive oculoplastic procedures). Each of the low- and high-risk categories provides guidance for managing patients on antiplatelet therapy or anticoagulants, specific to either warfarin or DOACs. Dr. Sng shared further: “The risk of thromboembolic events for each patient must be weighed against the risk of hemorrhagic complications, with the decision on whether to stop antithrombotic agents made after consideration of the clinical, as well as non-clinical factors, such as the patient’s preferences.”

The Importance of Getting Accurate Patient History A key piece to effective management is getting a complete picture of the patient’s history. Patients might not think that aspirin is noteworthy, or how a clot in their leg a decade ago and the medication for it applies to their upcoming cataract surgery. Or maybe they tell you about their prescribed anticoagulant — but leave out that they don’t always take it as indicated.

antiplatelet therapy (DAPT), which surpasses that of anticoagulants. Elective ophthalmic surgeries with a high risk of bleeding should be deferred until it is safe for the patient on DAPT to discontinue one of the antiplatelet agents,” Dr. Sng explained. The management plan from Makuloluwa proposes that all patients undergoing ocular surgery, high- and low-risk, “omit their dose of DOAC for two days preoperatively, and re-start one to two days postoperatively, if adequate hemostasis is achieved.” The guidance for antiplatelet and warfarin use varies between the low- and high-risk surgeries. For glaucoma surgery (classified in the paper as high-risk), Dr. Sng suggested the following: “Besides stopping antithrombotic agents in the perioperative period, other ways to reduce the risk of sightthreatening hemorrhagic complications associated with glaucoma surgery include preoperative anti-VEGF intravitreal injections for eyes with rubeotic glaucoma, and the avoidance of significant perioperative IOP fluctuations.” As for managing antithrombotic risks associated with anesthesia type, Makuloluwa concluded that all antithrombotic agents be continued for routine cataract surgeries performed under topical or subTenon’s anesthesia. For sharp-needle anesthesia, surgeons should avoid dual antiplatelet therapy; patients could continue their warfarin if the international normalized ratio (INR) was within the therapeutic range.

All About Mitigating the Risks

“It is also important for clinicians to note the risk of sight-threatening complications associated with dual

But are surgeons looking for guidance? An algorithm for management? As mentioned, a surprising 40% of surgeons were unaware of the guideline’s existence. A 2017 survey from the British and Eire Association of Vitreoretinal Surgeons (BEAVRS) found that the majority of respondents would not suspend antiplatelet administration (93% for aspirin; 82% for clopidogrel), and 79% would not stop warfarin before vitreoretinal surgery.5

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The more we know, the better prepared we can be to avoid potentially hemorrhagic complications. Getting all the details and coming up with a perioperative plan is time well spent.

Therefore, it is advisable to know the patient and their medications, and then plan the surgery and how to mitigate any risks. “In any case it is important to consider the indication for antithrombotic agents and the risk of thromboembolic events, as well as the risk of hemorrhagic complications, depending on the patient and surgical factors,” concluded Makuloluwa and co-authors.

References: 1

Williams CD, Chan AT, Elman MR, Kristensen AH, Miser WF, Pignone MP, Stafford RS, McGregor JC. Aspirin use among adults in the U.S.: Results of a national survey. Am J Prev Med. 2015;48(5):501-508.

Zheng SL, Roddick AJ. Association of Aspirin Use for Primary Prevention With Cardiovascular Events and Bleeding Events: A Systematic Review and Meta-analysis. JAMA. 2019;321(3):277-287.

Oh J, Smiddy WE, Kim SS. Antiplatelet and anticoagulation therapy in vitreoretinal surgery. Am J Ophthalmol. 2011;151(6):934-939.

Makuloluwa AK, Tiew S, Briggs M. Peri-operative management of ophthalmic patients on antithrombotic agents: a literature review. Eye (Lond). 2019;33(7):1044-1059.

Patel R, Charles S, Jalil A. Antiplatelets and anticoagulants in vitreoretinal surgery, with a special emphasis on novel anticoagulants: a national survey and review. Graefes Arch Clin Exp Ophthalmol. 2017;255(7):1275-1285.

Contributing Doctor Dr. Chelvin Sng is a glaucoma consultant at the National University Hospital in Singapore. She completed her glaucoma fellowship at Moorfields Eye Hospital and was named as one of the “Top 50 Rising Stars” on the global Ophthalmology Power List in 2017. Assoc. Prof. Sng has a special interest in glaucoma drainage devices, including minimally invasive glaucoma surgery (MIGS) devices. She is the convenor of the Asia-Pacific Glaucoma Society (APGS)MIGS Interest Group, and has conducted training courses on MIGS at the ESCRS and APAO meetings. She is also the co-inventor of the Paul Glaucoma Implant, which has attained CE mark and is currently undergoing international clinical trials. She has served in less fortunate communities which have little or no access to healthcare, and she volunteers regularly in medical missions to the less accessible areas in Southeast Asia, India and Africa. In her leisure time, she enjoys traveling, reading and spending quality time with her two sons. chelvin@gmail.com

NTERIOR SEGMENT OCULAR TRAUMA

The Lowdow n on

Managing Ocular Trauma by Joanna Lee

or the roughly two million people worldwide who are blind due to trauma, incidences vary widely. Among them, corneal perforations account for 53-82% of eyesight losses. During the National Symposium on Ocular Trauma, held in conjunction with the 78th Annual Meeting of the All India Ophthalmological Society (AIOC 2020), specialists discussed a wide spectrum of trauma cases and shared their expertise on handling these injuries.

The Role of Aesthetics in Eyelid Trauma “Aesthetics is not a minor consideration — it has bearings on how a person faces the world,” said Dr. A.K. Grover in his talk about “Challenges in the Repair of Eyelid Trauma.” Main topics included managing repairs to lacerations and marginal wounds and identifying levator injuries. He also covered suturing and reinsertion techniques, as well as tips for managing canthal and canalicular injuries. In regard to levator injuries, Dr. Grover said: “Whenever there is a fat prolapse, it should be identified as a possible levator and it should be put together with Vicryl sutures.” He emphasized that medial canthal injuries are of particular importance, as they can lead to deformities. Therefore, repairing the posterior crus of the medial canthal tendon is critical — and it should be repaired with 4-0 double

armed prolene sutures. “At other times, if there’s a complete avulsion, you might need to do a microplating,” he continued. Dr. Grover then showed traumatic eyelid deformities that resulted from inadequate or delayed repair. To manage these cases, he offered tips from his personal repertoire of repairs. This included: handling marginal misalignment, eyebrow malposition, corrections to the telecanthus, canthal repositioning, and traumatic ptosis. As he concluded his presentation, Dr. Grover’s dedication and passion for this area of expertise was clear. “Management of traumatic eyelid deformities can be extremely gratifying... it restores both function and aesthetics — and it can help transform lives,” he shared.

Techniques in Managing Corneal Scleral Lacerations Usually, ocular trauma cases occur at night and at odd times — so, it’s not always possible to evaluate and plan surgical management in these cases. According to Dr. Rajib Mukherjee, in his presentation on “Corneal Scleral Lacerations,” surgeons should be prepared for all eventualities in these cases. There are several types of corneal tears, namely: perpendicular tears, shelved lacerations, stellate lacerations and complication-related stellate

lacerations. In these cases, Dr. Mukherjee said: “Any manipulation within the anterior chamber should never be done from within the wound, but from the side port.” To suture the wound, there should be equal size bites from either side with a 90-95% depth; knots should also be buried away from the visual axis for good wound alignment. For shelved-beveled lacerations, he warned that applying perpendicular lacerations techniques on this type of laceration would result in bad alignment, poor healing and astigmatism. Instead, good alignment of the anterior and posterior edges is needed with unequal bite size sutures. He also recommended using Eisner’s technique with a 10-0 monofilament nylon suture for complicated stellate laceration, among other tips on globe rupture and corneal perforation surgical repair principles.

A Novel Treatment Option for Traumatic Optic Neuropathy Treatment for traumatic optic neuropathy (TON) remains controversial, with no clear solutions. At the symposium, orbital surgeon Dr. Kasturi Bhattacharjee shared her novel approach: Using stereotactic navigationguided transcaruncular orbital optic canal decompression on 52 cases, which reported positive results — even in PL negative patients. She has also used this navigation for complex orbital fracture patients. For maxillary correction, she explained that she uses technology to estimate how much correction is needed. Dr. Bhattacharjee said that “the navigation system helps surgeons align with the basic surgical principle of ‘get it right the first time’.”

Practical Tips in the Management of Various Ocular Trauma Meanwhile, in managing traumatic vitreous hemorrhage, IOFBs and retinal detachment, Prof. Dr. S. Natarajan said that it is his practice and philosophy

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NTERIOR SEGMENT OCULAR TRAUMA sticks, stones and blunt objects. In these patients, he said: “Avoid hydrodissection, low flow parameters, slow motion phaco. Anticipate posterior capsule rupture (PCR) and consider bimanual vitrectomy.”

A Perspective on WarRelated Eye Injuries Finally, the last segment offered an interesting perspective on “War Injuries: Nuclear, Chemical and Biological Warfare scenario,” with Army Ophthalmology Senior Consultant Maj. Gen. JKS Parihar outlining chemical, biological, radiological and nuclear (CBRN) incidents. If nuclear explosion happens, radiation effects would be limited to a 10-20km radius, with retinal burns around the 16.7km radius and flash blindness occurring within 5.9km from the epicenter. Besides these ocular injuries, optic nerve injuries from shockwaves could be present. Primary blast injuries could include lid burns, closed and open globe injuries with foreign bodies (from flying debris), radiation induced cataract and radiation retinopathy.

that eyes with no PL vision should also undergo a primary surgery — even when the anatomical success is estimated to be less than 1%. He reminded the audience of the principles of eye trauma management: “Kuhn rightly advised that there’s no trial-and-error basis”, said Dr. Natarajan, emphasizing the need for speed and accuracy during emergencies. In a segment on “Acute Chemical Injuries Management.” Dr. Rajesh Sinha started off with practical first aid steps. This involves irrigation for 30 minutes to stabilize the pH, with litmus papers ready to touch the cul-de-sac (five minutes after irrigation has ceased). The procedure should be repeated until the pH is at 7.

thorough than Roper-Hall’s, as it helps determine limbal ischemia at 360, 300 or 275 degrees. Dr. Sinha also explained how amniotic membrane transplantation, combined with medical therapy, provides greater pain reduction and promotes early epithelialization in patients with moderate grade burns (but not in severe burns). The discussion on chemical burns continued with Dr. Bhaskar Srinivasan’s talk on “Management of Sequale of Chemical Injuries.” He covered 12 cases of visual rehabilitation using keratoprosthesis after tenoplasty.

When grading the severity of injuries, he said that the Dua classification is more

“Anticipating the worst” was the take home message from Prof. Dr. Mohan Rajan’s “Challenging Traumatic Cataract Cases” talk. He highlighted several severe injuries involving fireworks, shuttlecocks, cricket balls,

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He also addressed eye injuries from biological and chemical warfare (nerve agents). He advised that health facilities must be 40-50km away from the cities (this is because fallouts usually occur in cities). He concluded that Ringer’s lactate can be used if city waters are not available for pH stabilization.

Editor’s Note: The 78th Annual Conference of the All India Ophthalmological Society (AIOC 2020) took place from 13 to 16 February in Gurugram, India. Reporting for this story also took place at the AIOC 2020. Media MICE Pte Ltd, CAKE magazine’s parent company, was the media partner at AIOC 2020.

COVER STORY

Ophthalmologist’s Opus

The Art of Patient Counseling by Brooke Herron

ost people agree that art is subjective. Each individual decides whether or not they like a particular work of art. And that there is no right or wrong way to appreciate it. On the other hand, in ophthalmology, conclusions regarding a surgeon’s “masterpiece” can be both objective and subjective. Objectively, visual acuity (VA) improvements and intraocular pressure (IOP) changes can be measured, while OCT and other images can clearly show the progression from before to after surgery. These are the facts of the procedure. Where the lines blur — and where art meets ophthalmology — is in the subjective

outcomes. Patients and their feelings, opinions and satisfaction following a procedure can influence overall clinical outcomes, even when the objective measures are positive. Consequently — and while not diminishing the importance of objective results — it is important that surgeons go beyond the science of ophthalmology and delve into the subtle art of enhancing subjective results. Like an errant brush stroke, insufficient patient counseling can disrupt the bigger picture. Therefore, of the different factors that color a patient’s attitude, we take a closer look at counseling and how more information — and a better doctor-patient relationship — can enhance overall results (and provide referrals!).

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COVER STORY

Artist: Dr. Sudhir Singh, Senior Consultant, Head of the Department at JW Global Hospital Research Centre, Mount Abu, Rajasthan, India Nickname: The Cezanne of Cataract

A Portrait of Preconceived Notions

“Patient counseling is an art that every ophthalmologist should learn. It helps avoid dissatisfied patients by resolving their preoperative doubts and misconceptions.”

Thanks to the Internet, we don’t have to travel to the Louvre to see the Mona Lisa. With a simple Google search, we can see hundreds of images of her slyly smirking face. Patients, like art aficionados, also use Google. But instead, they search for symptoms, treatments, results and more. This information — be it correct or not — can influence their expectations, and thus, resulting satisfaction.

Dr. Sudhir Singh said that this can make his job challenging. “Patients often come to a physician after gathering information on the Internet, or from an advertisement,” he shared. “They have lots of information about the disease and treatment modalities — some of it are good, some of it are junk.” Therefore, during each patient counseling session, he learns what the patient already knows about disease, treatments and outcomes, as well as their expectations. For example, in a cataract patient, Dr. Singh said he would listen to the patient and try to understand what he or she knows about

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cataract, the surgical options and types of intraocular lenses (IOLs). “I also try to assess what the patient’s expectations are about the procedure,” he said.

With this background, he then informs the patient about the disease, available modalities and course of treatment, risks and benefits, impact of comorbidities and the approximate cost. For a cataract patient, Dr. Singh said he also discusses the risks and benefits of the procedure, as well as the pros and cons of the various IOLs. “Then I tell the patient about the pre-, intra- and postoperative events,” he shared. He said this step is crucial to the patient’s understanding of the procedure, as well as to alleviate their doubts, misconceptions or fears. “After the counseling session, both the patient and relatives are well-informed about the procedure, its clinical outcome, treatment duration and cost,” he said. “This helps them make an informed decision for undergoing the procedure and making necessary arrangements at their homes and offices. They also know the total treatment cost, so they can make financial arrangements before admitting.”

Artist: Dr. Suhil Thakur, Clinical Research Fellow, Singapore Eye Research Institute (SERI) Nickname: The Picasso of Patient Counseling

Drawing Improved Subjective Outcomes “Seeing is beautiful... and so is taking care of sight. And similar to the art canvas, fine movements can have large effects in the eye.”

“Seeing is beautiful... and so is taking care of sight. And similar to the art canvas, fine movements can have large effects in the eye.”

Unfortunately, in ophthalmology, objective outcomes don’t always align with the patient’s subjective results. Dr. Suhil Thakur said this happens quite often with patients implanted with multifocal lenses who are not properly counseled. “There are many patients who end up with 20/20 vision, but who experience poor contrast sensitivity, glare and significant halos,” he explained. These postoperative visual effects can greatly impact the patient’s opinion of surgical success. “Another group of patients where you see this phenomenon are those who end up with inadequate near or intermediate vision,” continued Dr. Thakur. “Thus, providing proper counseling and limiting preoperative patient expectations can be extremely gratifying for early career surgeons and their patients.” Alio et. al. discovered similar results in their 2017 overview of multifocal lenses.1 While they noted most patients are pleased with the surgical result, common problems like blurred vision and photic phenomena, among others,

decreased satisfaction with the overall outcomes.

To avoid patient dissatisfaction after multifocal IOL implantation, the authors suggested that “it is important to consider preoperatively the patient’s lifestyle; perform an exhaustive examination including biometry, topography and pupil reactivity; and explain the visual expectations and possible postoperative complications”. Dr. Thakur also said that surgeons should explain all the available treatment options to patients before performing interventions that could easily be avoided. “After the success of the EAGLE trial2, a lot of surgeons, especially in India, are considering early lens extraction for the angle closure disease spectrum,” said Dr. Thakur. The authors of the EAGLE trial found that “clear-lens extraction showed greater efficacy and was more cost-effective than laser peripheral iridotomy (LPI) and should be considered as an option for first-line treatment”. As a result, several patients have consulted Dr. Thakur for a second opinion. “I’ve seen several patients in 35-45 age group where one eye has had lens removal and the other eye is planned within a month,” he explained. “These patients have documented early

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COVER STORY

sclerosis, 20/20 vision, normal IOP, mild iridotrabecular contact and healthy optic nerve heads (ONHs) — and they could have been managed with an LPI and/or conventional follow-up.” Ensuring that patients understand their options helps build trust, and therefore, can increase satisfaction.

When all Else Fails... Document In some cases, patients demand things that just aren’t in their best interest. “There have been cases where the patient wanted the best lens possible — such as a multifocal or toric lens. They’re counseled but refuse to accept the doctor’s opinion and end up with poorer vision from existing glaucoma or peripheral lasered proliferative diabetic retinopathyPDR),” said Dr. Thakur. “Today, patients are consumers and these cases can potentially become legal headaches,” he cautioned. To avoid this, he recommended that doctors perform meticulous eye examinations, create excellent documentation, and a take multi-step approach to patient counseling. “This can help make sure that you’re safe if lawsuits happen.” Dr. Singh agreed: “Most of the litigation, or medico-legal cases, usually happen due to poor counseling or documentation.” Documentation, along with counseling, can also help turn a dissatisfied patient into a happier one. Dr. Singh had a young male patient who was not satisfied after having an “excellent” strabismus surgery. Preoperatively, the patient and his relatives were counseled about the procedure and its expected outcome, with Dr. Singh documenting each step along the way. “After the operation, the patient’s eyes were well-aligned objectively, but the patient was not satisfied with the results of the operation. He wanted his eye to be the same as before the operation,” explained Dr. Singh. “In this case, we provided three counseling sessions before the operation, and each session was documented and signed by patients and relatives. We showed

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him the pre- and postoperative photos and counseling documents.” Using this documentation, Dr. Singh was able to convince the patient that he had an excellent surgical outcome. “Three sessions of counseling in the presence of relatives, wellsigned documentation by both the patient and relatives saved us. And, finally, he turned out to be a happy and satisfied patient.”

Different Strokes for Different Folks Like paintings in a museum, every patient is unique. According to Dr. Thakur, recognizing these differences and using a personalized counseling approach can help improve patient satisfaction. “Counseling can make or break your experience with a patient,” said Dr. Thakur, adding that counseling strategies can differ widely among countries. “There is a considerable difference in how counseling is approached in a country like India (where often only residents or doctors counsel), versus more service-oriented Singapore (where there is multi-level counseling with trained counselors, nurses and doctors).” Differences between countries, as well as individual culture, socioeconomic, religious and financial concerns are important to consider when counseling a patient. And as Dr. Thakur said, “there are no universal counseling guidelines to adopt as a ‘prescription for all’”. In addition, simple procedures can need as much (or in some cases, more) counseling as complicated ones. “At times, I have had to counsel patients undergoing an intraocular pressure assessment for a longer duration than some patients undergoing a pars plana vitrectomy (PPV) or a keratoplasty,” said Dr. Thakur. He emphasized further: “Recognizing this fact — and making sure you see each patient as an individual with specific needs rather than just a number — is the key to having satisfied patients. The results you promise before the procedure are another vital determinant,” he said. “Always under-promise and over-deliver! That makes everyone happy.” And happy patients, carrying their positive

Contributing Doctors subjective impressions, can not only boost outcomes — but business as well.

The Value of Subjective Outcomes Subjective impressions are also a valuable marketing asset. Satisfied patients often tell others about their experience. And these wordof-mouth referrals can have a big impact on the bottom-line. Dr. Singh said that word-of-mouth referrals are important both to him and to his hospital. “I’ve been with my hospital for 21 years, and I’ve never advertised my services or my hospital,” he explained, adding that their main focus remains on patient counseling. “Proper preoperative counseling has the potential to help patients prepare for surgery and increase their satisfaction with the entire process.” He also makes sure to keep commitments to patients, whether it be the cost of treatment or its results. “In other words, we ‘walk the talk’,” said Dr. Singh. “In my opinion, it makes a positive impact on the patients and their relatives if they get what they’re promised. Then they spread positive word-of-mouth about me and my hospital.”

Dr. Sahil Thakur is a clinical research fellow for the Ocular Epidemiology Research Group in Singapore Eye Research Institute (SERI). He completed his residency at Government Medical College, Chandigarh, India, and has collaborated with his mentor Dr. Parul Ichhpujani on several projects, including a book on the usage of mobile phone applications in ophthalmology, called Smart Resources in Ophthalmology, by Springer. Dr. Thakur has special interest in bridging the advancement in mobile computing with practical applications in everyday ophthalmology practice.

drsahilthakur@gmail.com

Dr. Sudhir Singh is a world-renowned ophthalmologist. He completed his MBBS and SMS, M.S. In Ophthalmology from Medical College Jaipur and he was trained in pediatric ophthalmology and strabismus by Orbis International. Dr. Singh has been an invited speaker and has performed live surgeries at various national and international conferences. He has intratunnel phacofracture (MSICS technique), SquintMaster software and many other innovations to his credit, and more than 30 national and international publications to his name. Dr. Singh is an ophthalmologist, a medical writer, a reviewer of national and international journals, and an instruction course evaluator at AIOS. He is also a computer programmer and has designed and developed ophthalmology software and websites. Dr. Singh is currently the senior consultant, head of the department at JW Global Hospital Research Centre, Mount Abu.

drsudhirsingh@gmail.com

References: 1

Alio JL, Plaza-Puche AB, Férnandez-Buenaga R, Pikkel J, Maldonado M. Multifocal intraocular lenses: An overview. Surv Ophthalmol. 2017;62(5):611-634.

Azuara-Blanco A, Burr J, Ramsay C, et al. Effectiveness of early lens extraction for the treatment of primary angleclosure glaucoma (EAGLE): a randomised controlled trial. Lancet. 2016;388(10052):1389-1397.

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‘Paints’ in the Palette of Patient Satisfaction

Improving patient’s subjective outcomes takes a multi-pronged approach, according to Dr. Thakur.

Doctors • Be the best version of yourself. • Obtain the best possible education and skills. • Know your limits: Even the best needs help sometimes.

Patients • Instead of simply prescribing, focus on healing. • Take time to talk to your patients — you never know what diagnostic leads you may get. • Under-promise, over-deliver.

Technology • Get the best possible equipment (that you can maintain) and leave room for upgrades. • Know your patients and their needs before you buy. • Maintain the equipment properly and keep spare accessories. • Know that faulty equipment can result in unsatisﬁed patients.

Marketing • Maintain a good social media presence: Remember if you can Google a diagnosis, the patient can also Google a doctor. • Engage with patients when you have a private practice (i.e., drug reminders, visit reminder emails/SMS, or birthday cards, etc.) • Don’t spam, but yes, everyone loves personal attention and good service.

“I know this may be unconventional, but with a rapidly changing healthcare horizon, if you want to sail the tides of competition, you need an 'unconventional' approach.”

Psychological • It doesn’t matter how good you are, there are going to be mistakes and unhappy patients sometimes. • Have a hobby or some activity that can recharge your batteries when everything looks bleak and dull.

“See the mistakes as stepping stones that can further improve your patient satisfaction numbers.” 22

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UDOS WOMEN IN OPHTHALMOLOGY

Bernie Ursell

A Passion for Eye Care Education by Chow Ee-Tan

ith an extensive career background in health and public relations, Bernie Ursell believes that her past experiences have ultimately led to her current role — and her calling — in the eye care industry. Based in Surrey in the south of England, Ursell is the director of communications and public relations for Allergan Eye Care. In this international role, she supports many key countries and covers internal communications, in particular, crisis communications. CAKE magazine caught up with the busy executive to get to know what it takes for women to thrive in the ophthalmology industry.

Looking Back at Nearly Two Decades of Experience Ursell’s connection with the eye care industry can be traced back to 2002, when she joined Bausch & Lomb and sub-specialized in eye care communications. “Prior to that, I worked in many therapeutic areas including cardiology, dermatology, oncology and even animal health,” said Ursell, who is married to consultant ophthalmologist Dr. Paul Ursell. “It was my husband’s boss who asked why I didn’t work in ophthalmology. He then facilitated the introduction to Bausch and Lomb and the rest, as they say, is history.” At Bausch and Lomb, Ursell worked as a medical writer alongside the communications director — which introduced her to medical education, across the company’s whole cataract

and refractive portfolio. She also worked at CIBA VISION for several years. Ursell’s mother was a nurse, which resulted in an early interest in healthcare. At the same time, writing was always one of her passions. “I also loved writing, so my ambition was to be a medical journalist. I was advised by the National Council for the Training of Journalists to obtain some kind of health training, so I moved to London to train as a nurse,” she shared. After that, Ursell continued to pursue her midwifery training at St. Mary’s Hospital, Paddington, before coming across public relations (PR), which helped fulfill her passion for both writing and health education. “As a stepping-stone into public relations, I worked as a pharmaceutical sales representative in the south of England, which provided valuable insight into the industry,” she added.

A Passion for Journalism and Healthcare From sales, Ursell eventually moved on to her first PR job at an agency in London. She had experience dealing with over-the-counter eye care products but she mainly specialized in neurology and cardiology. “My training as a nurse and midwife means that I have a good understanding of all the systems in the body and many disease areas, making my job significantly easier,”

she said. “From public relations life, I moved to in-house roles and spent around five years working as a freelance medical writer and journalist.” Ursell added that her experience as a freelance journalist has provided deeper understanding of what the media needs, what makes a great story, as well as its constraints. “Having a medical background helps with the technical and human aspects of my job. I spent 10 years as a healthcare professional and I can put myself “in the shoes” of our audience. I know very well what life is like in outpatients, in the wards and operation theatres,” she shared.

Finding a Sense of Belonging with the Right Company Eye care has always been — and remains — a key part of Allergan’s business. Over the last 70 years, the company has launched 125 eye care products and invested a huge amount of resources in new treatments for prevalent eye conditions, including glaucoma, ocular surface disease and retinal diseases, such as diabetic macular edema and retinal vein occlusion. From the very beginning, Allergan has worked in close partnership with ophthalmologists. The company’s first ophthalmic product — an antihistamine eye drop to treat allergic conjunctivitis — was first produced as a nose drop, but following the advice of an ophthalmologist, it was reformulated to become an eye drop and became the first product to treat the condition. Ursell is proud to work for a company

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UDOS WOMEN IN OPHTHALMOLOGY Hospital Samarjhola, Odisha, which was set up to provide qualitative and affordable eye care to the needy population of the Ganjam District and its surrounding areas.”

A Partnership in Life and Profession

that also supports patient advocacy groups and where possible, involves them in the company’s educational activities. “Our focus is very much on healthcare professionals as we deal in prescriptiononly products, which means we don’t engage directly with patients,” explained Ursell. To her, Allergan has made an important impact on ophthalmology, including education. “It is good to belong to a company that understands the business and ophthalmologists’ needs and constraints,” said Ursell. Working for a company that focuses on medical education — with content that is developed by doctors, for doctors — is another big plus for me. “Taking this approach, our education is about stimulating debate and discussion in a way that resonates and matters to ophthalmologists.” Ursell also pointed out that in 2018, the U.K. Royal College of Ophthalmologists conducted a census to identify gaps in the recruitment of ophthalmologists and workforce planning, amid a predicted 40% increase in demand over the next 20 years. “The results clearly showed that workforce capacity is a critical issue in the U.K.,” she said. “The report highlighted the assumption that ophthalmology is mainly cataracts and minor conditions. However, most ophthalmic patients have chronic lifelong diseases such as glaucoma, macular degeneration and diabetic retinopathy.”

At the Forefront of Programs with Social Impact Ursell also leads Allergan’s social impact program: Keep Sight, a multiyear initiative to tackle avoidable blindness from glaucoma in underserved populations. The initiative believes that ensuring screening, early diagnosis, and appropriate treatment is essential to help prevent vision loss. “In countries where resources, training or healthcare infrastructures are lacking, healthcare professionals struggle to help those most at risk,” shared Ursell. “Through our global Initiative, and in partnership with Sightsavers and the International Agency for the Prevention of Blindness (IAPB), healthcare professionals in low-and middleincome countries will receive essential training to screen, diagnose and deliver specialist care to help prevent glaucoma-related vision loss in high-risk populations,” she added. Allergan has two pilot programs underway in Nigeria and India. Sightsavers leads and implements the programs and works with local healthcare systems to strengthen them, as opposed to setting up parallel programs. Both programs are underway and making an impact with Sightsavers ophthalmologists. These pilot programs will eventually become blueprints for other countries. Ursell attended one of these community camps in a very remote and poor part of India, which proved to be a humbling experience for her. “Sightsavers has partnered with the Sankara Eye

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Ursell feels that being married to an ophthalmologist has been “extremely useful” to her career. “Not least because my husband provides tremendous technical support, but also because through him, I have “lived through” all the training, studying and applying for jobs. So, I have a pretty good understanding of the life and trials of an ophthalmologist,” she mused. “We hang out with a lot of ophthalmologists, so I get to regularly hear about the incredible impact of their work on their patients’ lives,” she added. “I also get to hear what they really think about the important issues happening in the world of ophthalmology. All of which helps me with my job to ensure that we truly meet their needs,” she concluded.

Contributor Bernie Ursell is the director for communications & public relations, Eye Care, at Allergan. Based in Surrey, United Kingdom, she has more than 20 years of experience in medical communications both in the U.K. and internationally. Armed with nursing and midwifery distinctions from St. Mary’s Hospital, Paddington, Ursell began her career as a pharmaceutical sales representative. For more than a decade, she took on different roles — from account executive to account director and communications manager to communications consultant in several international agencies and eye care companies. Ursell was communications manager at Bausch & Lomb for six years, communications consultant at CIBA Vision for three years, and senior communications consultant at MSL Group for two years, where she executed medical writing for major pharmaceutical brands. In May 2015, she joined Allergan as corporate affairs & PR manager, and took on the role of eyecare lead before assuming her current post in October 2018. Ursell_Bernadine@allergan.com

UDOS VOLUNTEERISM

Dr. Ian Yeo

On a Mission to Train Rural Ophthalmologists by Chow Ee-Tan

ith his expertise in retina and his passion for education, Prof. Dr. Ian Yeo is an integral team member of the ORBIS volunteer faculty’s training programs. Together with other industry experts, they travel to rural areas in China and around Asia to train rural ophthalmologists in the detection, management and treatment of sight-threatening eye disease. While he primarily focuses on retina, Dr. Yeo, senior consultant at Singapore National Eye Center (SNEC), has also participated in humanitarian trips to China, Vietnam, Laos and Myanmar to assist at cataract camps. His first trip with ORBIS was in 2017 to Shenyang, China. Dr. Yeo said that this particular one-week trip was special: During that visit, the new ORBIS airplane was unveiled, stocked with the latest diagnostic and audiovisual equipment for giving lectures and performing live surgeries. The ORBIS volunteer program is fortunate to have some of the world’s leading ophthalmic experts, including ophthalmologists, nurses, anaesthesiologists and biomedical engineers, from over 30 countries. These experts share their professional skills by providing ongoing training and support to eye care teams around the world. For Dr. Yeo, his main role is training young ophthalmologists to identify and treat retinal disease.

“The ORBIS programs generally take place in thirdtier cities, away from the bright lights and resources of the bigger cities. This is where there are many people in need of care,” shared Dr. Yeo.

The Importance of Training the Trainers The program in Shenyang was a focused endeavor to provide training to local doctors. Dr. Yeo gave lectures to ophthalmologists, nurses, medical students and allied health professionals, and showed these trainees the latest diagnostic tools (when available) on the ORBIS plane. “We were there to help the local doctors,” shared Dr. Yeo. “I worked with one or two doctors at a time to optimize their hands-on skills. But there was also a large team of local senior and junior ophthalmologists who joined to observe and to be trained.” Basically, the volunteers’ role was to help local junior and senior doctors learn to better manage patients. “Most importantly, we worked with the trainees to optimize the equipment and therapeutics in their own clinics. We also touched on screening and telemedicine to help improve in these areas,” added Dr. Yeo.

Prior to the ORBIS team’s arrival in Shenyang, the local doctors screened patients. This allowed for additional tests to be performed and provided time for discussion. “The local Chinese ophthalmologists often failed to pick up symptoms in the early stages, thus diagnosis and treatment were delayed. But after training, they were equipped with the necessary skills and knowledge to notice these symptoms and provide prompt treatment — thus, lowering chances of blindness,” said Dr. Yeo.

Taking Every Opportunity to Help While there, volunteers also spent time seeing patients. Dr. Yeo recalled a case that involved a young diabetic man with severe bleeding in both eyes. “The patient was operated on by an earlier team but was not doing well. I managed to redo the case and helped save at least one of his eyes,” he shared.

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UDOS VOLUNTEERISM It’s clear that such programs truly make a difference, with the philosophy: “Give a man a fish, and you feed him for a day. Teach a man to fish, and you feed him for a lifetime.” “The local ophthalmologists were very eager to have the opportunity to learn from experts from around the world,” said Dr. Yeo, who is still in touch with his previous trainees. Together, they continue to share knowledge and discuss cases over emails or WeChat. “This means the learning never stops,” he said. “It is an ongoing effort in rural areas where education can make a difference, along with the availability of healthcare.”

A Passion for Ophthalmology and Volunteerism In 2018, Dr. Yeo was also the primary ophthalmologist in another ORBIS volunteer program in Linyi, China. He said there are more serious eye cases in fourth-tier cities with limited medical resources. “The majority of the population there lacked knowledge and true understanding of diabetes, which is a lifelong disease that damages blood vessels, resulting in blindness,” he shared. He said there are many misconceptions about diabetes in the more rural parts of China. Patients do not seek eye care until their vision starts to drop. They will only come forward for treatment when more severe symptoms appear. According to Dr. Yeo, diabetes is the predominant problem in China, where a large number of patients require laser treatment (as it is the more affordable option). However, laser is a preventive measure that slows down the disease, but it does not correct the underlying problem. At the training, Dr. Yeo asked the ophthalmologists to review angiogram and optical coherence tomography (OCT) for diabetic conditions. He also taught them to use B-scans and how to apply a systematic way of categorizing all the scans for future references and records.

Dr. Yeo, training the trainers

Dr. Ian Yeo is passionate about ophthalmology as he is about volunteering.

Dr. Yeo at work

Photos courtesy of ORBIS Singapore and Dr. Ian Yeo

Another problem in Linyi was the lack of trust in doctors by the local patients. He said this can be improved by better public education and training. This is necessary so that moving forward, there will be better traction and acceptance of the medical workers. Dr. Yeo believes that despite the great scientific and medical progress in China today, there are still areas where ORBIS has a role to help. “Most facilities and trainings are done in primary, first-tier cities. Going to outer cities in China allows us to bring knowledge and technology to the doctors there. It is useful to be able to bridge some of these gaps,” he added. Dr. Yeo feels that it’s in places like Linyi where they can really help. “We hope that more and more rural patients receive quality eye care done in an ethical and evidence-based manner. The program had also opened up avenues for the doctors who have potential to go further, by giving them opportunities to do more for the rural folks in outer China,” he shared.

Funding and Donations Go a Long Way While volunteers can give their time and expertise, there is a real cost to provide medical training and equipment. “I am thankful for work done by ORBIS and their staff with the volunteer faculty,” said Dr. Yeo.

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Donations from the public also ensure that there are enough resources to continue this meaningful work. “No kindness will go unnoticed and we will be rewarded in many ways. I’ve been truly blessed from the experiences I’ve had, the friends I’ve made and the patients I’ve helped. I urge everyone able to help to experience this, too,” Dr. Yeo concluded.

Contributing Doctor Dr. Ian Yeo is a vitreoretinal surgeon with the Singapore National Eye Centre Retina Service. He manages both medical and surgical retinal patients in conditions such as age-related macular degeneration, diabetic eye disease and retinovascular conditions. He is also the deputy medical director and academic vice chair in charge of education and in charge of all training of medical personnel, including nurses, allied health professionals, and doctors starting from medical school to fellowship. Dr. Yeo is passionate about training the next generation of ophthalmologists and is actively engaged in their clinical practice and cataract training. He is also involved in humanitarian work in places like China, Vietnam and Myanmar. His contribution to training doctors in Singapore (and around Asia) is Dr. Yeo’s way of “paying it forward” for the training that he, too, had received in the past. ian.yeo.y.s@singhealth.com.sg

NLIGHTENMENT COVID-19 SPECIAL REPORT

Apart but United Fighting the Coronavirus Pandemic by April Ingram

s we rang in 2020 — a new decade, full of optimism — few of us could have predicted the ways in which the world would change in just a couple months. Admittedly, I had never heard the term “social distancing” until a couple months ago. At the time of writing, there aren’t many countries left untouched by the COVID-19 pandemic. However, this could also be a result of under-testing and under-reporting. And as of May 11, the number of cases in the United States surpassed that of all other nations... a tally that continues to change daily.

COVID-19: What We Need to Know Let’s get the terminology correct: The novel coronavirus, referred to as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was previously known by the provisional name 2019-nCoV. The highly contagious virus is what causes the severe respiratory disease known as COVID-19. This is not our first global experience with a coronavirus — SARS and MERS (Middle East respiratory syndrome) are also types of

coronaviruses. The current SARS-CoV-2 is an enveloped, single-stranded RNA virus — and although it appears to be not quite as fatal as the SARS or MERS coronaviruses, there have already been a significant number of global fatalities with more than 95,000 deaths worldwide at press time. Currently, the primary intervention is preventing the spread of COVID-19 by controlling infections. Public health authorities are carefully monitoring the situation to learn more about this novel virus and its associated outbreaks, so that we can better respond to the situation.

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NLIGHTENMENT COVID-19 SPECIAL REPORT For the most part, citizens are compliant with the social distancing guidelines. People have become diligent handwashers who stay at home when possible. Companies have established plans for teleworking, and the population has adapted to the cancellation of events. A challenge is teasing the facts from the myths (and fears) — and as members of the medical community, finding the time to provide accurate information, while being overwhelmed by caring for those that need help.

Innovation and Solidarity Amid a Pandemic The rapid spread of the virus has led to an extraordinary situation: Acute hospitals have been confronted with a massive influx of patients. Initially, this was absorbed by the restricting elective procedures and transferring patients to less intensive levels of care, to make ventilator-equipped beds available to those with the most dire need. Some countries have not yet seen their infections peak and have insufficient resources. Rationing decisions have become necessary, placing considerable burdens on medical staff. As an example, ventilator sharing is becoming more common. In an effort to address the lack of resources, companies that typically manufacture things like cars have transitioned their production lines into ventilator assembly. Manufacturers of sporting equipment are now making masks and gowns to protect front-line healthcare staff. And distilleries that were producing spirits for our favorite cocktails are making and distributing alcohol-based hand sanitizer. Be it necessity or desperate times that breed innovation, either way, these are important and valued initiatives.

Symptoms can appear as soon as two days, or as long as 14 days, after exposure. Severe complications include pneumonia. In a study published in the Annals of Internal Medicine on March 10 by Dr. Lauer and colleagues at Johns Hopkins, they found that the mean incubation period for SARS-CoV-2 was 5-7 days. More than 97% of those who developed symptoms did so within 11.5 days of exposure. This study further supports the current 14-day quarantine recommendations.1 Current understanding about how COVID-19 spreads is based largely on what is known about other similar coronaviruses — primarily person-toperson, through respiratory droplets produced when an infected person coughs or sneezes. There is also evidence it can spread from surfaces touched by an infected person, then touched by another person who then touches their mouth, nose or eyes. Viral RNA has also been found in stool samples from infected patients, raising the possibility of transmission through the fecal/oral route. As you wash your hands, consider a recent study from the New England Journal of Medicine, in which researchers detected viable SAR-CoV-2 in aerosols up to three hours postaerosolization. Although the study was performed in a laboratory Goldberg

Understanding COVID-19’s Symptoms, Incubation and Transmission COVID-19 patients typically present with respiratory illness, including fever, cough and shortness of breath. Conjunctivitis has also been reported.

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drum, which lacked ventilation and may not necessarily reflect virus behavior in the real-world, they found that the infectious virus survived up to 24 hours on cardboard, up to 4 hours on copper, and up to 2-3 days on plastic and stainless steel.2 The U.S. Center for Disease Control (CDC) identified SARS-CoV-2 RNA (not necessarily indicating infectious virus) on various surfaces within cruise ship cabins of passengers who tested positive up to 17 days after they had disembarked from the ship. Asymptomatic transmission is also a real concern, as detailed in a Feb. 21, 2020 report in JAMA. They describe a case of an asymptomatic carrier who potentially infected 5 family members despite having a normal chest CT.3 Notably, Dr. Li Wenliang, an ophthalmologist from Wuhan Central Hospital — who is recognized as the physician that originally sounded the alarm on the virus — believed that he was infected by a glaucoma patient who showed no symptoms. Dr. Li passed away on Feb. 7, 2020.

A Look at the Coronavirus’s Comorbidities Lancet Respiratory Medicine recently published a review of studies of the most distinctive comorbidities of

patients hospitalized with COVID-19.4 Xiaobo Yang and colleagues in Wuhan, China, reported that of 32 non-survivors (from a group of 52 intensive care unit patients), 22% had cerebrovascular diseases and 22% had diabetes.5 Similarly, findings from Zhang et. al., also from Wuhan, noted that 30% of COVID-19 hospitalized patients had hypertension and 12% had diabetes.6 Guan et. al. also published their study in the New England Journal of Medicine, which described 1,099 patients with confirmed COVID-19, 173 of whom had severe disease with comorbidities of hypertension (23.7%); diabetes (16.2%); coronary heart diseases (5.8%); and cerebrovascular disease (2.3%).7

A Race Against Time to Develop Vaccines and Treatments Currently, there is no vaccine to prevent infection. Trials for a mRNA coronavirus vaccine began enrolling patients on March 5, 2020 at Kaiser Permanente Washington Health Research Institute in Seattle, Washington, and at Emory Childrenâ&#x20AC;&#x2122;s Center in Decatur, Georgia, U.S. At this time, there are no proven agents for prophylaxis or therapy for SARSCoV-2. Remdesivir, a novel antiviral, nucleotide analog, developed by Gilead Sciences as a treatment for Ebola and Marburg virus infections, has shown activity in vitro and is currently in clinical trials. Chloroquine, approved for malaria, and hydroxychloroquine, approved for autoimmune disorders, are under investigation for the treatment of

COVID-19. However, it is very important to understand that the proposed doses being studied exceed the maximum daily dose considered safe for long-term therapy, as described an Asia-Pacific Vitreo-retina Society working group. Until more is learned about the toxicity associated with current regimens, decisions should be made on an individual basis, taking into consideration any pre-existing retinal disease. Unfortunately, members of the public have accessed chloroquine and/or hydroxychloroquine in efforts to self-medicate or prevent the virus, and several overdose-related fatalities have occurred since the conversation began. Also, shortages of these drugs have become apparent for patients that rely on them for prescribed treatment of autoimmune disorders.

Eye Safety: Coronavirus and Ophthalmology Recommendations for ophthalmologists during this pandemic have been

published by the American Academy of Ophthalmology. They highlight several reports that suggest the virus can cause mild follicular conjunctivitis, otherwise indistinguishable from other viral causes, and possibly be transmitted via aerosol contact with conjunctiva. Patients who present to ophthalmologists for conjunctivitis who also have fever and respiratory symptoms, including cough and shortness of breath, could represent cases of COVID-19. Protection for the mouth, nose and eyes when caring for patients potentially infected with SARS-CoV-2 is highly recommended. Current evidence supports that the virus causing COVID-19 is very likely susceptible to the same alcohol- and bleach-based disinfectants that ophthalmologists commonly use to disinfect ophthalmic instruments and office furniture. Disinfection practices to prevent officebased spread of other viral pathogens are recommended before and after every patient encounter.

References: 1

Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, Azman AS, Reich NG, Lessler J. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med. 2020 March 10.

van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, Tamin A, Harcourt JL, Thornburg NJ, Gerber SI, Lloyd-Smith JO, de Wit E, Munster VJ. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 2020 March 17.

Bai Y, Yao L, Wei T, Tian F, Jin DY, Chen L, Wang M. Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA. 2020 February 21.

Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med. 2020 March 11.

Yang X, Yu Y, Xu J, et. al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020 February 24.

Zhang JJ, Dong X, Cao YY, et. al. Clinical characteristics of 140 patients infected by SARS-CoV-2 in Wuhan, China. Allergy. 2020 February 19.

Guan W, Ni Z, Hu Y, et. al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 February 28.

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NLIGHTENMENT OPHTHALMIC BUSINESS

International Companies

‘Eye’ the Indian Market by Brooke Herron

he numerous international exhibitors in attendance at the 78th Annual Conference of the All India Ophthalmological Society (AIOC 2020) in Gurugram made it clear that the Indian market is receiving global attention. One such exhibitor was CIMA Technology, a U.S.-based intraocular lens (IOL) and visco-surgical device manufacturer that maintains a longterm relationship with India. Vice President Dan Mattson said that CIMA’s President & CEO, Dr. Jash Sharma’s family, has had a charity hospital in India for the last 30 years and was also one of the first to manufacture an IOL in India. Another exhibitor was Germanybased OCULUS, which manufactures ophthalmic diagnostic devices, and has started to include more educational and concentrated events in India. Richard White, Managing Director for OCULUS Asia, said that India is a growing market for them: “It’s one we definitely see as emerging, and it’s a younger market, too.”

that they also feel pressure from some of the larger, international companies.

To learn more, CAKE magazine spoke with executives from CIMA and OCULUS to discuss the opportunities and challenges of doing business in India.

reach into the rural areas of India. “We’ve been able to find distributors in some of the more remote areas, so that’s definitely helped our business,” he continued. “We expect another substantial increase in 2020. So for us, it’s booming.”

Business Status

Overcoming Challenges

However, the flipside to a challenging, competitive market brings forth new product opportunities. “Many companies here are coming out with new products, so we are also thinking of coming out with a new, premium IOL,” said Mr. Bhardwaj.

According to CIMA India Director Deepak Bhardwaj, India is rapidly growing for foreign business. “We’ve been in India for a number of years, and in the last few years we’ve actually seen a drastic increase in business,” added Mr. Mattson. He attributes some of this growth to CIMA’s

For CIMA, one of the biggest challenges as an international company is the domestic competition. “For domestic products that are manufactured in India, their manufacturing cost is much less than ours in the United States,” shared Mr. Mattson. “So, we compete with that on a daily basis,” he explained, adding

Mr. Mattson continued: “We’re a small company based in Pittsburgh, so we’re competing with the domestic suppliers here, as well as some of the international ones. But we do have a niche in the market, we have good clientele who want a US-made product and who also want an alternative to one of the larger companies.”

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For its part, OCULUS has also experienced challenges in navigating the Indian legal and political system. According to CEO Christian Kirchhübel, the challenging legal environment coupled with political inconsistency impacts business conducted in India to a certain degree, which can be especially difficult when conducting long-term business. Mr. White added that importation costs, like customs and associated fees, are also a challenge. “These are the fees imposed by the government for imports and to be involved in the market,” he said. “Even though it’s a large market with high volume, there is an import cost.”

Brooke with Oculus’ Richard White and Christian Kirchhübel

Opportunities for Growth in Remote Areas Mr. White of OCULUS sees the Indian market as an opportunity to enhance education. “We need to bring this education that we have from other territories, from other markets and from other doctors, to help expand here,” he said, adding that they hope to build on the current education platform and help Indian universities spread knowledge to other parts of India. “This is where the opportunity lies,” he added. “If we can provide that education, we can raise the level of everyone’s understanding.”

domestic suppliers here as well,” he explained. “We’re trying to streamline the manufacturing process and reduce our costs, while maintaining the same level of quality.”

Increasing access to education across India goes hand-in-hand with providing treatment to patients in rural areas. “There’s a big opportunity to go to the remote areas where people may wait a little longer than necessary for cataract surgery,” said Mr. Mattson of CIMA. “It’s a life-changing operation for them — they’re more beneficial to their family, maybe they can work again.”

Of the different OCULUS products available in India, Mr. Kirchhübel said that while the Pentacam has done the best, there has also been growing interest in their biomechanical devices. “These will help us to further improve the security and safety of refractive surgery,” he explained, adding that they plan to own a bigger stake in glaucoma as well.

Selling Well in India CIMA sells both of its two products, IOLs and visco-elastic, in India. Mr. Mattson said that both products sell well in India. However there are challenges in pricing — especially for the visco-elastic. “It’s challenging to get it to an acceptable price here because we have

Brooke with CIMA’s Dan Mattson and Deepak Bhardwaj

The Myopia Master from OCULUS was also launched in India at AIOC 2020. The Myopia Master is the world’s first device that combines all the necessary measurements for managing myopia. The device then creates a myopia report for each patient, helping with education. “This [Myopia Master] is tailored to help young kids to stay away from myopia, which is a growing epidemic,

especially in Asia,” said Mr. Kirchhübel. Additionally, he said their dry eye system [Keratograph 5M] has also been gaining traction. Overall, he concluded that in spite of the challenges faced, they find India to be an impressive country — both for travel and business.

Editor’s Note: The 78th Annual Conference of the All India Ophthalmological Society (AIOC 2020) took place from 13 to 16 February in Gurugram, India. Interviews and reporting for this story were conducted at AIOC 2020, prior to COVID-19 pandemic. Media MICE Pte Ltd, CAKE magazine’s parent company, was the media partner at AIOC 2020.

| May 2020

NLIGHTENMENT COVID-19 SPECIAL REPORT

Young Ophthalmologists’ for Surviving the COVID-19 Toolkit Pandemic Lockdown by Gloria D. Gamat

ocio-economically, the world may be on a stand still due to the coronavirus pandemic. But in the medical world, healthcare workers are being called to the frontline as the world goes to war against COVID-19. The magnitude of the problem, obviously, is something that we have never seen before. While governments and healthcare systems worldwide scramble to properly handle the issue, doctors (practitioners and medical students alike) are being called in to fill the manpower shortage. Ophthalmologists are not spared either. In India, even though ophthalmic clinics are not seeing regular patients and only emergency cases will be attended to, young ophthalmologists have been called to help with COVID-19 patients in overwhelmed hospitals. Speaking at a webinar organized by the Young Ophthalmologists Society of India (YOSI) in collaboration with Entod Pharmaceutical (Mumbai, Maharashtra India), Dr. Annu Joon, assistant professor, Dr. Baba Saheb Ambedkar Medical College, New Delhi, India, and executive committee member of YOSI, shed light on her experience on the frontline and shared necessary precautions and tips.

Dr. Joon emphasized that if social distancing and other quarantine protocols are important among the general public, the gravity of the matter is even more critical at the frontline (i.e. between a healthcare practitioner and patient, and between medical colleagues as well) where cross contamination is highly likely. “We need to be cautious at every step. Do not panic while on COVID-19 duty... greet each other with Namaste instead of a handshake,” she said.

Turn COVID-19 Lockdown into Ophthalmic Education On the other hand, if you find yourself staying at home (and with lots of time to kill), use the time to catch up on theory and practice with surgical videos, which can be found on various sites online according to Dr. Diva Kant Misra, vitreoretinal consultant at the EyeQ Super-Specialty Eye Hospital in Lucknow, India, and general secretary of YOSI. During his webinar presentation, Dr. Misra recommended various websites and other online resources that young ophthalmologists can check out during their own respective “quarantine or lockdown times.”

“All of us are facing this COVID-19 crisis and are all concerned not just about the contagion, but also about a lot of misinformation around us. Ophthalmologists are not immune to COVID-19, it has encompassed the medical community and fraternity in all aspects,” she shared.

Further, Dr. Kharan Bhatia, assistant professor and consultant, Regional Institute of Ophthalmology, Sitapur Eye Hospital, Sitapur, India, shared numerous outstanding websites that serve as repositories of ophthalmic surgical videos that young ophthalmologists can learn from — not only in terms of studying surgical

| May 2020

techniques, but also in creating surgical videos themselves. He also recommended tools and tricks (i.e. software and hardware) that are most suitable for this purpose. “The process starts with a good recording,” highlighted Dr. Bhatia. “You should shoot with editing in mind, like showing only the necessary steps and speeding/slowing the important sections,” he added. Practice makes perfect, he said, and it seems like the time of COVID-19 lockdown, now is the best time to accomplish just that. Speaking of time, the time that we have right now, according to Dr. Akshay G. Nair of the Aditya Jyot Eye Hospital in Mumbai, India, should be used positively. Time spent during COVID-19 lockdown should be spent with discipline: “Now, more than ever, is the time to optimize your social media presence and online marketing in ophthalmology,” he said, addressing the young ophthalmologists during the webinar. “Everything is online now, even choosing your doctor... and you have to market yourself and be responsive,” added Dr. Nair. From [creating] your website to social media, target your audience, he emphasized. “Instead of delving into politics on social media, better focus on your profession.” In addition, Dr. Nair reminded the audience that social media, when used properly, is a very productive marketing tool—especially for young ophthalmologists who are just establishing a clinical practice of their own. It’s the ophthalmologist’s clinical

Take a lesson from cats: Stretching is crucial if you’re going to lay around all day.

practice that is most severely hit by the COVID-19 pandemic—this is all happening now, in what is supposedly a peak practice season for eye doctors in India, Dr. Digvijay Singh, director and lead surgeon at Noble Eye Care in Gurugram, India, and the president of YOSI, reminded the webinar audience. “True ophthalmic emergencies are rare and infection rates in ophthalmologists create fear,” he said. Post-lockdown, noted Dr. Singh, would even be more challenging to young ophthalmologists especially. “Gearing toward a ‘new normal’ in a young clinical practice would be more difficult,” he shared. “It’s not that we cannot survive... just be positive. The world still exists and your prime focus should be your practice. Collaborate with other practitioners in your locality and maintain contact with your patients,” he advised.

Mental Health Matters Most While the first speakers delved into what young ophthalmologists can do to fully maximize the potential of the COVID-19 time on their hands, Dr. Soumya Nanaiah, cataract and refractive surgeon from Kodagu, India, saved the most important topic for last: physical and mental health during a lockdown! We’ve all seen how the general public went crazy on TikTok, heavily binged on Netflix and went overboard with

other ‘silly nonsense’ as displayed by social media and the internet, just to escape the elephant in the room that is COVID-19. At some point, young ophthalmologists and ophthalmic residents will eventually “get sick” of learning from or creating surgical videos and catching up on theory. After all, like the rest of the general public, they are humans too! “The COVID-19 pandemic brought with it an anxious and uncertain time,” said Dr. Nanaiah. Worrying about one’s family and friends while providing care for patients during a time of social distancing and self-isolation, can bring about stress and burnout, to say the least. “Having a lockdown routine that is closest to your normal routine would help,” she said. Starting an at-home exercise routine would be most helpful, she emphasized. “But, if you do yoga for example, do not compare yourself to what you see online. You don’t need to injure yourself in the process,” she advised. Also, comfort eating will get synonymous with stress eating in the time of COVID-19 lockdown. Dr. Nanaiah warned that we have to remind ourselves to eat right at all times, and that there is a difference between being hungry and being bored. “Get in touch with nature [even if you have a small garden or even just a balcony], avoid working in bed and obsessing over endless coronavirus coverage. Make use of technology to maintain

community and social connection,” she advised. Furthermore, Dr. Nanaiah emphasized that if you feel extremely anxious and you feel that you cannot function, seek out professional help. “Whatever your problems are, talk to your family and friends, to your peers and seniors... when people reach out to others, something good comes out of it. Do not fight this alone, we are all in this together. For most people this is a lockdown, but for us doctors, this is a war,” she concluded.

Editor’s Note: The YOSI Webinar, COVID-19: Toolkit for Young Ophthalmologists, was held on April 15, 2020, from 3.00 to 4.30 PM, India Standard Time. The live webcast was attended by 4380 participants across all platforms (webinar link and Facebook Live). As of April 20, the total views of the webinar video have reached 7500. Reporting for this story also took place during the live webinar. This story was first published online at cakemagazine.org — where we continue to publish digital content.

| May 2020

CONFERENCE HIGHLIGHTS ESCRS 2019 COVERAGE

Refractive Round-up SMILE Stays Strong by Hazlin Hassan

yopic patients undergoing refractive surgery have various sight-enhancing procedures at their fingertips, including SMILE (small incision lenticule extraction), LASIK (laser-assisted in situ keratomileusis), transPRK (transepithelial photorefractive keratectomy) and other topography-guided treatments. Each procedure comes with its own advantages and drawbacks, which makes patient selection crucial to optimum outcomes. Therefore, to help doctors and patients determine the most appropriate procedures, three experts shared their insights during a “Meet the Experts” session at the 37th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2019) in Paris, France.

Pain Avoidance and PRK The three main types of laser treatment for standard refractive correction are LASIK, transPRK and SMILE. And when it comes to transPRK, Dr. Rainer Wiltfang from Munich, Germany, discovered that patients have mixed feelings about the procedure’s comfort level.

“Is transPRK not a good solution for refractive surgery? I think it’s still an option, especially for low myopics to do this treatment. What we do is give 30-second ethanol on the cornea, after a while we do epithelial-rhexis with a sponge, then surface asblation,” he said of preparations for a normal PRK. Dr. Wiltfang said he did a normal LASIK on one eye on several patients, and transPRK on the other eye to find out what the differences were in terms of their experience during the procedure. He said some patients complained that the procedure using ethanol was very painful — but without it, it was comfortable. Others said that with the laser, the transPRK was very uncomfortable because of the smell. “So, we can’t see any huge difference between transPRK and normal classic LASIK in this small group at the moment. “What we see is more or less the same,” explained Dr. Wiltfang.

The Procedure of Choice SMILE is the first choice of procedure for Dr. Dan Reinstein, from the London Vision Clinic, UK.

| May 2020

“I want to tackle this question from a scientific standpoint. We are being told that for most myopic treatments, transPRK is the best option for patients,” shared Dr. Reinstein. “However, due to epithelial variability in patients, transPRK would increase the number of patients that are not corrected the way you intended,” he told the audience. “You cannot say transPRK is the procedure of choice for myopia. That is categorically incorrect.” As for topography-guided treatments, he said they are only used when it is necessary. SMILE is the primary choice in his clinic because they can use larger optical zones in the same cornea (that they would have used in the LASIK eye) to get less spherical aberrations. “The reason we can use larger optical zones is because the biomechanics are affected less. So, for the same biomechanical change, you can take out more tissue,” explained Dr. Reinstein. The advantages of SMILE include low impact on the corneal nerve plexus, less mechanical impact for equivalent tissue removal, a larger optical zone and reduced spherical aberration.

“From an optical standpoint, SMILE is superior,” he concluded.

SMILE: Here to Stay According to Dr. Joaquín Fernández, Qvision, Vithas Virgen del Mar Hospital, Spain, SMILE is now a mature procedure with 10 years of evidence. The first SMILE trial surgery was in 2007, followed by its market launch in 2011. “In 2014, a major part of our procedures was SMILE. From 2016, all procedures for myopia (≤ -7.0D) and myopic astigmatism (≤ 3.0D) have been conducted with SMILE,” Dr. Fernández shared. SMILE results improved from its development to early establishment stage — plus, outcomes of SMILE in low myopia have shown it to be safe and effective, similar to those previously reported for LASIK. Dr. Fernández added that in high myopia, both SMILE and LASIK

procedures are safe and effective. “But the stability at three years was better in SMILE,” he said. A prospective, randomized, contralateral eye study on “Functional Optical Zone and Centration Following SMILE and LASIK” concluded that SMILE created a larger FOZ (functional optical zone) than LASIK, despite the smaller programmed OZ (optical zone). This may be due to a difference in the biomechanical response between the two procedures. Visual outcome and centration were comparable between SMILE and LASIK. “We implemented SMILE in 2013, sharing half of our procedures with LASIK. In 2014, SMILE was completely established at our clinic. Our results have improved considerably from those years,” he shared. The take home message for SMILE? It is as safe, effective, predictable and stable as femtosecond LASIK (FSLASIK). Results are comparable for low, medium and high myopia, and the

use of nomograms can optimize the predictability. High order aberrations in SMILE are lower than FS-LASIK in major part of studies. Centration is comparable to LASIK and although there are negligible retreatment rates, several retreatment options are already available. “SMILE is here to stay,” concluded Dr. Fernández.

Editor’s Note: The 37th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2019) took place from September 14 to 18 at Pavilion 7, Paris Expo, Porte de Versailles, Paris, France. Reporting for this story also took place at the ESCRS 2019.

INDUSTRY UPDATE

China Approves Registration of First Glaucoma Device Based on Real-World Evidence

ecently, China’s National Medical Products Administration (NMPA) approved the registration of Allergan’s XEN® Gel Stent for the surgical management of patients with refractory glaucoma. This approval has perhaps signaled that China is working toward normality following its battle with COVID-19, but what’s also interesting is that the XEN Gel Stent is the first device approved based on real-world evidence. “We are honored that XEN has become the first medical product approved in China using real-world evidence,” said David Nicholson, EVP and chief R&D officer at Allergan. Real-world evidence is described as the “clinical evidence

regarding a medical product’s usage and potential benefits or risks from the analysis of real-world data.” This data can be generated by different study designs and analyses, including randomized trials. The “Real-World Evidence” pilot program was launched in Hainan in June 2019 through a partnership between the NMPA and the Hainan Provincial Government. For its part, Allergan teamed up with Hainan Boao Lecheng International Medical Tourism Pilot Zone to obtain permission to use XEN in clinical practice. This real-world data, combined with data from controlled clinical trials outside of China, facilitated

the XEN’s approval by the NMPA. The device is now approved in 32 countries for the surgical management of refractory glaucoma patients. It can be used in patients with primary open-angle glaucoma, as well as in pigmentary glaucoma with open angles that are unresponsive to maximum tolerated medical therapy; XEN can also be used in cases where prior surgical intervention was unsuccessful. “XEN has filled a gap in minimal invasive glaucoma surgery in China and provides a convenient, safe and effective treatment for glaucoma patients and doctors. We believe it will help advance the innovation and development of ophthalmology in China,” said Dr. Sun Xinghuai, chief of the Ophthalmology Department at the Eye and ENT Hospital of Fudan University, and Dr. Wang Ningli, director of the Ophthalmology Center at Beijing Tongren Hospital.

| May 2020

CONFERENCE HIGHLIGHTS ESCRS 2019 COVERAGE

Patient questionnaires can help determine patient satisfaction.

Managing an Unhappy

Pseudophakic Patient by Hazlin Hassan

hile the vast majority of pseudophakic patients are happy with the quality of vision following surgery, occasionally there are patients who are dissatisfied. To better manage these patients, renowned experts shared tips during a session at the 37th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2019).

When 20/20 Does Not Cut It

complications — sometimes even patients with 20/20 vision can be unhappy. “In Sweden, many ophthalmic departments take part in reporting postoperative data to the national cataract register (NCR),” said Dr. Maria Kugelberg of St. Erik Eye Hospital, Sweden. Around 10% of patients experience no benefits from surgery, according to reports from the Swedish NCR.

Although patients hope for perfect vision — and few (or no) surgical

“Based on questions posed to patients

| May 2020

from the preoperative stage to three months postoperative, 90.1% were satisfied, 2.2% were neutral and 7.7% were dissatisfied,” added Dr. Kugelberg. According to the reports, men were 1.3 times more likely to be satisfied with their vision than women. Patients without ocular comorbidity were 1.8 times more likely to be satisfied, while patients with a second eye surgery were twice as likely to be satisfied. Patients with ocular comorbidities reported higher incidences of dissatisfaction. Those with glaucoma

were twice as likely to be dissatisfied, while patients with macular degeneration were 2.8 times more likely to be unhappy. Meanwhile, patients with both glaucoma and macular degeneration were 5 times more likely to be dissatisfied. A survey of 1,239 patients also showed that the majority of patients (59%), did not obtain new distance spectacles postoperatively, while 41% did. A total of 68% said they could see well enough without glasses; 14% could see well with their old spectacles;13% said they planned to obtain a new pair; and 2% cited economic reasons for not purchasing new spectacles. Dr. Kugelberg concluded that if a patient had low disability or high visual acuity before surgery, the patient is “too healthy” and surgery can wait. On the other hand, if the patient has other eye diseases that make improvement unlikely, it’s also better to wait before scheduling surgery, as they are too sick.

What Makes Patients Unhappy? Prof. Konrad Pesudovs from the University of New South Wales in Sydney, Australia, and the Anglia Ruskin University in Cambridge, U.K., said that patients are usually concerned with 12 domains of ophthalmic quality of life. These are activity limitations caused by loss of vision and include: driving, ocular comfort symptoms, visual symptoms, general symptoms, emotional wellbeing, health concerns, convenience, social participation, economic concerns and coping. While cataract surgery aims to reverse these activity limitations, some 7.4% of patients still suffer from limitations after cataract surgery. Prof. Pesudovs concluded that the key question for new intraocular lens (IOL) design is whether or not the balance of near vision gains and the loss of quality of vision leads to patient satisfaction.

Properly managing visual expectations can turn an unhappy patient into a happy one.

All is Well Until the IOL Dislocates According to Tel-Aviv University Ophthalmology Prof. Ehud Assia, the late dislocation of a posterior chamber intraocular lens (PC-IOL), which occurs more than three months postoperatively, is not uncommon. There is increasing incidence for cases like this in older patients, due to a longer lifespan and longer follow-up. Cumulative incidence of late dislocation of PC-IOL was reported at 0.1% at 10 years, 0.2% at 15 years, 1.0% at 20 years, and 1.7% at 25 years. This shows that subluxation of a PC-IOL is not uncommon and may occur many years after implantation. Options include surgical management, changing the IOL or repositioning it. “Excellent results are usually achieved using modern techniques and instruments,” Prof. Assia concluded.

It’s All About Managing Expectations For some patients, the goal is perfection after surgery. But what does perfection mean? According to Dr. Beatrice CochenerLamard from the ophthalmology department at Brest University Hospital in France, this means spectacle independence at all distances and not even thinking about their eyes.

“Perfection does not exist,” she noted. “Neither does zero risk.” Therefore, it is important to inform the patient what each lens or surgical procedure is capable of achieving to avoid disappointment and create reasonable expectations. Before the surgery, the patient needs to know the advantages, limits and potential complications of the procedure. Sources of unhappiness can include inadequate visual acuity, double vision or multiple halos, ghost images, glare, photophobia, comet tails and dysphotopsia. These phenomena can be checked using questionnaires or with refraction, visual acuity, pinhole and/or slit lamp examination. In these cases, Dr. Cochener-Lamard suggested that patients wait for at least three months to allow for neuroadaptation and healing.

| May 2020

CONFERENCE HIGHLIGHTS AIOC 2020 COVERAGE

Latest Refractive Innovations In

the Spotlight

Dr. S. Natarajan, who led the Expert Session, explained that the ARTEVO 800 is completely different from traditional microscopes. For new users, it’s likely something they’ve never experienced before. He said that there is a bit of a learning curve for many first-time users. But once he used the 3D technology, he never used a conventional microscope again.

by Brooke Herron

During the 78th Annual Conference of the All India Ophthalmological Society (AIOC 2020) in Gurugram, Carl Zeiss Meditec (Jena, Germany) showcased its latest innovations with a series of Expert Sessions held on days two and three of the conference. Read on for expert insights into the latest technology.

Let’s Talk about SMILE SMILE (small incision lenticule extraction) is a sparkling gem in Zeiss’s crown. The refractive procedure is gaining traction not only for its predictable outcomes, but also for its flapless technique. According to SMILE expert Dr. Sourabh Patwardhan from Nandadeep Eye Hospital in Sangli, India, this is one of its biggest advantages. He said other benefits include the platform itself — and the fact that it’s a one-machine procedure. It also causes less dry eye and irritation postoperatively, which improves patient comfort. Dr. Patwardhan has more than four years of experience and around 600 SMILE procedures under his belt. “I’m quite happy with the procedure because my patients are happy and satisfied,” he said. “It has helped me in cases when LASIK (laser-assisted in situ keratomileusis) was not possible, like in dry eye or decentered pupil, as well as with a few pseudophakic refractive corrections.” With all of the positive attributes of SMILE, like any procedure, it does have some limitations. “We cannot do it for hyperopia or mixed astigmatism,” Dr. Patwardhan said. “Also, I don’t use it for very high cylinders, like -4 and above, because the predictability of vision is less. But of course, we can use the markers and do it for high cylinders,” he explained.

“Personally, I feel that this technology should replace conventional LASIK,” continued Dr. Patwardhan. “But due to the high cost involved, it is not possible. If the cost of the lasers goes down, it will spread the technology much further.”

Best of Class in IOLs If you ask Dr. Ashvin Agarwal from Chennai which intraocular lens (IOL) he prefers, the answer is easy. “Zeiss has the best IOL. It’s called CT Lucia and it’s a three-piece IOL,” said Dr. Agarwal, who led the Zeiss Expert Session on Glued IOLs.

“Some people have mental block that says, ‘No, you can’t use it’. But later I realized that everything has a learning curve. It just depends on your interests and passions,” continued Dr. Natarajan. “It is a change — and I think it’s a big change for the benefit of the patient.” Overall, he said the patient is first. “All technology should help the patient, not just the surgeon. But ultimately, in the year 2020, we want 20/20 vision or more,” Dr. Natarajan concluded.

“The idea behind the whole procedure is that you don’t have bag support, so you’re taking the haptics and externalizing them outside the eye,” he said, explaining the glued IOL procedure. “You tuck them [the haptics] under the flap inside the groove. To close the flap, you Dr. S. Natarajan use fibrin glue, which is made of tissue plasma.” His favorite thing about this lens? “The haptics are made of material called PVDF – which does not bend or break. Hence, it retains its memory,” Dr. Agarwal shared. Switching gears, he also commended Zeiss on the ARTEVO 800, which, according to him, “will change the way we do surgery”.

Heads Up with ARTEVO 800 As mentioned by Dr. Agarwal above, Zeiss’s ARTEVO 800 is a first-of-itskind digital microscope with heads-up 3D display. And it’s been receiving high praise around the industry for more than just its optics.

| May 2020

Dr. Sourabh Patwardhan

Dr. Ashvin Agarwal

https://2020.apvrs.org/

| May 2020

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magazine posterior segment • innovation • enlightenment

CAKE Magazine Issue 05: The ebook version ('The Art Issue', ASCRS 2020 Virtual Edition)

Articles inside

Experts’ Take on Preventing CME after Lens-Based Surgery

Ophthalmic Inserts, Promising Alternatives to Eye Drops?

Managing an Unhappy Pseudophakic Patient

Bernie Ursell: A Passion for Eye Care Education

Dr. Ian Yeo: On a Mission to Train Rural Ophthalmologists

Ophthalmologists Face ‘Grim Sight’ Amid the Coronavirus Pandemic

Apart but United: Fighting the Coronavirus Pandemic

Latest Refractive Innovations In the Spotlight