CAKE Magazine Issue 06: The ebook version (The 'Radio Show' Issue, WOC 2020 Virtual Edition)

THE WORLD’S SECOND FUNKY OPHTHALMOLOGY MAGAZINE

06

THE RADIO SHOW ISSUE June/July 2020 cakemagazine.org

Cover Story

CAKE ON AIR Ophthalmologists Shed Light on Today’s Crucial Industry Issues p18

The Next Generation

NEW Pentacam® AXL Wave The first device to combine Scheimpflug Tomography with Axial Length + Total Wavefront + Refraction + Retroillumination The new Pentacam® AXL Wave is a reliable partner for your refractive and cataract practice, creating the best prerequisites for surgery, based on pre-op metrics, and providing post-op measurements for reliable monitoring, in just one device ! With high-end hardware

and software for optimum treatment and satisfied patients, the new Pentacam® AXL Wave makes no compromises on quality.

!

Visit us at WOC!

IN THIS ISSUE...

Anterior Segment 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 Maricel Salvador

06

10

iTrack™ Ab-interno Canaloplasty A Novel MIGS that Reduces IOP and Preserves Tissue

12

A Lowdown on the Link between Conjunctivitis and COVID-19

16

Cataract

06 08

Latest Advances in Cataract Surgery Experts Tell All

Perioperative Infection Management in Cataract Surgery

Eye-Opening Webinar on Cataracts Demystifying ‘Nightmare’ Cases

Cover Story

18 CAKE Ophthalmologists Shed Light on Today’s Crucial Industry Issues

Kudos

Corporate Corner

Graphic Designer

PUBLISHED BY

24 Media MICE Pte. Ltd.

6001 Beach Road, #19-06 Golden Mile Tower, Singapore 199589 Tel: +65 8186 7677 Fax: +65 6298 6316 Email: enquiry@mediamice.com www.mediaMICE.com

SOCIETY FRIENDS

Quarantine Introspection Dr. Arun Gulani’s Two Cents’ Worth

Enlightenment

30 32

Insights from Europe Corneal Transplantations Amid the Pandemic Musings of an Ophthalmologist From Coronavirus Fellowship to the Dangers of Democracy

34 All India Ophthalmological Society

28

10 Things to Expect When You’re Expecting… a Digital Conference

Conference Highlights

36

ASCRS 2020 Pulls Off First-Ever Major Virtual Ophthalmic Conference

Ophthalmology Post-Pandemic A Glimpse Into the Future

38

First Time’s A Charm Israel Successfully Delivers First OIS Online

We are looking for eye doctors who can contribute articles to CAKE magazine.

Interested? Let's talk! Send us an email at enquiry@mediamice.com.

Ophthalmology Innovation Summit

To place an advertisement, advertorial, symposium highlight, video, email blast, or other promotion in CAKE magazine contact CEO Matt Young at matt@mediamice.com.

LETTER TO READERS

This issue of CAKE embraces the radio show concept and this delights me.

O

ne of my favorite things to do — when I get the office to myself — is ‘retune’ the office Sonos to LBC, a London-based talk radio station that has not so much ‘shock jocks’ but a cohort of highly opinionated, and rather controversial presenters that cover the extremes of political debate in the country, as well as the burning topics in the news each day.

reception (and on the slit lamps) — and mandate that face masks should be worn all-round. What was missing from the conversation is how to deal with the bigger problem: Clinics having to stop performing elective surgeries and only dealing with emergency cases; and where clinics are able to open normally, many patients are unwilling to come in for fear of contracting COVID-19.

And while I can shout at the radio in disagreement with some of the opinions being voiced (and nod along sagely when my own opinions are being reinforced), I realize that at least I’m being exposed to a wide spectrum of logic, rhetoric, and politics. And when the presenters turn to topics that aren’t intensely political, I usually learn something new along the way.

Things are starting to ease now that restrictions are being lifted — but there’s still a risk that a second spike in cases is coming. So, these problems might come back with a vengeance.

How will you cope the second time around, getting people the care they need, while at the same time not having a cash flow situation that will make the practice owner and bank manager weep? It’s about time we have a candid conversation about what we’re facing here, and how we are best able to deal with the challenges this situation — or the next pandemic — presents.

Understandably, most of the conversation on LBC is about COVID-19, and how the politicians in the U.K. are handling the situation. I hear many opinions, but not much in terms of hard facts. Few experts pop their heads above the parapet to give professional advice, and that’s something everyone really needs to hear now.

Everyone who works in eye care — from Li Wenliang onwards — knows the danger COVID-19 can cause in the clinic. We know that the danger comes from more than the fomites expelled by every breath a carrier takes; that the eye contains many ACE2 receptors that the virus uses to enter the cell; and that the conjunctiva is not only a conduit of coronavirus — it’s also a source of infection.

While it’s fairly simple to implement hand sanitizer and Perspex screens at

4

Given the situation we find ourselves in, does it make sense to invest for success? Will our patients invest in their own vision and pay for premium at the same rate as before? What is the next big thing we need to be aware of? Again, our intrepid editors, Gloria D. Gamat and Brooke Herron, ask the questions that need to be asked.

While our talk-show guests aren’t able to predict the future, their insight, opinions and predictions are the next best thing. I know that I over-research big financial and purchasing decisions before committing to them, and that input from those in a similar situation to me — or who have recently bought or committed to the item or action I was considering — is immensely valuable

| June/July 2020

in helping me make that decision. Talk radio, and the world in general, could do with more advice that comes from a place of expertise, not pure opinion.

But sometimes you need to let go of the spoken word and let thoughts of politics, finance and administration wash away. You need some music to focus… to relax… to enjoy.

Many surgeons have OR playlists to accompany them during surgery — and to give patients something to listen to while the procedure is underway.

If you have a playlist on Spotify, Tidal or Apple Music, why not share it with your fellow CAKE readers? We may be able to put them up on our funky new website — which I urge you to explore at your earliest opportunity (where you’ll see our show coverage of the online-only ASCRS and WOC congresses). Short of running an actual radio station, this is your chance to be the ophthalmology disc jockey you always dreamed of being, and good choices certainly earn you the “K” in CAKE: Kudos.

Dr. Mark Hillen

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

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

| June/July 2020

5

ATARACT SURGICAL INSTRUMENTS

Latest Advances in Cataract Surgery

Experts Tell All

by Tan Sher Lynn

A

t the recent annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS 2020), which was held virtually on May 16 to 17, the latest advances in cataract surgery were among the hot topics discussed — in particular, surgical systems, instruments and devices.

Below are some of the experts’ takes on these innovations.

Reducing occlusion break surge in cataract surgery Occlusion break surge during phacoemulsification (PKE) cataract surgery can lead to potential surgical complications. According to Dr. Kevin M. Miller from the David Geffen School of Medicine at UCLA in Los Angeles, USA, anterior chamber stability during cataract surgery is essential for patient safety and occlusion break surge risks this stability. Surge volume factors include PKE system (hardware), operating settings (software), and eye compliance.

In an experimental study, he and his colleagues characterized post-occlusion break surge volume (SV) with the Centurion Active Sentry peristaltic system (CAS; Alcon Inc., Geneva, Switzerland); Whitestar Signature Pro peristaltic system (WSP; Johnson & Johnson Vision, Jacksonville, Florida, USA); and Stellaris PC venturi system (SPC; Bausch + Lomb, Quebec, Canada), under varying intraocular pressures (IOP), vacuum limits (Vac), and aspiration rates (Asp).

6

To provide surgical measurements, a mechanical eye model that mimics the compliance of the human eye was used to imitate the anterior chamber volume-pressure change behavior.

Using this model, the SV of the systems was characterized at a Vac of 300 to 650mmHg, IOP of 30 to 80mmHg, and Asp of 20 and 40cc/min (the SPC does not have an Asp setting).

“We found that SV is heavily dependent on the phaco system used and its surgical settings,” shared Dr. Miller.

“CAS had a significantly lower surge volume at all surgical settings compared to WSP and SPC. CAS also had the highest level of case-to-case consistency compared to WSP and SPC,” he further explained.

Effects of torsional power during PKE Meanwhile, Dr. Santaro Noguchi from Saneikai Tsukazaki Hospital in Japan examined how torsional amplitude, sleeve type, tip type and IOP settings affect the intraocular perfusion supply.

He found that the infusion rate during PKE is greatly affected by torsional power (TP).

Using the Centurion Vision System (Alcon), the weight of BSS (balanced saline solution) Plus 500 (0.0184%) injected during torsional PKE was measured. He discovered that except for the balanced tip+ultra sleeve setting, all perfusion flow tended to decrease due to the influence of TP. In particular, in the case of TP with 80% or more, the decrease of perfusion

| June/July 2020

rate was remarkable. Dr. Noguchi concluded that the anterior chamber is likely to become unstable in cases requiring high TP, and suggested the use of the ultra sleeve especially for hard nuclei, and that it is better to raise IOP only when TP is high.

Maximum visual outcomes, minimum iatrogenic effects The goal of modern cataract surgery is to produce excellent visual outcomes while minimizing iatrogenic effects and improving procedural efficiency.

Dr. David M. Lubeck and colleagues performed a systematic literature review (SLR) to evaluate recent clinical evidence comparing safety, efficacy and efficiency of different PKE systems.

They searched through PubMed and EMBASE/MEDLINE databases to compare clinical efficacy and safety data for the Centurion Vision System versus other PKE systems. From 6,132 records, they identified 27 relevant articles and extracted data from eight articles comparing the Centurion and Infiniti Vision Systems (Alcon).

“While the Centurion Vision System maintains the excellent safety profile established by the Infiniti Vision System, results show that the Centurion

Vision System uses significantly less cumulative dissipated energy (CDE),” observed Dr. Lubeck.

“The reduction of CDE is associated with less endothelial cell loss (ECL) and corneal edema, and may translate to better visual outcome and patient recovery. Besides, the Centurion Vision System uses similar or less fluid volume and achieves shorter lens aspiration times than the Infiniti Vision System.

Superiority in these efficiency measures may result in reduced ocular trauma, quicker patient recovery and superior visual outcomes,” he added.

Advantages of a new laser capsulotomy device Dr. Erik L. Mertens, physician, CEO and medical director of Medipolis Eye Centre in Antwerp, Belgium, shared his early clinical experience of using the CAPSULaser (Excel-Lens, California, USA), a new selective laser capsulotomy (SLC) device, in routine cataract surgery.

The CAPSULaser is an SLC technique using a 590nm orange wavelength laser, which is selectively absorbed into a trypan blue stained capsule to create a perfectly sized, centered and circular capsulotomy.

“First, the CAPSULBlue (trypan blue 0.4%) is used to create a deep stain of the anterior chamber. It was left on for 60 seconds before washing off. Next is to position and focus the patient interface and laser on the anterior capsule. Then, the laser is activated and in one-third of the second, a 5mm circular capsulotomy is performed,” shared Dr. Mertens.

Dr. Mertens concluded that the CAPSULaser has an easy learning curve using standard techniques, and the workflow and surgery time of CAPSULaser are equivalent to conventional cataract surgery.

“The capsular edge created by the CAPSULaser is stronger than the one created by femtosecond laser-assisted cataract surgery (FLACS), due to the doubling of capsular edge thickness,” he shared. “This is because thermal changes of the anterior capsule

transformed regular ordered collagen type IV to amorphous collagen with increased elasticity. We also found that 100% of the CAPSULaser group have complete 360-degree capsulotomy coverage. In terms of economics, it is cost-effective, which means it will replace some FLACS systems and allow many smaller practices to adopt laser cataract technology,” he further explained.

Understanding corneal incision contracture Cataract surgery is accompanied by various issues, one of which is corneal incision contracture (CIC), where the heat from the phacoemulsification needle is transferred to the incision site, which may cause collagen contracture.

Nathan R. Jensen and colleagues of the University of Utah Health, USA, aimed to understand the role of an ophthalmic viscosurgical device (OVD) in heat, specifically at the site of incision, in a scenario where vacuum is present versus when vacuum is obstructed.

In the study, a thin membrane was placed on top of a chamber containing BSS. An OZil (Alcon) handpiece was placed into the chamber, piercing the membrane. Next, 0.1ml of BSS, Viscoat (Alcon), ProVisc (Alcon), DisCoVisc (Alcon) or Healon5 (Johnson & Johnson Vision, California, USA) were placed on top of the membrane with the temperature gauge, which recorded the temperature at time zero, 10 seconds, 20 seconds, and 30 seconds.

The authors found that in the absence of both vacuum and flow, each OVD/BSS had an average increase of temperature from baseline to 30 seconds of at least 6.88°C and an average difference of 8.34°C. “In the absence of vacuum, the average final temperature of DisCoVisc, Healon5 and Provisc was below that of the average final temperature of BSS,” explained Jensen. “In the presence of vacuum, BSS featured the greatest change from the initial temperature to the final temperature. Both parts of the study demonstrate the ability of temperature to rise even across a thin

membrane, though the presence of vacuum mitigated that rise,” he added.

Gaining confidence in proper use of new instruments Meanwhile, the new miLOOP (Carl Zeiss Meditec, Jena, Germany) is a micro interventional device designed to deliver low energy endocapsular lens fragmentation, mainly in dense cataract and complicated cases.

Dr. Matteo Piovella, president of the Italian Ophthalmological Society, and colleagues examined the use of miLOOP technology in 47 patients over 58-years-old with medium/hard cataracts.

In the study, the metal loop was inserted in the capsular bag and opened throughout the edge of the hydrodelineation line. Once the loop was in the proper vertical position, it was retracted to split the nucleus into two parts.

Dr. Piovella noted that a learning curve is involved in the adoption of the miLOOP technology and the device should be used in simple cases first to gain confidence and to avoid devicerelated complications. He added that in one case, the loop did not match the capsular bag and caused mild zonula damage with no significant event.

He concluded that miLOOP adoption in dense cataract and complicated cases reduces phaco energy by 50%, reduces I/A fluid use by 30%, and makes hard nucleus cataract removal more controlled and efficient.

Editor’s Note: ASCRS 2020 Virtual Annual Meeting — the world’s first-ever successful virtual ophthalmic conference — was held on May 16 to 17, 2020. Reporting for this article also took place during the virtual ASCRS 2020 conference, where CAKE magazine’s parent company, Media MICE, was the only exhibiting independent media.

| June/July 2020

7

ATARACT SURGICAL PEARLS

Eye-Opening Webinar on Cataracts

Demystifying ‘Nightmare’ Cases

by Sam McCommon

O

n April 23, Entod International Group (Mumbai, India), in conjunction with the Rajasthan Ophthalmological Society (ROS) and the Maharashtra Ophthalmological Society (MOS), held an eye-opening (literally and figuratively!) webinar featuring some truly impressive surgeries.

Top-notch surgeons presented difficult cataract cases, showing the advanced techniques they applied as well as the results delivered. The surgeries presented in the webinar were shown for a reason. They were complex, difficult cases that required creative techniques.

Indeed, the surgeries were classified as “nightmare” surgeries by the webinar.

Patients with complications, comorbidities, and other problems were featured along with the techniques surgeons used to treat them.

One of the presenters was Dr. Arun Gulani, founder of the Gulani Vision Institute in Jacksonville, Florida.

“It was a pleasure to be part of this webinar with some of the most stellar eye surgeons — who presented their most complex cases — as I shared my

8

concept to stop these situations, rather than succumb to these complexities,” Dr. Gulani said.

We caught up with the world-class doctor to talk about his presentation and the webinar in general, and how to demystify ‘nightmare’ cases that sometimes plague our surgeons.

1

There’s no such thing as a nightmare case.

One of the main takeaways from the webinar was Dr. Gulani’s exhortation on attitude — the psychological element that’s perhaps the most critical in the surgeon’s tool kit.

He said that by calling complicated cases ‘nightmare cases’, surgeons paralyze themselves and decrease expectations for the patient before the surgery even begins. “I don’t believe any case is a nightmare,” he said.

Once the term ‘nightmare’ had been redefined to mean ‘difficult’, he introduced his breakdown of just what it meant. “Now, what is a nightmare?”

| June/July 2020

he asked. ”It could be anatomical, which is the easiest to fix because it’s a surgical skill; refractive, which can be difficult; and psychological. So any nightmare you describe has to fall into these categories. There’s nothing else,” he shared.

Dr. Gulani continued: “I’ll break the psychological category further into patient and surgeon. The surgeon’s reaction to the situation is crucial. For example, Samresh’s video was excellent for the main reason that not only did he show calm and poise, he also did not back out of giving the patient the vision properly.”

He stressed that a surgeon’s attitude and demeanor are crucial in dealing with any complicated surgery and that no surgeon should accept anything less than a complete success.

In presenting a complicated case, for example, he pointed out a significant improvement in astigmatism for a patient. His main point was that he didn’t care how bad the astigmatism was — the goal was to fix the problem entirely. “I aim for everything,” he said.

2

Focus on the patient.

According to Dr. Gulani, a surgeon’s interaction with the patient is just as important as the techniques themselves. “Every patient deserves 20/20,” he said. “They trust you.” He stressed that doctors must get addicted to the outcome and not the surgery, and further encouraged doctors to create a positive ambiance for the patients to feel comfortable and welcome.

“How does the patient feel in your hands?” he asked.

As an example, he shared that a recent patient drove him around on his motorbike, demonstrating trust in his work, as well as a personal touch.

The personal touch is a crucial element of what makes his practice so popular.

“If you see any of my surgical videos or anything I do, you’ll see that the patient’s face is in it,” he said. “The reason I do that is very important. In fact, it’s the most accountable way of showing your surgery. Otherwise, what’s the point of doing surgery if the patient cannot be shown smiling with you during surgery? Then again the next day post-op, and then flying away saying you’re amazing. So, to me it’s very important to show the patients,” he shared.

He also encouraged doctors to celebrate with their patients. It serves as a reminder of why the surgery was done in the first place, and how helping people feels good.

technology. It’s just one technique in a surgeon’s repertoire, like sautéing, frying or baking are for a chef. All skills and technologies need to be used by a surgeon in different situations, ignoring everything except the result.

4

Be confident and practice steady-handed leadership.

The calm that comes from having an experienced, even-keeled leader was palpable throughout the webinar.

Dr. Gulani’s steady hand reassured surgeons — who are experts in their own right — and encouraged them to be confident. As he put it, a teacher should make their students self-assured when facing a difficult task rather than fearful. Hence his aversion to the term “nightmare”. Being a surgeon is no easy task, but surgeons should embrace challenges.

The response to his guidance was overwhelmingly positive, including in messages received after the webinar.

Some referred to him as a “big brother” who “warmly but firmly” guided and inspired surgeons who, again, are experts in their own right.

Presenters in webinars have commented that they’ve changed their presentation when they knew Dr. Gulani would be present. When you have alreadyrespected surgeons turning to another for advice, you know you’re seeing a leader.

5

Embrace technology, but never forget your core purpose.

The technology available to modern surgeons and the skills they have developed would make a surgeon from even a few decades ago wildly envious.

Patients, too, would be thrilled with the option to improve their vision with something even as simple as a modern cataract surgery.

But the only thing that matters in healthcare, as it always has been, is the health of the patient. We’ve come a long way, but that fact will never change. By maintaining that focus, ophthalmologists can remember their core purpose: improving lives by improving vision.

Editor’s Note: The Entod Webinar took place on April 23, 2020. Moderated

by Dr. Harshul Tak — Chairman, Scientific Committee, ROS — the live webinar was attended by a total of 3,267 viewers across all live platforms. As of this writing, the view count has passed 5,000 worldwide. A version of this story was first published on cakemagazine.org.

3

Get the job done.

Remember, outcomes are the only metric of success.

The point of a surgery is to fix a problem — if the surgery does that, it’s a success. That’s essentially the end of the discussion. Dr. Gulani pointed out that it doesn’t entirely matter how the surgery gets done — just that it does.

“Surgical acrobatics without 20/20 is a waste of time,” he said. Furthermore, in comparing skills and technology to cooking, Dr. Gulani encouraged surgeons to not give credit to

Dr. Gulani encouraged doctors to remain positive in difficult cases.

| June/July 2020

9

NTERIOR SEGMENT GLAUCOMA SURGERY

iTrack™ Ab-interno Canaloplasty A Novel MIGS that Reduces IOP and Preserves Tissue

by Konstantin Yakimchuk

Glaucoma surgery continues its metamorphosis . . .

O

pen-angle glaucoma remains a severe health issue affecting the quality of life of patients and their families. Fortunately, the evolution of surgical methods for the treatment of glaucomatous patients has led to the development of novel minimallyinvasive forms of glaucoma surgery.

The evolution of glaucoma surgeries Currently, the standard surgical treatment for medically resistant openangle glaucoma is trabeculectomy.

However, this procedure possesses severe adverse effects to patients, including scar formation, wound leakage, hypotension and detachment of the choroid.1 To confront these complications, canaloplasty — a novel surgical method by circumferential viscodilation and tensioning of Schlemm’s canal — was developed over 10 years ago.

Performed via an ab-externo approach, traditional canaloplasty was designed to viscodilate the trabecular meshwork and Schlemm’s canal to repair outflow.2,3 This surgery is recommended for primary openangle and pseudoexfoliative types of glaucoma. Both the decrease and modulation of intraocular pressure are the main current indicators of the surgical treatment efficacy in patients with glaucoma.

canaloplasty, ab-interno canaloplasty or ab-interno canal-based glaucoma surgery, performed with the iTrack™ surgical system (Ellex, Adelaide, Australia), is a new step in the surgical treatment of glaucoma.4 How unique is this novel technique? In contrast to the original canaloplasty, the ab-interno technique does not apply a tensioning suture and requires no conjunctival manipulation.

During the ab-interno procedure5, 360-degree catheterization of the Schlemm’s canal is followed by circumferential viscodilation with the injection of a high-molecular weight viscoelastic. The passage of the iTrack™ microcatheter through the Schlemm’s canal mechanically breaks adhesions within the canal and pushes herniations of trabecular meshwork out of collector channel ostia. This restores a more patent architecture to the Schlemm’s canal. Hydraulic pressure caused by injection of HA-based OVD stretches the trabecular meshwork, with possible creation of microperforations into the anterior chamber.This dilates the Schlemm’s canal, ostia and collector channels.

The iTrack™ ab-interno canaloplasty reduces IOP by reducing resistance in all segments of the conventional outflow system, including the trabecular meshwork, Schlemm’s canal, and proximal and distal collector channels.

In addition to the original ab-externo

Importantly, iTrack™ ab-interno canaloplasty preserves the angle:

10

| June/July 2020

it does not damage or remove tissue.

This is an important distinction of the iTrack™ procedure, as it does not preclude future treatment options.

As an added benefit, iTrack™ is one of the few MIGS options that can be performed outside cataract surgery, as a standalone procedure.

Clinical findings in favor of iTrack™ On average, iTrack™ ab-interno canaloplasty achieves a reduction in IOP of 30% and a 50% reduction in medication dependence.6 The procedure has been demonstrated to lower IOP and/or reduce the patient medication burden when performed as a standalone procedure, and in conjunction with cataract surgery.7 It has also demonstrated efficacy in cases of controlled and uncontrolled glaucoma.8 Several studies reporting the application of ab-interno canaloplasty with the iTrack™ surgical system were presented at the American Society of Cataract and Refractive Surgery (ASCRS 2020) Virtual Annual Meeting this year.

Among them, a novel study by Dr. Mark Gallardo9 has aimed to evaluate the efficacy and safety of the ab-interno iTrack™ procedure in reducing IOP and glaucoma medications burden in patients with open-angle glaucoma.

The author compared the interim

36-month results for iTrack ab-interno canaloplasty performed as a stand-alone procedure (iTrack-Alone)(n=24) and in combination with cataract extraction (iTrack+Phaco)(n=26). Notably, at three years post-surgery, mean IOP was reduced to 13.5 mmHg at 36 months from a baseline of 21.1 mmHg in the iTrack-Alone group. In total, 83% of patients recorded IOP of < 15 mmHg. In the iTrack+Phaco group, IOP reduction was also significant, falling from 19.5 mmHg to 13.3 mmHg at 36 months, with 85% of patients recording IOP < 15 mmHg. As to the safety of the procedure, no negative effects were observed. The author has concluded that iTrack™ ab-interno canaloplasty effectively decreased intraocular pressure and medication burden during the 36-month follow-up and can be an effective and safe technique as either a stand-alone surgery or a combination with cataract extraction.

Also, other studies of iTrack™ abinterno canaloplasty were presented

by Dr. Mahmoud Khaimi from Dean McGee Eye Institute.10 One of them reported the interim 36-month results of a non-randomized, single academic center-based, retrospective review of iTrack+Phaco and iTrack-Alone performed by two attending physicians, four fellows, and 22 residents at the Dean McGee Eye Institute in Oklahoma City from January 2013 to September 2017. In line with the studies described above, a significant decrease of intraocular pressure was observed in patients with open-angle glaucoma.

Importantly, iTrack™ also presented an excellent safety profile. 90% of patients in the iTrack-Alone group and 92% of patients in the iTrack+Phaco group remained free of adverse events.

The most common adverse event was postop IOP elevation (≥30 mmHg at 1 week), occurring in 8% and 10% of patients in the iTrack+Phaco and iTrack-Alone groups, respectively. Only 2 (0.3%) of Track+Phaco patients and zero of the iTrack-Alone patients required additional surgery to address IOP spike.

According to this study, iTrack™ abinterno canaloplasty can be effectively used in patients with different types of glaucoma, including cases that are especially hard to treat. Moreover, intraocular pressure was well contained,

allowing a decrease of anti-glaucoma therapies.

Another study by Dr. Khaimi has reported the effectiveness of iTrack™ ab-interno canaloplasty or pigmentary and pseudoexfoliation glaucoma .11 The procedure was found to be effective for controlling intraocular pressure in patients with these types of glaucoma.

Furthermore, Dr. Juan Carlos Izquierdo has compared the efficacy and safety of iTrack-Alon versus iTrack+Phaco in medically controlled patients.12 One hundred seven (107) eyes of sixty-three patients were included.

Intraocular pressure was 16.19 mmHg and 17.10 mmHg in the iTrack+Phaco and iTrack-Alone groups at baseline, reducing to 10.84 mmHg( p<0.001) and 11.41 mmHg (p=0.003) at the12month follow-up. In the iTrack+Phaco group medications decreased from 2.2 to 0.2 (p<0.001), with 82% of eyes medication-free at 12 months. In the iTrack-Alone group, medications decreased from 2.7 to 0. (p < 0.001), at 12 months, with 63% of eyes medication-free. Visual acuity outcomes and complication rates were similar between the 2 groups. iTrack™ ab-interno canaloplasty, today and tomorrow

Current minimally invasive techniques provide sufficient reduction of intraocular pressure without notable side effects compared to standard surgical treatment. Many MIGS procedures require the placement of a stent to bypass the outflow pathway, or involve the removal and/or destruction of tissue. This can compromise the ability to intervene later in the disease process – and it is well understood that glaucoma is a multifactorial disease, and that no one glaucoma treatment lasts forever. In iTrack™ ab-interno canaloplasty, physicians have a tissuesparing MIGS that can achieve excellent efficacy outcomes, while also preserving future treatment options.

Editor’s Note: ASCRS 2020 Virtual Annual Meeting — the world’s first-ever successful virtual ophthalmic conference — was held on May 16 to 17, 2020.

Reporting for this article also took place during the virtual ASCRS 2020 conference, where CAKE magazine’s parent company, Media MICE, was the only exhibiting independent media.

REFERENCES: 1

Chou J, Turalba A, Hoguet A. Surgical Innovations in Glaucoma: The Transition From Trabeculectomy to MIGS. Int Ophthalmol Clin. 2017;57(4):39-55.

2

Lewis RA, et al. Canaloplasty: Circumferential viscodilation and tensioning of Schlemm canal using a flexible microcatheter for the treatment of open-angle glaucoma in adults: Two-year interim clinical study results. J Cataract Refract Surg. 2009;35(5):814-824.

3

Vastardis I, Fili S, Gatzioufas Z, Kohlhaas M. Ab externo canaloplasty results and efficacy: A retrospective cohort study with a 12-month follow-up. Eye Vis (Lond). 2019;6:9.

4

Gallardo MJ, Supnet RA, Ahmed II. K. Viscodilation of Schlemm’s canal for the reduction of IOP via an ab-interno approach. Clin Ophthalmol. 2018;12(10):2149-2155.

5

Grieshaber MC, Pienaar A, Olivier J, Stegmann R. Clinical evaluation of the aqueous outflow system in primary open-angle glaucoma for canaloplasty. Invest Ophthalmol Vis Sci. 2010;51(3):1498-1504.

6

Smit BA, Johnstone MA. Effects of viscoelastic injection into Schlemm’s canal in primate and human eyes: potential relevance to viscocanalostomy. Ophthalmology. 2002;109(4):786-792.

7

Gallardo MJ, Supnet RA, Ahmed IIK. Circumferential viscodilation of Schlemm’s canal for openangle glaucoma: ab-interno vs ab-externo canaloplasty with tensioning suture. Clin Ophthalmol.

2018;12:2493-2498.

8

Gallardo MJ. 24-Month Outcomes Following Transluminal Viscodilation of Schlemm’s Canal (ab-interno canaloplasty) for the Treatment of Open-Angle Glaucoma. ASCRS Virtual Annual Meeting 16-17 May, 2020.

9

Khaimi MA. The Safety and Effectiveness of Ab Interno Canaloplasty in Patients with Narrow-Angle or Chronic Angle-Closure Glaucoma. ASCRS Virtual Annual Meeting 16-17 May, 2020.

10

Khaimi MA. The Effectiveness of Ab Interno Canaloplasty (iTrack) in the Treatment of Pigmentary and Pseudoexfoliation Glaucoma. ASCRS Virtual Annual Meeting 16-17 May, 2020.

11

Waldner GM, et al. Novel Technique for Treatment and Evaluation of Open-Angle Glaucoma: Ab Interno Canaloplasty Combined with In Vivotrypan Blue Venography. ASCRS Virtual Annual Meeting 16-17 May, 2020.

12

Izquierdo JC, et al. Ab-Interno Canaloplasty Combined with Phacoemulsification and Ab-Interno Canaloplasty Stand-Alone Procedure in Medically Controlled Glaucoma. ASCRS Virtual Annual Meeting 16-17 May, 2020.

| June/July 2020

11

NTERIOR SEGMENT CONJUNCTIVITIS

A Lowdown on the Link between Conjunctivitis and COVID-19

by Joanna Lee

I

n the light of the current COVID-19 situation, diagnosing the pink eye or conjunctivitis has now an added dimension of caution. The alert came about after anecdotal sources and researchers raised the alarm about “the possibility of eye infection and the ocular route as a potential infection source.”1 This and several other reports2,3 prompted the American Academy of Ophthalmology (AAO) to issue guidelines, which included warnings that “the virus can cause conjunctivitis and possibly be transmitted by aerosol contact with conjunctiva.”4 The circumstances of its infection mode have put ophthalmologists around the globe on the frontline, and it has been especially poignant ever since the passing of Dr. Li Wenliang, the ophthalmologist from Wuhan who warned of the virus in December 2019.

It was believed that he contracted the novel coronavirus from a glaucoma patient.5

been wrongly prescribed antibiotics.6

These two types are infectious.

This common but ineffective use of antibiotics in conjunctivitis treatment was addressed recently when Cofounder and Director of Operations at OasisEye Specialists and Refractive Surgeon Dr. Khaw Hoon Hoon, spoke in a webinar titled, “Conjunctivitis: Stop the Use of Oral Antibiotics,” during the Centre’s Facebook Live “Eye to Eye Talk Show.” The talk was held as part of an educational series to reach out to fellow ophthalmologists, medical practitioners, opticians, optometrists and the public, during the lockdown in Malaysia.

“Viral conjunctivitis is usually associated with upper respiratory tract infections (URTI’s). Eyes would be watery, reddish with lots of discharge,” she said. This type also comes when patients have sore throats, colds, flu — thanks to the common cold associated with adenovirus. This is where ophthalmologists and doctors would pay closer attention to their similarities with symptoms found in COVID-19 patients.

In a subsequent interview, Dr. Khaw shed light about the nature of this infection in the conjunctiva that can be also found in COVID-19 patients.1

Differentiating types of conjunctivitis

Coupled with this situation, the AAO also reported in its 2017 study that 60% of people with conjunctivitis have

“The most common type of conjunctivitis is due to viral infection.

About 90% of conjunctivitis infections are due to viral origins,” Dr. Khaw said. The second would be bacterial conjunctivitis, which is rare, she added.

12

| June/July 2020

Bacterial infections would have signs of thick, yellow-green discharge, and most cases would clear up within one or two weeks without treatment.

Bacterial infections are rare but can be commonly seen in young children or babies like the monococcal bacteria, or even in adults in association with sexually transmitted diseases.

“The third type is allergic conjunctivitis which is usually caused by irritants in the air (seasonal allergies in temperate countries), chlorine, cosmetics or any product that has come into contact with the eyes. It usually takes two or three weeks to clear up. They would usually go to family care practitioners or eye doctors,” Dr. Khaw explained.

Allergic conjunctivitis is recurrent and seasonal, yet it is non-infectious and can be treated with antihistamines.

Awareness of its contagious nature “Because the lacrimal duct in our eye connects to our oral cavity, whenever a person has a URTI — with a sore throat and runny nose — the virus can tract upwards through the duct and infect our eyes,” she said. “From the eye secretions, it can spread through contact like touch.”

Close contact and coughing and sneezing can spread the infection as well. The incubation period for both virus and bacteria for conjunctivitis is about 24 to 72 hours before the eye turns red.

“When one person gets it, usually the family members would be infected if one does not practice proper hygiene,” warned Dr. Khaw.

Just how contagious is conjunctivitis?

Dr. Khaw said, “Conjunctivitis is like a “membership” because patients would see us in a group. It would start with the children getting coughs, upper respiratory tract infections, then the mother, or both parents would come in later, then their siblings, domestic helper and then the grandparents,” she explained.

“Spread by touch, it is highly contagious. So, with the coronavirus which is airborne, one can imagine how much more contagious it can be,” she said further.

The talk aimed to address the wrong use of antibiotics for conjunctivitis, especially if it is not of bacterial origin. “Yes, it can have a role in treatment if it’s proven to be bacterial conjunctivitis,” Dr. Khaw said.

“Start with topical antibiotics. If no improvement is seen, then only do you give oral antibiotics,” she said.

Physical precautions similar to COVID-19

practitioner, so we usually see only the more complicated ones who haven’t recovered after one or two weeks,” Dr. Khaw shared. “However, we often see conjunctivitis cases daily at our center. Some patients see us because they’ve seen family members subsequently develop complications from conjunctivitis so they’re very concerned about their own condition as well,” she said.

For conjunctivitis patients, some develop complications like severe dry eye, punctate keratitis or pseudomembranous conjunctivitis.

Hygiene precautions taken for coronavirus at eye care facilities would be the same as at any healthcare facility. “We wear masks, gloves, wash our hands, sanitize the slit-lamps after examining conjunctivitis patients.

We would tell patients to wash their hands and to avoid touching anything, especially their own eyes and face.

Now, the whole world is practicing the same caution.”

Conjunctivitis patients are advised to be isolated — to have their towels and washcloths changed and washed daily, for instance. Hands must also be washed after touching pets. At their center, they have also prepared isolation rooms and protective equipment for staff use.

“That is why this is one of the first topics we address for our series of talks,” said Dr. Khaw, referring to the similarities between the caution and approach towards managing conjunctivitis amidst the coronavirus pandemic, as well as its management to prevent any further spreading.

Editor’s Note: The “Eye to Eye Talk” Facebook Live Webinar by OasisEye Specialists was attended by members of the Malaysian Association of Practicing Opticians and the Association of Malaysian Optometrists, as well as members of the public.

REFERENCES: 1

Xia J, Tong J, Liu M, et al. Evaluation of Coronavirus in Tears and Conjunctival Secretions of Patients With SARS-CoV-2 Infection. J Med Virol. 2020;92(6):589-594.

2

AJMC Peer Exchange. COVID-19 May Be Transmitted Through the Eye, Report Finds.

Available from: https://www.ajmc.com/ newsroom/covid19-may-be-transmittedthrough-the-eye-report-finds. Accessed date: 21 June, 2020.

3

Web MD. Can You Catch COVID-19 Through Your Eyes?. Available from: https://www. webmd.com/lung/news/20200526/can-youcatch-covid19-through-your-eyes. Accessed date: 21 June, 2020.

4

American Academy of Ophthalmology (AAO). Important coronavirus updates for ophthalmologists. Available from: https://www. aao.org/headline/alert-important-coronaviruscontext. Accessed date: 21 June, 2020.

5

Al Jazeera. Grief, anger in China as doctor who warned about coronavirus dies. Available from: https://www.aljazeera.com/news/2020/02/ chinese-doctor-sounded-alarm-wuhancoronavirus-dies-200207004935274.html.

Accessed date: 21 June, 2020.

6

American Academy of Ophthalmology (AAO).

When Do You Need Antibiotics for Pink Eye? Available from: https://www.aao.org/eye-health/ news/when-do-you-need-antibiotics-pink-eye.

Accessed date: 21 June, 2020.

Contributing Doctor Dr. Khaw Hoon Hoon is the cofounder and director of operations of OasisEye Specialists Centre, subspecializing in Cataract and Refractive Surgery. She graduated from Universiti Kebangsaan Malaysia (UKM) and went on to obtain her post-graduate qualification, FRCS Ophthalmology, in Glasgow, U.K. in 2000.

Dr. Khaw has vast experience in managing patients with a wide range of eye diseases.

She started her career in private practice in 2005 and pioneered in providing ophthalmology services in Pantai Hospital Ampang, Kuala Lumpur, Malaysia. She subsequently moved to Sunway Medical Centre where she ran a busy practice. Her energy, enthusiasm and genuine care for her patients have led to her reputation as the friendly doctor in the area, where she performed many cataract surgeries for the elderly. She became one of the earliest doctors to provide multifocal lens implants.

Alongside cataract surgeries, Dr. Khaw is also experienced in performing refractive surgeries, where she previously practiced LASIK and femtosecond laser surgery. Now at OasisEye Specialists, she continues to focus on the newer generation Implantable Collamer Lens (ICL), a novel option for refractive surgery where a corrective lens is implanted into the eye, without permanently damaging any parts of the eye and can be removed if needed.

“Most patients can recover when they see their family healthcare

| June/July 2020

13

Vivinex™ Promises Clearer Vision and Better Control

D

uring the HOYA Surgical Optics (HSO) Lunch Symposium at the Annual Meeting of the AsiaPacific Association of Cataract & Refractive Surgeons (APACRS 2019) held in Kyoto, Japan, in October 2019, several leading experts presented updates on the Vivinex™ multiSert™ and Vivinex™ Toric preloaded IOLs. Vivinex™ offers unprecedented clarity of vision for cataract patients by incorporating a proprietary aspheric design that is more tolerant to sources of coma than other leading aspheric designs, a hydrophobic acrylic material that is glistening-free, and reduced posterior capsule opacification (PCO) through active oxygen processing treatment of the posterior surface and a sharp optic edge. Vivinex™ Toric’s proven rotational stability offers patients with precise astigmatism correction, leading to better clarity of vision.

The multiSert™ injector provides surgeons with the option to use either the single-handed push, or the twohanded screw injection within one device, while the uniquely designed adjustable insert shield provides precise injector tip insertion depth management.

“In Germany and Europe, we really have had a huge problem (with calcification) in the last couple of years... it’s not only one company, it’s several companies that sometimes produce lenses that opacify,” he told delegates at the session.

Prof. Auffarth went on to discuss a study he and his team made which used an accelerated aging protocol to induce glistenings in hydrophobic IOL materials, comparing HSO’s Vivinex™, Alcon’s Acrysof IQ (SN60WF) and J&J Vision’s Tecnis (ZCB00).

Glistenings are fluid-filled microvacuoles that can result in increased straylight and may cause a reduction in vision quality in some cases.

The IOLs were immersed in a balanced salt solution (BSS) at 45°C for 24 hours. The temperature was reduced to 37°C for 2.5 hours using a water bath.

The results? Alcon’s SN60WF had the highest number of microvacuoles (around 200) per mm2.

multinational, bilateral, paired-eye, open-label study to evaluate the Vivinex™ and AcrySof (Alcon, Fort Worth, TX, USA).

The primary endpoint of the study is the rate of PCO, while secondary endpoints included glistenings.

The study consists of 85 subjects, with an average age of 74 years, and each was randomized to receive the Vivinex™ IOL as the study device in one eye and the Alcon AcrySof IOL as the control device in the other eye.

At 2 years, PCO incidence was low in both groups. However, there was a trend towards more opacification in the AcrySof group.

He noted that no YAG laser capsulotomy was performed in eyes implanted with Vivinex™ versus one eye implanted with AcrySof, which had to undergo capsulotomy within 6 months after implantation.

Glistenings were assessed on the slit lamp under pupil dilation and the difference in glistening formation between the two groups was found to be statistically significant. Compared to AcrySof, Vivinex™ was found to have significantly less glistening at one year (p<0.0001). A total of 93.8% of the Vivinex™ group versus 40% of the AcrySof group demonstrated <10 glistenings per 10 x mm field.

This is consistent with previous work indicating that glistenings are extremely common in AcrySof (33.5% were shown to have moderate glistening levels, and 26.9% high glistening levels*).

The Vivinex™ and the Tecnis showed the lowest number of microvacuoles, on average below 10 per mm2.

“In conclusion, Vivinex™ shows in vitro and clinically excellent results with very low glistening numbers, and is essentially glistening free,” he said.

Professor Gerd Auffarth from the International Vision Correction Research Centre, University of Heidelberg in Germany, said the advantages of hydrophobic acrylic IOLs include: a low PCO rate, a higher refractive index and consequentially thinner IOL. In addition, unlike hydrophilic materials, there is no calcification of the IOL material.

“This is what we consider glisteningfree,” said Professor Auffarth.

Bigger is not always better

14

| June/July 2020

Separately, the Vivinex™ and Alcon’s AcrySof were evaluated in a European Multicentre Study carried out between 2017 and 2019, at two investigative sites in France and two in Germany.

The ongoing clinical study is a postmarketing prospective, randomized,

Dr. Khiun Tjia from Isala Clinics in Zwolle, Netherlands, presented “Surgically Induced Astigmatism: Personal experience with Vivinex™ multiSert™ and Clareon AutonoMe when using a 2.2mm incision to analyze the surgically induced astigmatism which occurred.”

“Of course, the tip size going through the incision is of the utmost importance,” noted Dr. Tjia.

The primary endpoint was uncorrected visual acuity (UCVA) of 0.8 or better at three months postoperatively.

“The total outer dimension for AutonoMe is significantly larger than the Vivinex™ multiSert™, which has consequences, obviously,” he explained.

The results showed that all eyes achieved decimal visual acuity (VA) of 0.8 or greater while subjective astigmatisms were significantly reduced to 0.5D.

Showing a video of a surgery, Dr. Tjia noted that at 2.20 mm AutonoMe requires enlargement of the outer half incision, while the Vivinex™ multiSert™ offers a very smooth and consistent IOL delivery through a 2.20 mm incision, without requiring incision enlargement.

He shared his retrospective analysis on surgically induced astigmatism (SIA) with both preloaded injectors. Each group (Vivinex group = 23 eyes; AcrySof group = 20 eyes) comprised standard patients with clinically significant cataract, potential visual acuity in each eye of 0.5 (20/40) or better, and with no changes of the cornea in previous refractive surgery.

The results showed that there was no significant difference of SIA for Vivinex™ between OS and OD for all calculation methods.

However, the mean, median and centroid SIA was consistently smaller for Vivinex™ for both OS and OD. “For Vivinex™ multiSert™, the surgically induced astigmatism (SIA) is consistently small and hydration of the main incision is not necessary,” Dr. Tjia said in summary.

Smaller refractive errors The results of a clinical trial on Vivinex™ Toric IOL in Japan showed that the refractive error was ‘very small’, said Professor Hiroko BissenMiyajima, chairman and professor of ophthalmology at Tokyo Dental College Suidobashi Hospital in Japan, and president of APACRS. The prospective single-center clinical trial was carried out on 20 eyes including at least 2 eyes in each model, to evaluate efficacy and safety of the Vivinex™ Toric IOL.

In addition, it scored the lowest for incidence of repositioning surgery.

“Vivinex™ Toric is the ‘new generation’ of toric IOLs,” said Prof. Oshika.

He concluded by saying that Vivinex™ Toric, which is already available in a preloaded injector, had a smooth and quick unfolding capability, excellent rotational stability, with no glistenings and no surface scattering. In the near future this lens will also be available in the 4-in-1 multiSert™ preloaded injector.

Spectacle dependency was reduced, with 95% not using spectacles for distance.

“There was a high rate of patient satisfaction,” she added. She noted that there was also faster expansion inside the capsular bag with Vivinex™ Toric, which leads to an easier implantation and a more stable fixation of the IOL.

“I strongly believe this is the number one toric IOL in the market,” he said in summary.

There was a lively discussion after the presentations, where questions were posed to the speakers.

In conclusion, favorable results of the Vivinex™ Toric IOL were found in the Japanese clinical trial, and the use of the Vivinex™ Toric IOL in cases with significant corneal astigmatism was found beneficial.

When asked if he prefers to use a screw or a push technique for the multiSert™ preloaded injector, Dr. Tjia replied: “If you use just a push, the amount of force required is so much less than any device on the market and it provides so much control, it’s way above any competitive product.”

Vivinex™ can potentially ‘rule’ the market Professor Tetsuro Oshika, chairman and professor of ophthalmology at University of Tsukuba in Japan, predicted that the “Vivinex™ Toric can rule the market” with its new generation toric IOLs.

When using the multiSert™ preloaded injector in push mode, surgeons only need one hand for implantation, freeing the other hand to stabilize the eye.

He started off by saying that “There is always some misalignment for every IOL for every surgeon”.

A study was conducted to compare the three most commonly used models of toric intraocular lenses in Japan: AcrySof toric intraocular lens (Alcon Laboratories, Inc.) with 34 eyes tested, TECNIS toric intraocular lens (Johnson & Johnson Vision, Inc.) with 13 eyes and HSO’s Vivinex™ toric intraocular lens with 30 eyes.

Members of the panel agreed that, indeed, the multiSert™ combines the best of both worlds, and is easy to handle in either the screw or the push mode. Every surgeon, whatever their preference, will appreciate the versatility of the multiSert™ preloaded injector. * Colin J, Orignac I. Glistenings on intraocular lenses in healthy eyes: effects and associations.

J Refract Surg. 2011;27(12):869-875.

Some of the products and/or specific features as well as the procedures featured in this document may not be approved in your country and thus may not be available there. Design and specifications are subject to change without prior notice as a result of ongoing technical development. Please contact our regional representative regarding individual availability in your country. HOYA, Vivinex, iSert and multiSert are trademarks of the HOYA Corporation or its affiliates. Third-party trademarks used herein are the property of their respective owners.

©2019 HOYA Medical Singapore Pte. Ltd. All rights reserved.

Vivinex™ Toric outperformed the other two lenses, showing the least amount of misalignment at one month, compared to Tecnis Toric and AcrySof IQ Toric.

It also had the fastest unfolding time when tested at room temperature (24 degrees Celsius) compared to Tecnis and AcrySof.

| June/July 2020

15

NTERIOR SEGMENT ANTI-INFECTIVES UPDATE

Perioperative Infection Management in Cataract Surgery Before, After… and Don’t Forget During…

E

ven the most experienced surgeon, performing the most unremarkable, routine, ‘feel-like-I-could-do-thisin-my-sleep’ cataract surgery can still have results devastated by infection.

Despite all the advancements we have seen in technology and technique, resulting in high precision refractive outcomes, infection, particularly endophthalmitis, continues to haunt surgeons globally.

Dr. Prashant Garg and Dr. Aravind Roy of The Cornea Institute and L.V. Prasad Eye Institute in Hyderabad, India, recently shared their insights into perioperative infection management for cataract surgery. They emphasized that the rates of infection are highly variable from region to region, and even within institutions within the same region. Attempting to narrow in on the causative microorganism can also be unpredictable, “where gram positive organisms continue to dominate in the West, gram-negative bacilli are

16

by April Ingram

reportedly higher in India where fungi and Actinomyces (Nocardia) have also been reported. Microbiology also varies between sporadic versus cluster endophthalmitis, which involves more environmental organisms,” shared Dr. Garg.

Knowing how your patient will fare after endophthalmitis is dependent on a number of factors. “Importantly, visual acuity at presentation, clinical picture (lid edema, corneal haze, anterior chamber reaction and visibility of fundus), culture negativity and causative organism,” said Dr. Garg.

He explained that although there are a wide variety of preventative interventions practiced, they really fall into four categories: (1) Patient selection — Understanding risks of advanced age, being immunocompromised from systemic disease, other ocular disease or contact lens wear. (2) Preoperative measures

| June/July 2020

— Topical antibiotics, a highly variable practice among countries or regions, and use of povidone iodine (PVI). “Physicians consider this combination the most effective in reducing periocular flora and thereby endophthalmitis.” (3) Perioperative/ intraoperative measures — Ensuring asepsis of the operating room, highquality sterility of surgical supplies and intracameral antibiotic use. (4) Postoperative measures — Topical antibiotics, although a universally accepted modality, the choice of antibiotic remains under high debate.

Socioeconomic disparity may also play a role in infection management, although, as Dr. Roy explained, things are improving: “In India, the quality of surgery and rate of endophthalmitis are a spectrum, similar to the Western world at one end, and less than expected surgery quality and much higher rates of endophthalmitis at other end. Notably, more surgeons

are adopting protocols that ensure protection against endophthalmitis, including the use of PVI, attention to asepsis and sterility of supplies, and intracameral antibiotics,” he said.

An All India Ophthalmological Society (AIOS) survey1 showed similar results to ASCRS with 40% using intracameral antibiotics and 46% preferring intracameral antibiotics in high-risk patients. Moxifloxacin is the antibiotic of choice for intracameral and topical use. PVI is used preoperatively by 83% and 46% use subconjunctival antibiotics at the end of surgery.

Dr. Garg helped us to dig a bit deeper into the recent discussion of intracameral antibiotic injections and the large number of publications that have highlighted the value of antibiotic injected in the anterior chamber at the conclusion of surgery in the prevention of endophthalmitis. “Kessel et al2, in a meta-analysis, reported a reduction of the incidence of endophthalmitis to 0.035% when intracameral antibiotics were used compared to 0.2% when this intervention was not used,” he noted.

The use of intracameral antibiotics has been slow to make its way into routine practice, although trends appear to be increasing.

For example, in a different study, Espiritu and Bolinao3 reported the safety of intracameral injection of levofloxacin 0.5% ophthalmic solution as prophylaxis for patients undergoing cataract extraction and intraocular lens implantation. While safety results are promising, the investigators recommended that further study is required to demonstrate the effectiveness of intracameral injection of levofloxacin 0.5% ophthalmic solution in the prevention of endophthalmitis.

Which antibiotic to use intracamerally?

“Several antibiotics are used for intracameral injections, including cefuroxime, cefazolin, vancomycin, aminoglycosides, and fluoroquinolones.

However, there is not much difference in their relative efficacy,” explained Dr. Roy. He noted that in the paper by Kessel et al, they reported a significantly lower rate of endophthalmitis in patients treated with intracameral cefuroxime, cefazolin and moxifloxacin, but not vancomycin.

“Similarly, in an observational cohort study of 315,246 phacoemulsification procedures, Herrinton et al4, did not find any difference in endophthalmitis risk among intracameral cefuroxime and moxifloxacin groups,” highlighted Dr. Roy. Be forewarned, that despite the excellent safety record of intracameral antibiotic use, hemorrhagic occlusive retinal vasculitis, sudden loss of vision from retinal toxicity, and allergic conjunctivitis have been reported.

According to Dr. Garg, these publications raise the question, “Is it justified to expose our patients to the risk of intraocular toxicity although extremely low in an attempt to prevent equally rare complication.” To which he responded, “Well, there is no definitive answer to this question but, these reports clearly highlight the need for being vigilant.”

When asked about the future of prophylaxis of infectious endophthalmitis, Dr. Garg replied: “With increasing enthusiasm in intracameral antibiotics and support for its uses by regulatory agencies and national and international ophthalmology societies, a favorable environment for innovations has been created that is helping availability of commercial

REFERENCES: 1

Maharana PK, Chhablani JK, Das TP, et al. All India Ophthalmological Society members survey results: Cataract surgery antibiotic prophylaxis current practice pattern 2017. Indian J Ophthalmol.

2018;66(6):820-824.

2

Kessel L, Flesner P, Andresen J, et al. Antibiotic prevention of postcataract endophthalmitis: a systematic review and meta-analysis. Acta Ophthalmol. 2015;93(4):303-317.

3

Espiritu CRG, Bolinao JG. Prophylactic Intracameral Levofloxacin in Cataract Surgery - An Evaluation of Safety. Clin Ophthalmol. 2017;11:2199-2204.

4

Herrinton LJ, Shorstein NH, Paschal JF, et al. Comparative Effectiveness of Antibiotic Prophylaxis in Cataract Surgery. Ophthalmology. 2016;123(2):287-294.

5

Garg P, Venuganti VVK, Roy A, Roy G. Novel Drug Delivery Methods for the Treatment of Keratitis: Moving Away From Surgical Intervention. Review Expert Opin Drug Deliv. 2019;16(12):1381-1391.

preparations as well as newer ways of drug delivery.”

Some of these novel approaches include drug delivery of nano particles, double crosslinking to conjugate chitosan gelatin with cefuroxime and IOLs or their haptics being pre-loaded with antibiotics. Dr. Garg and his team5 are at the forefront of infection management (i.e. developing a bandage contact lens-like device made of PVP that delivers antibiotics and corticosteroids).

Contributing Doctors Dr. Prashant Garg, MBBS, MS, specializes in infectious diseases of the cornea and anterior segment, and eye banking procedures. He has been associated with L. V. Prasad Eye Institute for more than two decades, and is currently the Director of Kallam Anji Reddy Campus, Hyderabad (India) and Kode Venkatadri Chowdary Campus, Vijayawada (India). Dr. Garg has received research grants from national and international organizations and has been a principal investigator for several clinical trials. Dr. Garg is on the editorial board of the Canadian Journal of Ophthalmology and Indian Journal of Ophthalmology and is a reviewer for various ophthalmology journals. He has over 150 scientific publications in peer-reviewed journals and has authored chapters in several textbooks.

He has been invited to deliver lectures including named lectures in various forums across the world and is a recipient of the American Academy of Ophthalmology’s Achievement Award (2004) and senior achievement award (2012). prashant@lvpei.org Dr. Aravind Roy specializes in the cornea and anterior segment, with focus on infectious diseases and eye banking. Currently, Dr. Roy serves as a consultant ophthalmologist at the L. V. Prasad Eye Institute at its Kode Venkatadri Chowdary Campus in Vijayawada (India). He did his fellowship in Comprehensive Ophthalmology (2011), and Cornea and Anterior Segment (2013) from LVPEI, before joining the institute’s Kode Venkatadri Chowdary Campus in Vijayawada. Dr. Roy has authored several papers, video and poster presentations throughout his career. He is the recipient of the Amjad Rahi award for best poster presentation in clinical sciences at the Indian Eye Research Group meeting 2010.

He has also published several articles in peer-reviewed journals in various research areas, including corneal pathology, and cataract and refractive surgery. aravindroy@lvpei.org

| June/July 2020

17

COVER STORY

CAKE

Ophthalmologists Shed Light on Today’s Crucial Industry Issues

by Brooke Herron

W

elcome to the inaugural CAKE RADIO SHOW! In this segment — hosted by DJ Bananaman and the CAKE Crew — we asked ophthalmologists worldwide to ‘call-in’ to our Radio Show and answer some of the biggest questions topping the charts today in ophthalmology.

Below, we explore their insights in this first-of-its-kind CAKE magazine multimedia feature.

Dr. Laura Periman

Dr. Cheryl Ngo

Dr. Ehsan Sadri

Prof. Tim Roberts

Seattle, Washington, USA

Singapore, Singapore

Sydney, Australia

Founder and Director of Dry Eye Services and Clinical Research at Periman Eye Center

Consultant and Medical Director at the Adult & Child Eye Clinic (ACE)

Newport Beach, California, USA

Song Request: “Kiss on My List” by Hall & Oates

18

Song Request: “Happy” by Pharrell

| June/July 2020

CEO and Founder at Visionary Eye Institute Song request: “Eyes Without a Face” by Billy Idol

Professor of Ophthalmology at the University of Sydney & Consultant Ophthalmic Surgeon at Royal North Shore Hospital

COVID-19: Lessons learned No doubt, the novel coronavirus has taken the world by storm. If it was a rising star in the music world, it would be selling out stadiums. Instead, it’s pushing people into hospitals and keeping them indoors. Of course, all industries have felt its boorish brunt, some more so than others.

How are ophthalmologists finding harmony and balance amid the pandemic? Let’s find out.

CAKE: What’s one thing in ophthalmology that you think may permanently change as a result of coronavirus?

Dr. Sadri: COVID-19 has dramatically changed many things in medicine and it will take many years to figure out its exact impact. But one striking example is the telemedicine component of interacting with patients. This is something that has been around for a long time. However, the technology was never embraced by physicians or patients. There has been a major cultural shift due to the practicality of the diagnostics. The technology allows physicians to radically enhance their practice and provide better care for patients in a remote fashion. My personal belief is that telemedicine is here to stay indefinitely.

Dr. Periman: Telemedicine! [There’s] tremendous patient satisfaction. I’m amazed at what we can diagnose with high-resolution photos and video interviews.

CAKE: That’s two for telemedicine! We at CAKE also agree that telemedicine could have a lasting impact in the medical field. What else?

Dr. Ngo: The use of slit lamp breath shields, protective eyewear and face masks when examining patients.

CAKE: You’re right! Some surgeons have reported creating their own shields, while others have purchased them. Anything else?

Prof. Roberts: I think this pandemic will permanently end the ‘carry on even when sick’ ethos that so many of us have been guilty of in the past.

That’s important for several reasons.

First and foremost, comes the health of our patients and other staff in the clinic.

But then we also have to consider the financial implications if the clinic (and potentially a co-located day surgery) has to shut down because someone with COVID-19 has come to work.

We’re talking about peoples’ lives and livelihoods. It’s a bit of a cliché, but everything really is for the greater good now — it’s not just about people as individuals.

CAKE: Another good point! In the era

improvement in vision and it’s a functional necessity, and therefore the demand is certainly strong.

CAKE: That’s really interesting. What other procedures are restarting?

Dr. Periman: I only do dry eye procedures. In fact, I used the ‘Great Pause’ to start my own specialty dry eye treatment and research center. Patients are frequently calling to schedule their elective in-office treatments — IPL, iLux, TearCare, Radiofrequency, etc.

of COVID-19, the greater good has got to come first in order to make progress.

In the spirit of moving forward, which elective procedures are you seeing return first after reopening?

CAKE: That’s great news about

Dr. Ngo: In Singapore, I’m seeing

Ophthalmology business: Gearing up for the new normal

cataracts and strabismus surgeries return in which patients complain of significant visual deterioration or disabling diplopia.

Prof. Roberts: In Australia, we are seeing a very slow return to normal because many people are still worried about coming out. However, as we predicted, cataracts make up most of the procedures returning first. Although, I have also performed a handful of minimally-invasive glaucoma surgery (MIGS) operations. This is so important because of the individual, social, economic, and public health value of cataract surgery. The real issue will be clearing the backlog of surgeries in the public system, which isn’t as well placed as the private sector to expand its capacity.

the new center, Dr. Periman — and certainly a productive use of time during the pandemic.

The beginning of 2020 looked bright, didn’t it? Oh, but how things can change. Many businesses are hurting — along with medical practices — thanks to the pandemic. So, what can ophthalmic industry device and equipment manufacturers expect for the rest of the year? We want to know.

CAKE: Are you, or is your clinic or hospital, planning to purchase any new equipment or devices in 2020?

In 2021? And if so, what are you interested in?

Dr. Periman: I plan to purchase a

new radio frequency device and a highresolution photo and video-capable slit Dr. Sadri: In California, most practices, lamp from Eyefficient (Aurora, Ohio, including mine, have resumed elective USA). surgeries. These include cataract and glaucoma surgeries. Laser vision Dr. Ngo: No. correction surgery has also returned in a big way.

Dr. Sadri: COVID-19 has strongly and negatively impacted the balance CAKE: That’s great these patients sheets for many businesses, including are returning! I wondered about which ophthalmologists. If I was giving advice surgeries would restart faster following to myself, I would say defer any major reopenings — cataract or refractive? purchases for the balance of the year.

Dr. Sadri: There are some signals as

CAKE: What about premium

far as the demand in younger patient populations that they are no longer interested, or have made a decision not to get laser vision correction surgery.

The elderly patients in our clinics still need good care. These patients require

procedures? Premium intraocular lenses (IOLs)? How do you predict the demand will go for these?

Dr. Periman: As a dry eye specialist, I think we will see an uptick in dry

| June/July 2020

19

COVER STORY

Breakthroughs in medical and surgical treatments could deliver improved outcomes to patients — an ideal outcome for any therapy.

CAKE: In your opinion, what do you think is the most important topic today in anterior segment disease or treatment?

Dr. Periman: From the perspectives of sheer prevalence, visual performance and quality of life impacts, I think the most important topic today in the anterior segment is dry eye.

Dr. Ngo: It may not be the most

eye severity — people are at home, with increased screen time and dietary changes. We will need to be more mindful of tuning up the dry eye prior to offering premium IOLs, since we know dry eye has a significant impact on visual performance and patient satisfaction, no matter how perfect the surgery, IOL or equipment was.

CAKE: That’s true. More time at home can certainly lead to more screen time.

Prof. Roberts: It will be interesting to see how premium IOLs fare throughout this period. Premium IOLs are not for everyone — patient selection is critical with these lenses because of the visual trade-offs. I’ll continue to have comprehensive discussions about lens options with my patients, but only time will tell whether they feel premium lenses still offer value in a pandemic setting. This will mostly depend on how motivated they are to be spectacle-free.

The personal decision to have refractive lens surgery with a premium IOL is not affected by the pandemic — rather it is access to surgical facilities as the government is restricting the type of surgery performed to preserve PPE.

CAKE: I see. So in this instance, it’s not decreased patient demand, it’s lack of access to facilities.

Dr. Ngo: [Regarding premium IOLs,

patients are more aware of their choices and have greater visual demands — and they want the convenience of spectacle freedom. We are now seeing the group of patients who previously had laser refractive surgery and now need cataract surgery. They are especially difficult to manage as their lens calculation is tricky and yet they still want spectacle freedom and good quality of vision.

CAKE: Right, patients want good vision and to remain spectacleindependent if possible.

Dr. Sadri: Premium services or the advent of advanced lens implants will always remain strong in the hands of practices that are great at conversions.

There’s a certain art to this. Patients who elect to have this procedure have the means, and will certainly have it done regardless of the economics.

This is where I believe education of physicians is really vital.

CAKE: Certainly, patient education is vital when it comes to premium IOLs — and it’s encouraging to hear optimistic predictions for this market.

Anterior segment in the spotlight

I think there will be] more demand as

The pandemic aside, it is an exciting time to be in ophthalmology.

20

| June/July 2020

important topic, but allergic conjunctivitis causes significant problems. Patients are often disabled or troubled by it, especially during an acute flare-up, as it causes significant discomfort and reduction in vision.

And it is often recurrent. In children, long-term treatment with steroids has to be balanced carefully against potential side effects. There are now steroid sparing agents for long-term treatment, and immunotherapy is a potentially promising treatment option.

Dr. Sadri: I believe the management of glaucoma using advanced and two-segment surgeries is the most important. This field is growing rapidly and will have an immense impact

Prof. Roberts: Restoring sight has positive impacts for those suffering from cataracts and their caregivers.

However, despite the evidence that cataract surgery brings significant patient value and financial value to society as a whole, this is not widely understood or appreciated by the general public, policymakers and funders, the healthcare community, and many clinicians. Our challenge, then, is to better communicate the social and public health benefits of cataract surgery to key stakeholders and the wider community with the final goal of improving funding and patient access to cataract surgery, delivering more efficient use of healthcare resources, providing higher quality patient care, and achieving greater community wellbeing.

CAKE: Wow, all great points — and certainly all conditions that not only affect patients’ quality of vision but

their quality of life as well. We’re looking forward to hearing more about these upcoming treatment options. So, let’s talk about MIGS. Of the various instruments and procedures available now, do you have a preference for any one in particular?

Dr. Sadri: I believe it’s case-by-case.

The exciting news in MIGS is that there are many options today. When I was first designing the original I sent with my mentor Dr. Hill in 2003, there was only one. Now there are half a dozen and growing.

Prof. Roberts: I prefer to assess the patient’s needs as a whole before selecting the most appropriate MIGS procedure — assuming MIGS is the right option. That means looking at how advanced the glaucoma is, whether it’s progressing, the IOP decrease we’re looking to achieve, how the patient is coping with eye drops from both an adherence and a tolerance aspect, etc.

CAKE: Right, so it’s a bit like finding a good MIGS ‘fit’ for each patient. What are some other benefits to these less invasive techniques?

Dr. Periman: I’m a huge fan of how MIGS helps preserve the cornea by minimizing or eliminating ocular surface offending glaucoma medications. I’m excited about the injectable prostaglandin analog options coming to market.

CAKE: From a corneal and ocular surface standpoint, MIGS does offer benefits. So, on that corneal note, let’s switch gears to refractive surgery. Which procedure do you perform most often and why?

Dr. Periman: I am cornea and refractive surgery trained. From a dry eye disease expert perspective, I am interested in the corneal nerve subbasal plexus sparing options of small incision lenticule extraction (SMILE) and photorefractive keratectomy (PRK).

Dr. Sadri: I love SMILE and laserassisted in situ keratomileusis (LASIK).

I would probably state that LASIK is more readily down in my practice than SMILE.

like SMILE is certainly gaining some speed, thanks to its reported corneal biomechanical advantages.

Unfortunately, that’s all the time we have for the inaugural CAKE Magazine Radio Show. We’d like to thank the “callers” who participated — and don’t forget to visit www.cakemagazine.org for the recorded video show!

Editor’s Note: Answers to these questions were submitted via email by the surgeons interviewed. Responses have been edited for length and clarity and edited into a Radio Show transcript. And while the CAKE RADIO SHOW did not occur in real time, the answers are real.

Contributing Doctors Dr. Laura M. Periman is a board-certified ophthalmologist, fellowship-trained cornea and refractive surgeon, and ocular surface disease (OSD) expert. Dr. Periman completed her ophthalmology residency and cornea/refractive fellowship at the University of Washington in Seattle. She has 11 peer-reviewed publications and has written extensively on the topic of OSD. As founder and director of Dry Eye Services and Clinical Research at Periman Eye Center in Seattle, Washington, USA, she combines her clinical care passion, scientific drive, and innovative creativity to provide first class OSD management. dryeyemaster@gmail.com Dr. Cheryl Ngo is a consultant and medical director at the Adult & Child Eye Clinic in Singapore. She completed her specialist ophthalmology training in Singapore, holds a Master of Medicine (ophthalmology), and received a medal for her fellowship examination in ophthalmology. Dr. Ngo is currently a fellow of the Royal College of Surgeons of Edinburgh. She also completed a prestigious subspecialty fellowship training at the Hospital for Sick Children, Toronto, Canada. She is the immediate past head of Pediatric Ophthalmology and Strabismus in the National University Hospital Singapore (NUHS) from 2014 to 2019, as well as the research director and an assistant professor of the Yong Loo Lin School of Medicine. She remains as a visiting consultant to NUHS and an adjunct assistant professor at the Yong Loo Lin School of Medicine, NUS. drcherylngo@adultchildeye.com Prof. Tim Roberts is a clinical associate professor of ophthalmology at the University of Sydney and medical director of Vision

Eye Institute (VEI) — the largest private provider of ophthalmic care in Australia, with 27 locations across the country. He is also a consultant ophthalmic surgeon at Royal North Shore Hospital, a major public teaching hospital in Sydney with COVID-19 dedicated facilities. From the beginning of the coronavirus outbreak, Prof. Roberts has met weekly via video-conferencing (but more frequently during the height of the pandemic) with VEI’s CEO and Medical Advisory Board, to steer VEI through the pandemic. tim.roberts@visioneyeinstitute.com.au Dr. Eshan Sadri is the CEO and founder of Visionary Eye Institute in Newport Beach, California, USA. He is also the general partner and co-founder of Visionary Ventures Fund. He is board-certified, fellowship-trained in treating LASIK, cataract and glaucoma surgeries. Dr. Sadri is trained in the most progressive ocular surgical techniques including cataract surgery, phakic intraocular lenses, LASIK, PRK, refractive lensectomy, and AK. He has performed thousands of eye surgeries utilizing advanced techniques for treatment of myopia, hyperopia and astigmatism. Dr. Sadri obtained his medical education at the University of Michigan in Ann Arbor.

There he completed a prestigious Fight for Sight fellowship in retina and glaucoma research at the highly esteemed Kellogg Eye Center. Dr. Sadri completed his ophthalmology residency at the University of Maryland in Baltimore and his glaucoma and cataract fellowship at the University of California, Irvine. His research has been presented at national ophthalmologic meetings and published in medical journals. esadrii@gmail.com

CAKE: As a newer procedure, it seems | June/July 2020

21

F rom Da Nang, Vietnam to the World Q&A from Quarantine

A

s the coronavirus traversed the globe, countries around the world imposed social distancing and shelter-in-place orders (with various levels of restrictions) on their citizens. During this time, all but essential services came to a standstill, including non-emergency and elective ophthalmic procedures.

How did surgeons and industry professionals cope — and continue to learn, network and share information — during the pandemic?

To learn more — and as part of PIE and CAKE magazines’ continuing coverage of the COVID-19 pandemic and its impact on ophthalmology — CEO Matt Young, in Da Nang, Vietnam, interviewed KOLs from around the world. Here are some of those connections . . .

Be sure to check out all the videos in the video section of our new websites cakemagazine.org and piemagazine.org.

1

2

3

Mr. Charles Holmes

Dr. Jorge Alio

Mr. Tiago Guerreiro

VP, Head of Eye Care Global at AbbVie London, UK

Professor and Doctor of Ophthalmology at University of Alicante Alicante, Spain

Global Marketing Manager, Ophtec BV, Groningen, The Netherlands

6

5

4

Dr. Francis Mah

Dr. George Beiko

Mr. Hamadi El-Ayari

Advanced Corneal, Cataract and Refractive Surgeon La Jolla, California, USA

Lecturer, University of Toronto and Assistant Clinical Professor, McMaster University Toronto, Canada

VP of Sales and Marketing at Geuder AG Heidelberg, Germany

7

8

9

Dr. Julie Schallhorn

Mr. Warren Foust

Weill Cornell Medicine New York City, New York, USA

Assistant Professor of Clinical Ophthalmology at the University of of California San Francisco, California, USA

Worldwide President Surgical Vision at Johnson & Johnson Vision Orange County, California, USA

22

| June/July 2020

Dr. Christopher Starr

10

11

12

Mr. Scott Korney

Dr. Richard Lindstrom

Dr. Boris Malyugin

Chief Operations Officer at Avellino Lab San Francisco, California, USA

Founder at Minnesota Eye Consultants Minnesota, USA

President of the Russian Ophthalmology Society Moscow, Russia

15

14

13

Mr. Kuntal Joshi

Mr. Nikkhil Masurkar

Area Director for Asia-Pacific at SIFI Singapore, Singapore

Managing Director at Entod Research Cell UK Ltd. Mumbai, India

Dr. Reena Sethi Medical Director at Arunodaya Deseret Eye Hospital Gurugram, India

16

17

18

Mr. Shane Hage

Dr. Ziad Khoueir

Mr. Bassem Bouhabib

Regional Director for Asia-Pacific at Icare Finland Oy Adelaide, Australia

Ophthalmologist and Glaucoma Specialist Lebanon

VP of International Sales at Iridex Lebanon

18 Dr. Sana Saydi Ophthalmologist Tunisia

| June/July 2020

23

UDOS COVID-19 SPECIAL REPORT

Quarantine Introspection Dr. Arun Gulani’s Two Cents’ Worth

by Sam McCommon

A

s the world slowly emerges from tight lockdowns, we can’t help but wonder, what have we learned from months of isolation? In a conversation with Dr. Arun Gulani — founder of the Gulani Vision Institute, the world-renowned ophthalmologist delved into a refreshingly positive philosophy.

He discussed his uplifting outlook as a doctor in the context of COVID-19. Dr. Gulani’s ethos does not only apply to ophthalmologists but also doctors of all kinds, and, indeed, to anyone willing to explore the themes.

A time for self-reflection “I often say this to my fellows,” said Dr. Gulani, “how we react to pressure determines whether we become diamonds or crumble like charcoal.

Look at every difficult time as a polisher. Let it rub you the right way so we end up sparkling even more,” he added.

Dr. Gulani said the current situation reminds him of a recent global nightmare he faced. “Our ocean-front home was struck by hurricanes Matthew and Irma, both a time of personal tragedy, perceived helplessness. I got into the ‘Why me?’ mode,” he shared.

He continued: “While I was in this personally fragile mode, I was approached by a private equity firm that wanted to buy my practice for an eight-

24

| June/July 2020

figure sum — to include relocating me to Malibu as an exclusive surgeon to movie stars and celebrities.”

Dr. Gulani went into his ‘locked-downlook-in’ mode and asked himself what drove him? “Was it money? Would it be geography — in this case, Malibu?

And my answer was no! I loved what I did every day and it made the world fly to my location. I am addicted to my patients’ surgical outcomes and I love treating them like family with as much time as I can give,” he shared.

“So, I refused the private equity offer and to ensure that my wavering mind ‘got the message,’ while facing staggering expenses for home repair, I invested everything I could and built the world’s first Cataract Spa in Jacksonville, Florida,” he said. “My mind got the message. And I changed my attitude from ‘Why me?” to ‘Try me!’”

‘Look in’ when ‘locked in’ According to Dr. Gulani, the quarantine, though depressing to many, can actually be quite useful personally.

“While we have been ‘locked down’ in our houses, may I encourage you to ‘look in,’ and lock yourself down in your conscience for a while,” he said.

“Get inside, stay there, and look at you.

You’re you, and you don’t have to wear any paraphernalia.”

Dr. Gulani suggested that you use this time for personal reflection — to think about the areas of your life that you enjoy, that you don’t enjoy, things that are working well for you, and things that need improvement. It’s a rare circumstance, indeed, that so many people have been forced this opportunity to stop and think deeply about their lives. How often do people have the chance to get off of the hamster wheel of routine and hard work?

It’s a good time to ask yourself important questions. Are you happy?

Are you doing what you want? As a doctor, is your practice going the way you would like? If not, what can you do to change it? This time for selfreflection allows people to look in the

metaphorical mirror and conduct a mental and emotional check-in.

Most notably, Dr. Gulani encourages doctors to recall why they became a doctor. Is it your dream to have waiting rooms packed with delayed, complaining patients who came in following expensive advertisements, and then hurtling them through cookiecutter surgery mills with a constant fear of repercussions? Is it right that so many doctors are constantly anxious about their external environment, envious of colleagues, and then waiting for 5 p.m. to get out of their offices they themselves own?

“You are a doctor!” he said. “For many, doing so was a lifelong dream. Are you doing it for yourself, your family, or your patients? How do you measure your success?”

Show me the patient Dr. Gulani’s metric for a doctor’s success is quite simple: If a patient’s life is improved, then the doctor has done their job. “Think about it,” he said. “If you’re a surgeon and none of your postoperative patients is calling you with any complaints during this lockdown time — that means you’ve done an amazing job. Your patients are healed! You should be happy.”

He added: “Your patient decides your success, not you.” This is underscored by his patients included in his every surgical video. He said that is the highest accountability of success, not some engineered statistical charts.

A sharp-dressed man — he designs his own suits — Dr. Gulani has a keen

eye for detail and a vibrant personality.

“Authenticity is the most important thing,” he said. “You can stand out by being yourself. Patients appreciate a personal touch and being treated as humans rather than as simply a source of income for a doctor,” he continued.

“You have to have the persona and the heart, not just the look. Patients will come to see you because they like you personally.”

Even during COVID-19-related webinars on his laptop, he wore his newly designed suits. And yes, he said, even on a virtual conference, he was wearing the suit with trousers, not pajamas. This shows a mark of consistency, he said, which should be a hallmark of surgeons.

Indeed, Dr. Gulani’s personal touch has earned him high praise from patients, many of whom fly from all over the world for his treatments. His colleagues look up to him as well not only to fix their complications but also as a life coach in many instances. He is often invited to be a key speaker at conferences and seminars worldwide.

High regard for colleagues beyond the frontline The fashionable surgeon also talked at length about his great respect for members of the medical community, especially doctors dealing with COVID-19.

“People say that doctors are on the frontline, but you really cannot compare soldiers to doctors,” he said.

“Who else could stay up for 72 hours in high-stress situations and still appear professional and capable to do their extremely complicated eye-

Every week, worldwide patients would huddle with Dr. Gulani before flying home.

| June/July 2020

25

UDOS COVID-19 SPECIAL REPORT However, they still occupy a privileged status in society and should remain cognizant of that.

“You could travel anywhere in the world and have a job,” said Dr. Gulani. “You could be in the Amazon rainforest or the outback of Australia or literally anywhere people exist, and a doctor will have a job.”

Doing your part when ‘business is back’ Dr. Gulani compared surgery to cooking in a recent video.

hand coordinated surgical procedures?

Doctors are rockstars!”

To doctors, he said: “Think about this: you were among the smartest in your class at college, hence you achieved a medical seat. Then among these intelligent medicos, you were so smart that you achieved the very coveted ophthalmology residency. So, why are you anxious and worried? There is nothing you cannot do.”

When it comes to ophthalmologists, his admiration for the field shows a sense of wonder. “A doctor can technically put his or her fingers on a three centimeter eyeball and change a patient’s life while they are breathing. How amazing is that?”

On keeping busy amid the pandemic During the lockdown, Dr. Gulani said nothing has changed for him besides not seeing his dear patients and performing surgery. “I have been busy teaching in back-to-back worldwide webinars and designing my new fashion line for men and women, while also designing new surgical instruments,” he shared. “I authored a textbook, spent time with family, saw movies, walked on the beach, conducted community fundraisers, and took calls from colleagues. But I did this every weekend anyways. It is gratifying to know that I don’t need to change anything.”

Dr. Gulani noted that doctors are by nature empathetic and will surely help patients in the future. Demand for treatment will not diminish, but patients’ ability to pay might.

Consequently, he suggested kindness and leniency. Working with patients on payment plans, extending credit, lowering costs, or even working at cost for patients who are in trouble financially, can all help to ease the burden.

There is also a possibility of an increase in surgical volumes and consults since people might realize how fragile life is and take care of their vision as soon as they can.

He recommended that the eye care industry and pharmaceutical companies help medical practices in a similar fashion in order to lessen the financial strain the pandemic has created. Essentially, he said, we have the opportunity to express our shared humanity and foster kindness.

He added that this is also a good time for doctors to stop being envious of each other. As he put it, “We’re all in the same boat. Raise your goals, and your bottom line will automatically rise.”

Everyone everywhere is affected by the pandemic — doctors are no exception.

Regarding practices weathering the storm, he suggested for doctors to reevaluate their financial situation and the health of their practice. If doctors find themselves struggling to pay staff, for example, they may be overstaffed or have too much overhead or costs.

Similarly, if a practice is in good financial health and does not find itself struggling, doctors can come back with the confidence that they were doing things right, to begin with.

26

| June/July 2020

A rare opportunity to do better and be better It certainly feels like the world is going through a great reset at the moment.

Rather than panicking or falling prey to fear-mongering, taking this opportunity to deeply evaluate your life can prove invaluable. This evaluation can be on the practical side, like with finances or business function, or it can be on the more philosophical side, like evaluating personal fulfillment.

“What will you leave behind?” asked Dr. Gulani. Indeed, it’s a question for the ages. As the saying goes, ‘society grows great when old men plant trees whose shade they know they’ll never enjoy.’

Taking stock of the bigger picture — gaining perspective on your role in the world and how you help humanity — can lead to deep contentment and satisfying life.

Editor’s Note: A version of this story was first published on cakemagazine.org.

Contributing Doctor Dr. Arun C. Gulani is a world-renowned LASIK, cataract, and corneal surgeon. He performs the entire spectrum of advanced vision surgeries to reduce dependence on glasses and contacts, customising vision correction surgery to meet each patient’s unique goals. He has extensive experience in a wide variety of eye surgery techniques and technology. He was formerly the Chief of Cornea and Assistant Professor of Ophthalmology in the University of Florida’s School of Medicine before founding the Gulani Vision Institute in 2003, where he receives a global clientele and acts as a consultant to eye surgeons and the eye care industry as well. With an eye of an artist, his passion is to make people see; and with his no-hype, one-on-one personalized care, he has turned Jacksonville, Florida, into a vision destination for the world. gulanivision@gulani.com

INDUSTRY UPDATE

Santen and Orbis International Collaborate on Telemedicine Platform

P

rior to the COVID-19 pandemic, telemedicine was garnering some attention from dedicated fans, but it definitely had not taken center stage.

Now, in the era of social distancing, digital platforms for learning and networking are gaining rapid popularity.

To continue spurring this online innovation forward, Santen Pharmaceutical and Orbis International have announced a three-year global partnership to develop a suite of digital training tools for eye care professionals worldwide. The telemedicine platform will feature online courses, live surgical demonstrations, and artificial intelligence (AI) focused on glaucoma.

“Santen values the advancements that can be made through collaboration and digital learning. And especially in

times like these, this partnership will be another step forward for better eye care for millions of patients,” said Shigeo Taniuchi, president and CEO of Santen.

users in nearly 200 countries. Since the pandemic began, a record number of eye care professionals have registered on Cybersight.

“Digital resources and solutions are critical to ensure doctors can provide optimal care to their patients. This partnership combines Orbis’s innovative technology in ophthalmic training and our global industry knowledge to enhance our joint mission of improving eye health for people around the world,” he continued.

“Technology has opened so many doors in our work to end avoidable blindness.

This initial step in the new partnership with Santen is very significant for Orbis because it allows us to further strengthen Cybersight offerings and reach more ophthalmologists in more countries,” said Dr. Danny Haddad, chief of programs at Orbis International.

The initiative uses Orbis’s award-winning telemedicine platform Cybersight, and will offer digital tools in Chinese, in an effort to increase educational opportunities in languages other than English, as well as to reach doctors in more rural or remote areas. Currently, the platform has more than 25,000

“As we increase eye care professionals’ access to training in their local language, we are ensuring that more patients get the quality care they deserve,” he concluded.

| June/July 2020

27

CORPORATE CORNER OPHTHALMIC EDUCATION

10 Things to Expect

When You’re Expecting…

a Digital Conference

by Matt Young

W

hat do you call jetlag when you experience the same symptoms but no jets are involved?

“Jetless lag,” our editor Brooke Herron interrupted.

Our team broke out into hysterical laughter.

But it was a serious problem we were suddenly confronting, and the word, along with the entire digital conference experience, needed some defining.

In very short order, we would be digitally exhibiting at and covering the American Society of Cataract and Refractive Surgery (ASCRS 2020) Virtual Meeting — from our base in Asia-Pacific.

For many of our team members, that meant networking, promoting and doing live coverage of the show at, or near a 12-hour time difference. You might say we’d all suddenly have 9-to-5 jobs over the weekend (9 p.m. to 5 a.m. local time, to suit the 9 a.m. to 5 p.m.

Eastern Standard Time meeting).

Additional factors would make this an even more grueling process.

First, we would be publishing digital “show dailies” — what amount to ophthalmology congress newspapers, where you typically start with blank pages in the morning (well, in this case, evening), and need to complete a full newspaper by the end of the “day.” This happens in sequential days over the course of the congress, such that your team virtually turns into an actual newspaper publisher. Now, we were actual newspaper publishers . . . virtually.

That meant we’d be adding a few elements. We would create video collages of the ASCRS event on the

28

fly, to be inserted into our show daily e-blasts. We would create content that would filter directly to our online news site. We would still create our standard show daily e-books. And in between all of that, we would be posting regular updates on social media to reach our thousands of fans… mostly to feed off their support to get through the night.

What quickly became apparent was our shophouse in Da Nang, Vietnam, became a mini virtual conference center. Laptops were strewn about — the kitchen dining table, the front office workspace and couches — but all were tuned into different sessions at ASCRS Virtual.

Much like in a convention center, people were going and coming at all hours — some to go take a nap at home in between sessions; some just getting in from taking in a late-night live show at “The Workshop” down the street, which is an artists enclave; and some, by sheer willpower, pushing through to yet another media task at dawn.

Needless to say, we learned a lot that weekend (yes, all this was over a weekend!). Below, I’ve rounded up my Top 10 list of what to expect when you’re expecting a digital exhibition.

10

Expect Intense engagement. You’ll be

glued to your seat more than you expect.

There’s a lot going on during a digital congress (these are not the same as mere “webinars”). You have symposiums you want to attend. You have networking sessions you’d like to be a part of. You have contacts you’d like to make. There’s an exhibition hall you’d like to explore.

And you probably have to do this all in a curtailed exhibition environment, because these aren’t going to run three, four or five days like they used to. Time is of the essence. Others might not be glued to their desks the whole time. That would be a mistake.

| June/July 2020

9

Nervous energy. As

8

To be wired. Make no mistake,

mentioned, our shophouse is at my home. And yet I experienced the same nervous energy surrounding our home-based conference activities I experienced during a standard convention. While it was more convenient to stay home and not have to travel a far distance, other factors made this more challenging. There was no real upside of seeing friends in person, which exude support and assuage doubts. You are in your bubble, and while in our case teammates were around, everyone was extremely busy doing their own thing. So there was a strange mix of conference adrenaline, and often there was nowhere for that adrenaline to go other than right into your laptop, which isn’t the same as an engaged person.

this is a paradigm shift in conference attendance. The entire experience is digital. If you’re not used to playing video games, it can feel like you are suddenly totally “plugged in” and “wired.” This is a shift that is happening in the world around us.

Coronavirus encouraged us to engage with our devices more than ever before. There is talk of man eventually becoming a machine. But this is one more step along the way in which your work life becomes almost completely digital, save for the breaks because nature still calls.

7

Creativity. Because you are

exploring a new digital frontier, you are going to be in a new environment.

No real creature comforts to be had here, despite the home-based amenities. Those are a mirage. You’re a digital animal, exploring the binary wilderness of 1s and 0s for quite possibly the first time in this scenario.

New thoughts will come to you. From there springs an idea. Suddenly: Fire! Fire good! But it’s not about creating actual fire, as in the woods of yesteryear. That’s the fire in your mind.

Embrace it.

6

Jetless lag. As briefly explained

above, you’re not getting on a flight, but if you plan to attend a digital conference across multiple time zones, be prepared for some odd hours. Many of our team members started shifting

their sleep cycles days in advance to prepare. Digital conferences almost certainly are going to be held at inconvenient times for many people.

Are they worth attending? Absolutely.

Do you need to crack a Red Bull to get through it? Absolutely.

5

Missed connections. Digital

conference communication software is in its infancy. I completely overlooked this prior to ASCRS Virtual. I assumed that one could casually agree to meet at ASCRS Virtual, and it would be as easy as stopping by a physical booth almost anytime to meet up and either have an ad hoc meeting or make an appointment for another time. That was absolutely not the case. One of the trickiest parts of a digital conference — we have observed — is setting valid meeting appointments within the virtual venue. One can set an appointment in advance by offering to Google Meet, Zoom or have an old-fashioned call. And in virtual terrain there are ways — but unfamiliar to users and possibly just not used by many. When in congress cyberspace with everything going on, there has got to be a better way to “exp” (send a text message in a virtual expo, per our virtual exhibition definitions by Media MICE) and easily meet up. Otherwise, prepare to be “silhoued” or “schedultated” — see our accompanying digital conference definitions.

4

You’ll want a set of “trous”. Admittedly during

ASCRS Virtual, I wore shorts that didn’t match my colorful blazers for

3

the obvious reason — the chest-and-up video interviews. Being a stylish guy, but also moderating from 99°-FahrenheitVietnam (that’s 37° Celsius), I chose the half-measure. But, given that I design my own funky tailored suits, I am definitely getting matching sets of “trous” for the next digital conference (trousers that have been cut in half to be worn more comfortably on business webinars without anyone realizing it — also per our new digital exhibition definitions).

Sales change-up. The sales

game has changed. You’re not going to be able to press the flesh to seal the deal. You can’t expect delegates to walk out of a corporate symposium, all jazzed up, and straight to the relevant booth to make a purchase. Instead, you’re going to have to adjust to figure out how to sell digitally. Hopefully, the digital conference organizer will help. But unfortunately, they have relied on floor space sales since time immemorial.

Societies and organizers are out of their digital league here. Does it mean you give the virtual meeting a pass?

No. There are few if any physical conferences still happening currently.

So what else are you doing with your day? You still need to stay connected.

You still need to work whatever sales angle you can. You still need to show up with your digital booth and suggest that you’re all well and good, despite the pandemic. The more you pivot digitally now, the better off you’ll be not only currently, but for when hybrid meetings come into play in 2021. You’ll need to be ready to exhibit and attend both virtually and physically. Why not get the learning curve over while you have nothing better to attend?

2

Innovation in communication. For years,

I’ve been preaching innovation in ophthalmic communications, and often I’ve gone to extremes to make a point.

I’ve worn banana outfits — to say the least — in a sea of conservative suits.

What’s clear now is that digitally,

traffic and eyeballs are more important than ever. We have witnessed the All India Ophthalmological Society (AIOS) membership wear strange hats during a webinar just to stand out and be different. What seemed crazy before now has logical impact and ROI. Boring methods of communication will continue, to be sure. Victory goes to those who think outside the booth, physically at least, and explore new creative terrain in the digital realm.

1

Financial loss. I said expect

it, and then look forward to the upside. No way 2020 gets back on track financially for the vast majority of companies. But, what if 2021 or 2022 is brighter because we not only have a physical space to engage one another, but we now also have refined virtual spaces? That’s eventually more connections. That’s eventually more engagement. That’s eventually more sales. We should not hope so. Together, we should make it so.

Home has returned to normal. There are no more conventions here — at least not until the World Ophthalmology Congress (WOC), where we have been named Media Partner and are anticipating yet another “home-based” congress. At least we’ll be covering a more civilized time zone from Asia this time.

Warren Buffet once said, “Be fearful when others are greedy and greedy when others are fearful.” Based on that, my final advice is: Now is a great time to be greedy, and get involved in as many digital exhibitions that you can afford while the competition is busy attending nothing.

Editor’s Note: ASCRS 2020 Virtual Annual Meeting — the world’s first-ever successful virtual ophthalmic conference — was held on May 16 to 17, 2020. Reporting for this article also took place during the virtual ASCRS 2020 conference, where CAKE magazine’s parent company, Media MICE, was the only exhibiting independent media.

| June/July 2020

29

NLIGHTENMENT COVID-19 SPECIAL REPORT

Insights from Europe Corneal Transplantations Amid the Pandemic

by Brooke Herron

Getting testy with COVID-19 In addition to having fewer transplant procedures, increased safety measures have decreased the number of recovered donor corneas by about 50%. Plus, there are a lot of unanswered questions — like, can recipients get COVID-19 from donors?

Do we need to test donor corneas?

In most cases, corneas are not being tested because there simply aren’t enough test kits available.

“The problem with testing donors is that it reduces the number of swab tests available. Do you want to take away a test from someone else who needs it?” Mr. Börgel pointed out.

He added that the tests are made for living people, not post-mortem corneal donations. Instead, they follow the screening protocol established by authorities, like the European Eye Bank Association.

A

s COVID-19 continues its nefarious course around the globe, its effects are rippling through just about every industry. In ophthalmology, most non-emergency surgeries have ceased. And while this is necessary for now, halting procedures can have unintended consequences.

CAKE magazine and Geuder AG (Heidelberg, Germany) spoke with experts in Italy and Germany to learn how the pandemic is affecting corneal donor and transplantation in Europe.

Ciao, cornea transplants In Italy, Dr. Diego Ponzin, Medical Director and Corneal Consultant, Veneto Eye Bank Foundation in Venice, shared that at the moment, their transplant activity is 10% of what it was in the first half of February. “And there is the risk that a number of tissue will not be used for keratoplasty because they are going to expire,” he shared.

30

Dr. Ponzin noted that the number of positive COVID-19 cases in the country is still growing but at a reduced rate.

“We are probably seeing the beginning of the flattening or decline.”

However, he doesn’t expect the number of corneal transplant procedures to increase in the following months. And even once that occurs, Dr. Ponzin said there will be a discrepancy in term of needs and the ability to satisfy them.

Meanwhile, in Germany, Mr. Martin Börgel, CEO of the German Society for Tissue Transplantation (Deutsche Gesellschaft für Gewebetransplantation or DGFG), said their March transplant numbers were nearly normal. However, come April the numbers of both transplants and donations have totally dropped.

“Now, we’re doing half of what we normally do, and I expect this will go on through the end of the month,” he shared, adding that Germany might get back to 65% to 70% of its preCOVID-19 transplants in May — if they’re lucky.

| June/July 2020

“In our experience, the most important thing is serious and very consistent screening by medical doctors, and that they check the donor history. If there is any hint of going down the road to COVID-19, we skip the donor and we don’t use it,” he explained.

COVID-19 transmission: Possible through corneal transplantation?

Dr. Silke Wahl, head of quality management at Eye Clinic Sulzbach, Germany, said no. “The responsible party in Germany said there is no sign that the coronavirus or COVID-19 is transmitted by tissue transplantation.

Therefore, we think that our transplants are safe,” she said.

Dr. Wahl added that they are, of course, following other screening measures. “We review their travel history, including affected countries like Italy, Spain and China,” said Dr. Wahl. “We also ask relatives if the donor had contact with anyone who tested positive for COVID-19.”

Dr. Wahl, like Mr. Börgel, agreed that there simply aren’t enough test kits to use them on donated corneas. “We found a laboratory that was willing to do the tests for us, but it’s difficult

to get enough test kits. So that’s also a reason why we decided not to do it,” she explained.

In Italy, Dr. Ponzin said they have also become more selective in evaluating the clinical history of potential donors.

And unlike his colleagues in Germany, they are testing their donor corneas for COVID-19. “We swab every donor for genetic testing and genetic research of the virus,” he said. After a negative COVID-19 test, the donor tissue can then be released for use.

It’s clear that the definition of a “corneal emergency” varies, along with the capabilities of the hospitals in different regions. In Italy, Dr. Ponzin said that emergency cases could include perforation or impending perforation, as well as infections that require keratoplasty.

“Perhaps a keratoplasty that is producing pain or suffering, or for some degenerative conditions that produce significant pain. But besides those, all other procedures are elective,” he added.

“We have sufficient tests available because we have a reference laboratory that is very effective and is providing us the material,” explained Dr. Ponzin, adding that they do not test the recipients. Rather, that is left to the discretion of the treating surgeon or hospital policy.

According to Mr. Börgel, things will (hopefully) begin to normalize over the summer. “Our expectation is that the summer break will not really be a summer break. We think a lot of hospitals will restart their transplantation programs at that time,” he said.

Elective corneal emergencies amid the pandemic

Ways of storing cell cultures: To change or not to change?

In the age of emergency-only surgery, which procedures get that urgent status seems to vary. While many have reported a decline in corneal transplants and Descemet’s membrane endothelial keratoplasty (DMEK) grafts, Dr. Wahl noted the opposite.

The loss of donor corneas — either from the expiry or red flags during the screening — is a hard pill to swallow.

So, will the pandemic change the way cell cultures are stored?

“At present, we don’t have an actual decline. We just know that at some hospitals they are not doing transplantations at the moment.

But we [at the Eye Clinic in Sulzbach, Germany] are not reducing surgeries, everything stays normal for transplantation,” she said. “The DMEK, or corneal transplantation, is not an elective surgery. So, if the patient needs it, we are doing it if we can.”

In addition, postponing corneal transplantations can actually result in an emergency scenario. “If you start to postpone elective patients, some will become emergency cases — these people need their transplantations,” said Mr. Börgel. “That’s what we’re seeing now. Some of the cases are becoming close to urgent, so their surgeon is deciding to do the operation now (depending on the resources they have in their hospital).”

According to Dr. Ponzin, there should definitely be research into ways of storing tissue for a longer period. “This would probably be a strategy that could ensure our survival. And we are also committed to our donor’s families,” he shared.

“Regardless of the epidemic, it will be very disappointing for them to know that the tissue of their beloved could not be used because we couldn’t store it beyond our current capabilities,” Dr. Ponzin added. Currently, cornea donations can only be stored for about one month.

Meanwhile, Mr. Börgel said that the cell culture system in Europe is quite good.

Dr. Wahl agreed that it’s not something they’re considering to change either. “If the crisis was recurring, then we would think about changing the media,” concluded Dr. Wahl.

Contributors Dr. Diego Ponzin is the medical director and corneal consultant of the Veneto Eye Bank Foundation in Venice, Italy, with a clinical interest in ocular surface and corneal diseases, cornea biology, storage, and selection for transplantation. He obtained his medical degree at the University of Padua, Italy and his post-doctoral diploma in Ophthalmology at the University of Udine, Italy, and has been a research associate at the Department of the FIDIA Research Laboratories in Padua, and expert for eye banking of the Consulta Nazionale Trapianti, Rome. He has received multiple national and international awards. As a reviewer of several journals, including the British Journal of Ophthalmology, European Journal of Ophthalmology, and Cornea. He has coauthored multiple papers and book chapter reviews. In his spare time, he writes novels and plays electric bass with a band.

Mr. Martin Börgel is the managing director of the German Society for Tissue Transplantation (DGFG) and has led the non-profit, universitysupported German Society for Tissue Transplantation (DGFG) since 2002. Over the years, he has established a nationwide network of 13 tissue banks, over 100 donation clinics, and hundreds of transplantation programs for cornea, cardio-vascular tissue, and amniotic membrane. The DGFG network provides about 50% of the tissues transplanted in Germany every year.

Dr. Silke Wahl is the head of Quality Management at Knappschaft Tissue Bank in Sulzbach, Germany, since October 2015. She has a degree in Human and Molecular Biology and a Ph.D. in Anatomy and Cell Biology, both from the University of Saarland, Germany.

Editor’s Note: Geuder AG develops, produces and markets ophthalmic instruments and systems for the latest surgical techniques, including instrumentation for corneal transplant procedures.

A version of this story was first published on cakemagazine.org.

| June/July 2020

31

NLIGHTENMENT COVID-19 SPECIAL REPORT

Musings of an Ophthalmologist

From Coronavirus Fellowship to the Dangers of Democracy

The impact on low-income individuals has been particularly acute both in the U.S. and other Western countries.

Dr. Alio noted that an unexpected feature of the pandemic is that socialist nations like Vietnam and North Korea have weathered the storm better than their Western counterparts. Dr. Alio attributed this to a culture of deference within these societies.

by Andrew Sweeney

W

hen the coronavirus pandemic ends, one of its most enduring images will be hospital hallways strewn with patients struggling to breathe. In the last months, images of people gasping for air, slumped over chairs or even lying on blankets on the floors became all too familiar. What’s more, they were filmed in European hospitals in countries whose public health services are considered among the best in the world.

Spain is one of the countries most affected by coronavirus, and it is only now emerging from one of the world’s most restrictive lockdowns. Medical personnel from all sectors were drafted to join the fight against coronavirus, and ophthalmology was no exception.

Elective surgeries will likely become possible again as coronavirus restrictions are eased. But how will such procedures be able to proceed without trained ophthalmologists? In Spain and many other countries, eye surgeons are more likely to be found in an emergency room, rather than at an ophthalmology clinic.

Dr. Jorge Alio is one such ophthalmologist. An industry veteran with decades of experience, Dr. Alio is a specialist in cataract, cornea, and refractive surgery. Based in Alicante, Spain, he has been frustrated both by the inaction of governments in the face of coronavirus, particularly in the United Kingdom, as well as the lack of a framework to support ophthalmologists in general medicine.

Ophthalmologists in Spain like Dr. Alio are being thrust into the pandemic with relatively limited check-ups, which, in Dr. Alio’s case, is a biennial cardiopulmonary resuscitation test.

He’s concerned that doctors are being placed in difficult positions with only theoretical preparation. Dr. Alio believes a fellowship system is the solution.

“You have to take a mini-fellowship with a practitioner you know” Dr. Alio said.

“That means that you become his or her assistant and you have to follow them.

Meanwhile, you have to get a handbook on intensive care.”

Like previous generations drafted into war, many ophthalmologists have joined the fight against this insidious enemy.

He added: “We are very keen to help, we are ophthalmologists, but to be in the emergency room is totally different.

Our skills have not been updated.”

A need for a coronavirus fellowship program

Is democracy good for disease?

Indeed, the pandemic has had a tremendous impact on ophthalmology as a whole. Young professionals just out of medical school were thrust into a high-intensity environment, fresh from their general medical training. More experienced professionals, prepared for the chaos of mass-triage, reported concerns about their skills not being updated sufficiently.

Dr. Alio was likewise critical of the response by many Western governments to the coronavirus. In particular, he criticized the handling of the crisis

by U.S. President Donald Trump. Dr. Alio said the president is incapable of viewing the crisis as it is, as a medical crisis, and views it instead as a business issue.

32

| June/July 2020

“All the countries with authoritarian governments, such as North Korea, Russia, China and Vietnam, all of these countries are doing better because the authorities are making the right decision,” Dr. Alio said.

“They took the right advice and they followed it without thinking about political decisions, because political decisions are imposed on society. In those countries you don’t decide the politics, you suffer the politics and they did well,” he added.

Whether a more authoritarian or socialist form of government makes a country’s survivability during coronavirus more viable is debatable.

But certainly, more decisiveness and clarity on the part of Western governments would be welcome.

Like all industries, ophthalmology needs support to return to normal once the crisis passes, while medical personnel working in the industry may need assistance in fighting the virus on the frontlines. Dr. Alio’s idea of a fellowship program could be easily implemented and would doubtless provide welcome support to ophthalmologists.

Editor’s Note: This story is part of the ‘Q&A from Quarantine’ series of CAKE Talks, where Matt Young (CEO of Media MICE and Publisher of PIE and CAKE magazines), during the time of COVID-19 lockdown, reached out to KOLs and industry friends to evaluate and discuss the impact of this pandemic to the ophthalmic world. A version of this story was first published on cakemagazine.org.

INDUSTRY UPDATE

SNEC & SERI Launch Heroes Fund to Strengthen Defense Against Future Epidemics

I

t’s clear that COVID-19 has had

evolving needs of our patients, health care

training and upgrading of skills — ensuring

devastating consequences worldwide

providers and research teams, especially

that these healthcare heroes can complete

— industries across every sector have

during this period of enormous change

their training and acquire the skills needed to

been impacted, including ophthalmology.

and uncertainty,” said Adjunct Associate

treat increasingly complex eye diseases, and

Therefore, in an effort to deal with the

Professor Ho Ching Lin, Director of

thus giving patients a better quality of life.

ongoing crisis, and strengthen Singapore’s

Philanthropy, SNEC. “While COVID-19

defense against future epidemics, the

remains, there are many patients who are

Speaking on the Heroes Fund, Professor

Singapore National Eye Centre (SNEC)

also suffering from eye diseases that may

Wong Tien Yin, Medical Director at SNEC

and the Singapore Eye Research Institute

lead to vision loss. This is why it is critical

said: “We must continue to be forward-

(SERI) have launched the Heroes Fund.

that we focus on new ways to approach the

looking and future ready. COVID-19

This campaign aims to raise $1 million by

crisis and with better preparedness. The

has presented us with an opportunity to

January 31, 2021.

funds will greatly enable us to improve on

innovate and better equip ourselves to

our clinical care processes and to develop

face what is ahead of us. Therefore, it

cutting-edge research as we move forward.”

is imperative to continue to channel our

The campaign is named for SNEC and SERI’s frontline medical workers; funds will

efforts to upgrade our existing model of

support the Centre’s healthcare workforce

New models of care, like using technology

care, develop cost-effective treatments and

by providing them with the latest training,

to conduct tele-consultations for glaucoma

create breakthroughs in the research for

tools, innovation and methods of care in

patients, are already in place at SNEC.

COVID-19.”

ophthalmology. This includes redefining

The Centre has also implemented a home

clinical care to meet the urgent needs of

monitoring service in an effort to decrease

The Heroes Fund is part of the VisionSave

patients; driving cutting-edge research to

non-essential visits and proactively detect

campaign, a philanthropic drive spearheaded

keep COVID-19 at bay; and maximizing

those who may experience severe visual

by SNEC and SERI. Corporate, personal, or

healthcare knowledge for a future-ready

symptoms and prevent blindness.

anonymous donations can be made to the

frontline workforce.

“We recognize the urgency to meet the

Heroes Fund by visiting the online campaign Funds raised will also help to develop

website at www.giving.sg/shf-snec-fund/

e-learning programs to facilitate undisrupted

heroes-fund.

| June/July 2020

33

NLIGHTENMENT OPHTHALMIC BUSINESS

Ophthalmology Post-Pandemic:

A Glimpse Into the Future

by Sam McCommon

If everyone had a crystal ball, they wouldn’t be worth much.

F

rom finding effective methods to store corneas to determining the efficacy of single-use surgical instruments — there are a lot of issues facing ophthalmologists today. Not to mention, how do we even start going back to “normal” after the pandemic or while the threats of coronavirus still looming on the horizon?

In a conversation with CAKE magazine CEO and Publisher Matt Young, Mr. Frederic Giulj, the export director of Moria Ophthalmic Instruments, gave us an insider’s view into the possible future of the ophthalmic industry. His company makes several specialized ophthalmic tools — and they certainly have a wealth of experience to share.

Below are highlights of their conversation — a wild ride through the industry and across regions.

tissue was very real. It hearkened back to the darkest days of the early part of the AIDS epidemic in the 1980s.

The United States may go from being the world’s leading exporter of cornea tissue to playing a much smaller role, especially considering the outbreak in the U.S. is far from over.

Questions still exist concerning corneas: How is it best to store them, considering surgery demand is far lower than it was months ago? How do you test corneas to make sure they don’t contain the coronavirus? How can you transport corneas when borders are shut in many parts of the world? This is a major concern for the cornea transplant market, especially when the U.S. is involved.

One of the most important ophthalmic sectors that have been affected by COVID-19 is keratoplasty. When the outbreak began, it was unclear just how the virus spread — and the possibility of it spreading through eye

European countries, however, seem to have fared far better in managing eye banks. As Mr. Giulj put it, “I have feedback from German companies, and they’re telling me they’re going to go back to normal — they’re not really going to be affected. But concerning the American eye banks, the discussion we have internally with the U.S. guys is that they have not thought about it.

They didn’t look at the testing issues or that the testing could be an issue.

Are they going to find out, is COVID-19

34

| June/July 2020

Cornea transplants, a world apart

testing on tissue going to be a problem for the American eye banks, or is it easy to make not a problem?”

He continued, “The problem is, the U.S. provides tissues to half of the world. If you look at the Middle East, Asia, and some European countries, it’s going to be quite a big issue for cornea eye banking. The U.S. seems quite messy right now and they have no clue about what’s going on and what’s going to happen.”

Eye banks in Italy may prove to be the gold standard for the entire world — and Italy was particularly hard hit by the pandemic. Mr. Giulj speculated that the reason for this was tied to the technical expertise in handling the virus in general.

“The eye bank in Venice is probably the best in the world for many reasons,” he said. “I was just reading an article about how Venice handled the crisis.

They had an expert who contacted the governor and told them to put him in charge of the program and they’ve done a massive testing program. They handled the situation much better than the other regions. They said they could test the whole city in five days, and they did. It’s a coincidence — but I’m not

surprised because Venice’s eye bank is really the cream of the cream. I haven’t seen anyone so professional and so scientific anywhere else.”

Being professional and scientific is certainly something ophthalmologists everywhere strive for — which has led some to change the tools they use.

Disposable products: A double-edged sword One option that has become much more attractive due to the virus is the use of disposable surgical products. These single-use products prevent the spread of the virus by, well, being single-use.

As Mr. Giulj said, “Regarding microkeratome surgery, there’s an opportunity we have right now to put more pressure on disposable products and therefore the development of a disposable line of cataract instruments.

If you also have to do a lot of cataract surgeries tomorrow, you may ask if the sterilization system is going to interfere with the timing. If you have enough instruments and you want to do more surgeries, you may go with disposable products.”

Disposable products may seem like a godsend now, but they come with their own set of problems, including quality and availability due to supply chain pressures.

“The problem with disposable,” said Mr. Giulj, “is you have a whole logistical aspect to look at, and production-wise we’re at maximum capacity. And the quality of most of the instruments is not so good. So, is it going to push the industry of ophthalmology to generalize Chinese and Pakitanese cheap,

disposable and low-quality instruments, or is it going to create the demand for disposable products that are a little bit more expensive but of better quality?

We’re at a crossroads.”

Asia wakes up first The world is also at a crossroads when it comes to pandemic management.

The end goal must be to return to some semblance of normalcy — and the first to do it will likely reap huge rewards.

In terms of which region comes back to normalcy first, Mr. Giulj was unequivocal: It will be Asia, for many reasons. “The way I see it, they handled the crisis much better than anyone else because they’ve been facing such a crisis for the past 15, 20 years,” said Mr. Giulj. “Everybody’s wearing a mask wherever you go in Asia. Lockdown, testing, quarantine — they do it and no one is raising any questions about human rights or about having the cops around or trying to take advantage of this. There’s a better understanding, they’re better prepared, they have more experience and maybe the mentality is more adjusted to the common situation and also to get things done.”

That doesn’t mean that other regions will be behind forever — Mr. Giulj pointed out that it “was in the American market’s genes” to catch up quickly to industry trends without a huge amount of investment. But the pandemic will certainly shape the future of the industry.

COVID-19’s long-lasting impacts on ophthalmology

the 2008 economic crisis’s effects on ophthalmology and the potential outcomes from the current crisis. He noted especially that femtosecondlaser surgery procedures peaked in 2008 and are down 40% since then — largely because the technology and the procedures are expensive.

While refractive surgery centers will be unlikely to reduce their prices, he said, demand will remain relatively flat post-virus. He speculated that some refractive centers will likely close down unless they find a way to reduce their prices.

He specifically pointed out that he believed femtosecond laser-assisted cataract surgery (FLACS) will go the way of the dodo due to its price and the negligible impact on surgery outcome the laser has.

Mr. Giulj said that, on the other hand, femtosecond lasers will continue to have a place in laser-assisted in situ keratomileusis (LASIK) treatments.

The alternative is a microkeratome — which Moria makes. As Mr. Giulj said, the company is the last in the industry to make the tool and represents a wholesome ‘back-to-basics’ approach.

The world will return to “normal” at some point, but the effects of the virus will likely be felt for a long time afterwards. This may include a change in the patient marketplace, a change in the way tools are used, or even changes in what tissues are available where.

Whatever the case, the ophthalmic industry is resilient and will bounce back — but individuals and businesses within it will need to adapt in order to survive.

Mr. Giulj drew comparisons between

Editor’s Note: This article is part of the ‘Q&A from Quarantine’ series of CAKE Talks, where Matt Young, CEO of Media MICE and Publisher of PIE and CAKE magazines, reached out to KOLs and industry friends during the time of COVID-19 lockdown to evaluate and discuss the impact of this pandemic on the ophthalmic world.

Is this sword stuck in a stone, too?

| June/July 2020

35

CONFERENCE HIGHLIGHTS ASCRS 2020 VIRTUAL COVERAGE

ASCRS 2020 Pulls Off First-Ever Major Virtual Ophthalmic Conference

by Andrew Sweeney

J

ust as most organizers started postponing and canceling seminars and conferences lined up for the year, the American Society of Cataract and Refractive Surgery Virtual Annual Meeting (ASCRS 2020) boldly announced that they were going virtual.

True enough — on May 16 to 17, ASCRS 2020 pulled off the world’s first-ever successful virtual ophthalmic conference during a pandemic.

Prior to the virtual seminar, expectations were high. There were mutterings that a purely virtual conference couldn’t cut the mustard.

Many asked whether ASCRS was doomed to fail a major coronavirus litmus test.

Well, consider the mustard correctly cut and spread successfully over a superlative sandwich. Nobody expected a fully virtual conference to be just as good as one in the flesh, but the ASCRS proved itself superbly.

No lockdown can stop the tribe Ophthalmology professionals from all corners of the globe chimed in on different topics — from coronavirus to cataracts to canceled treatments.

And all were glad for the opportunity to share their experiences.

However, no matter how successful the event was, there was something left to be desired about virtual exhibitions.

Sources noted the following challenges: 1) Missing in-person social connections that seem irreplaceable 2) Missed connections due to somewhat clunky communication methods inside the virtual space, and 3) A desire to find a

36

better way to connect discussions about products with actual commercial sales.

These are understandable, of course, given that ASCRS was bold enough to put on the first real digital ophthalmology exhibition ever, challenges were to be expected.

Star(ship) appearances The first day of the conference ended on a particularly high note — literally.

After a day of statistics, reports, e-posters and more, the conference wrapped up with the 38th Film Festival Reception and Awards Ceremony, featuring a special guest appearance by Jefferson Starship lead Singer Mickey Thomas, who treated viewers to his own special version of “I Can See Clearly Now,” by Jimmy Cliff.

Of course, most of the films were more related to ophthalmology.

| June/July 2020

We particularly enjoyed Dr. Sergio Canabrava’s “Intrascleral Intraocular Lens Fixation Technique; No Flaps, No Knots, No Glue”. The surgical footage was as insightful (and gory to the uninitiated) as the name was long.

Kudos to Dr. Canabrava for his two years of research.

Also on the first day of ASCRS 2020, the former U.S. FDA Administrator, Dr. Scott Gottlieb, covered the coronavirus in a symposium sponsored by Novartis.

Dr. Gottlieb stated that the coronavirus infection rate in the U.S. is currently low and that it’s a safe assumption that most people infected with the virus will subsequently develop immunity, similarly to other coronaviruses.

This was welcome news for ophthalmologists stuck with shuttered clinics and desperate for more patients to feel safe enough to return. Dr Gottlieb also emphasized his view that telemedicine, which has experienced a

massive uptick, is here to stay, pointing to his own experience of improved productivity, thanks to video calls.

Of cartoons, predictions & telemedicine Have you ever seen those episodes of The Simpsons that appear to predict the future, including video calls and the Trump presidency? The Jetsons was another prophetic cartoon, predicting telemedicine back in the 1960s.

At least that was according to Dr. Ranya Habash, who spoke during the “Turning the Lights Back On: Part 2” symposium.

As a self-described telemedicine enthusiast and cartoon fan, to Dr. Habash, using telemedicine is more than just good practice — it’s a Darwinian crux. We’ve arrived at a sinkor-swim moment, and telemedicine is the life raft.

“This is simple evolution, if we are to survive we must adapt. It’s an opportunity to spur medicine forward, and we should embrace that,” Dr. Habash said.

Now, while we’re not likely to use The Jetson’s flying cars anytime soon, Dr. Habash is right. Telemedicine is the future of ophthalmology and a virtual conference is a good hint toward this.

Technology offers a lot, particularly for those who find it difficult to access medicine, like the elderly and children with disabilities.

Interesting posters to note Kids with Down’s syndrome in particular face particular challenges in ophthalmology. Their corneal thickness, for example, is usually 100mm thinner than average healthy levels, according to One Extra Chromosome X, Makes One Special Child-Don’t Miss out Mr X. This e-poster’s study screened children with Down’s syndrome over eight years old.

Five eyes were diagnosed with grade two keratoconus and one presented with acute hydrops. The children received treatment, which was described as rewarding, with better visual quality and accompanying cognitive and emotional

As the song says we’ll meet again, and we’re sure it won’t be long!

development. The study’s authors stated that close monitoring and screening can significantly help similarly disabled children, and overall improve their behavioral and emotional state.

These researchers called for targeted screenings and marksmanship, not unlike another standout e-poster from the conference. Rifle Marksmanship Following Small Incision Lenticule Extraction saw researchers team up with the U.S. Army to examine the effects of small incision lenticule extraction (SMILE) treatment for myopia.

The results of the study were fascinating. Out of four marksmanship categories, soldiers in the lower three performed the same or worse after SMILE treatment — yet expert shooters (the highest category) actually improved. The researchers concluded shooting was as good post-SMILE without correction as it was with correction preoperatively.

A start of a new normal?

The marksmanship in the military e-poster was in fact a fitting symbol of the overall atmosphere of the ASCRS conference. It succeeded because of the Blitz-spirit that the ophthalmology industry is experiencing. People from all areas of the industry are coming together to survive, to learn the best lessons we can from the crisis, and to thrive after it’s over.

Dr. David W. Parke, CEO of the American Academy of Ophthalmology, perhaps best summed up this zeitgeist.

Churchillian in tone, he pointed out that in the U.S., 79% of baseline visits have been cancelled in ophthalmology — the worst affected medical sector.

However, he offered more than defiance in this present adversity. Rather, he offered optimism and pride. “The normal of the future will never be the normal of last January. We will always have the memory of how it is to shelterin-place, to furlough staff, and defer patient care,” Dr. Parke said.

“Years in the future, every ophthalmologist will be able to tell their grandchildren that they played an important role in blocking virus transmission and preserving scarce PPE,” he added.

If ASCRS 2020 Virtual Annual Meeting has taught us one thing, it’s that ophthalmology shall never surrender.

Editor’s Note: ASCRS 2020 Virtual Annual Meeting — the world’s first-ever successful virtual ophthalmic conference — was held on May 16 to 17, 2020. Reporting for this article also took place during the virtual ASCRS 2020 conference, where CAKE magazine’s parent company, Media MICE, was the only exhibiting independent media.

A version of this story was first published on cakemagazine.org.

| June/July 2020

37

CONFERENCE HIGHLIGHTS OIS@ISRAEL 2020 COVERAGE

First Time’s A Charm

W

hile we would certainly prefer to be indulging in the world’s best hummus and shakshuka in Tel Aviv’s Bauhaus cafes after a day’s work covering Israel’s Ophthalmology Innovation Summit (OIS@Israel 2020), the pandemic, unfortunately, had other plans. But Israel didn’t let COVID-19 get in the way of successfully delivering its first OIS meeting. And so, on July 18, OIS held its first-ever international meeting in Israel — virtually!

Israel is characterized as being quick to adopt the latest technology and was one of the first countries to lock down in response to coronavirus. Restrictions have now been lifted in the country, which has only experienced 303 fatalities.

Israel Successfully Delivers First OIS Online by Andrew Sweeney

ophthalmological conditions ranging from eye microsurgery to strabismus treatment. Characterized by rapidity in utilizing the latest technology to cure and treat eye conditions, Israel’s ophthalmology industry is a world leader.

A time for everything, even online The OIS Israel 2020 was originally scheduled to be held in Tel Aviv, Israel’s economic heart. According to the conference’s organizers, the country was chosen due to its strategic location, record of technological innovation, and attractiveness to venture capitalists.

The startup nation is one of the world’s leading destinations for medical tourism and the country is at the forefront of medical research and innovation.

Medical facilities in the country offer cutting-edge treatment for a variety of

The summit was originally conceived

by Dr. Emmett T. Cunningham Jr., MD, PhD, MPH, of Blackstone Life Sciences, a multinational business investment group. OIS has held events in the United States for a number of years and 2020 was due to be the event’s

38

| June/July 2020

inaugural event in Israel. Coronavirus obviously waylaid that plan — and while a “real life” meeting would naturally be preferable, Dr. Cunnigham and his fellow organizers acquitted themselves well.

The online summit was structured as a two-hour webinar with an additional hour for networking. The first segment, OIS@Israel Company Showcase, served to highlight local Israeli companies working in ophthalmology. The second segment, Industry Insights and Innovating Internationally, examined the ophthalmology industry more broadly.

Israel proves it is a leader in AI A number of leading ophthalmology and medical companies from Israel presented during the first segment of the conference. While all of the presenters worked in various fields within the ophthalmological industry, all were similarly characterized by a

focus on technological innovation and ingenuity.

In particular, discussions about artificial intelligence (AI) accounted for a large segment of the presentation session.

This is unsurprising as Israel is also a world leader in AI technology, and a number of multinational AI developers have operations located in the country.

Yaacov Michlin, the chairman of DiagnosTear, discussed how his company uses AI-driven technology to treat dry eye. The condition’s commonality makes it an excellent testing ground for AI-driven solutions, noted Mr. Michlin. His company’s diagnostic companion device, TeaRx™, can be used at home and represents the vanguard of a combined science approach.

“DiagnosTear is a great example of Israeli innovation, combining chemistry, biology and AI into what we call bioconvergence,” shared Mr. Michlin.

amblyopia at home — worth noting given the recent explosion in the uptake of telemedicine technology.

The glasses-based system is designed specifically for children and was developed to ensure a high degree of functionality.

could be conducted with AI research.

“Kids hate eye patches, they don’t look good, they don’t see well, so they just remove them. We’re talking about a less than 40% compliance rate and a 25% recurrence,” said Ran Yam, the CEO and co-founder of NovaSight.

“I’ve seen a lot of companies there that are virtual, and this is going to be a trend that increases in the coming years. Innovation doesn’t happen in just a couple of concentrated areas,” he added.

“That’s why we came up with the home treatment device. The kid wears glasses watching his favorite Internet content on any device. The glasses blur the image in the strong eye and the kid only needs to use it for one hour a day,” he added.

As the session drew to a close, the discussion shifted to the fundamentals of how ophthalmological business will change due to coronavirus. Two issues were noted in particular. Firstly, the backlog in elective surgery offers an opportunity for private healthcare providers. Secondly, research companies should look to run trials in more countries to mitigate the damage of coronavirus-related lockdowns.

Lessons from Israel: How can ophthalmology learn from the country?

SensEyez also uses AI-based machine learning technology in ophthalmology.

The company is working on what it describes as game-changing retinal imaging technology for teleretinal screening and monitoring called Snapshot Multispectral Fundus Imaging. It uses machinelearning algorithms to detect retinal abnormalities that cannot be seen in standard fundus color images.

The conference’s second session was given over to a detailed discussion about ophthalmology in general. The panel, which included ophthalmologists from Israel, Singapore, France, the United States, and the United Kingdom, also focused on the wider impact of coronavirus on the industry.

The six main participants all reported their appreciation for Israel and the country’s ophthalmology industry.

Notal Vision’s CEO Kester Nahen was one of the next industry leaders to present his company. His team uses patient self-operated devices and realtime AI-enabled data interpretation to provide home diagnostic services, offering a tailor made care experience for patients. Notal Vision’s ForeseeHome device is the first ophthalmic home diagnostic tool with Level 1 evidence and reimbursement system. The HOME study has shown that 94% of patients whose conversion to wet AMD is detected by this home diagnostic tool retain their functional vision (≥20/40).

The consensus of the panel was that the coronavirus pandemic means increasingly innovative solutions are required. Laurent Attias, a member of Alcon’s executive committee, believes companies need to consider a target product profile (TPP) when embracing innovation. This can be a scientific or technical focus, but the TPP concept is needed to shape innovative products to meet market needs.

AI-enabled ophthalmology is also a specialty of another presenting company, NovaSight. One of its flagship products is NovaSight’s CureSight™, which allows for treatment for

Dr. Prahbu Velusami, a senior developer at Johnson and Johnson’s branch in London, agreed with Mr. Attias’s comments about innovation and pointed to Israel as a good example of a receptive business culture. He also said that ophthalmologists should look at gene therapy and cell therapy. A major focus in Israel, Dr. Velusami said these

“There’s such a density of talent in Israel and the ecosystem from the funding perspective is extremely attractive to innovate there,” Dr. Velusami said.

Dr. William J. Link, the host of the session and managing director at Versant Ventures, closed the conference by thanking the participants and sounding an optimistic note about the pandemic. He said that business is already getting back to normal. Dr. Link also shared his vision of the nexus required for successful innovation going forward.

“We need the inventor, the entrepreneur, the doctor and the key opinion makers, the early adopters.

Each of these constituencies was represented today, so thank you,” Dr. Link said.

Editor’s Note: OIS@Israel 2020 Virtual, OIS’s first international meeting, was held on June 18. Reporting for this story also took place at OIS@Israel 2020 Virtual, where CAKE magazine’s parent company, Media MICE, was Media Partner. A version of this story was first published on cakemagazine.org.

| June/July 2020

39

CONTENT MARKETING

+

6001 Beach Road, #19-06 Golden Mile Tower, Singapore 199589 Phone: +65 8186 7677 | U.S.: +1 302 261 5379 E-mail: enquiry@mediamice.com Web: www.mediamice.com

ADVERTISING

+

MEDICAL WRITING

magazine posterior segment • innovation • enlightenment

www.piemagazine.org

www.cakemagazine.org