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& cataract • anterior segment • kudos • enlightenment
14 | 02 | 20 posterior segment • innovation • enlightenment
CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments
HIGHLIGHTS
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Know what to do in difficult cataract cases.
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See clearer with the best phakic IOLs.
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Learn straight from the laser gurus!
It’s Official! 2020 AIOC Kicked off with the Opening Ceremony & Inauguration of New AIOS President by Brooke Herron
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fter a full day of sessions, instructional courses and more, the first day of the 78th Annual Conference of the All India Ophthalmological Society (AIOC 2020) concluded with the Opening Ceremony and Inauguration. The welcome address was delivered by Dr. A. K. Khurana, who introduced two special guests: Chief Guest Sh. Amitabh Kant (CEO, NITI Aayog) and Guest of Honor Gen. DP Vats (MP), along with the panel of renowned ophthalmologists sitting onstage. Following this, Dr. Ajay Sharma delivered the invocation to the audience, welcoming all attendees to Gurugram, in the state of Haryana, and thanking them for their contributions to AIOS and the ophthalmic industry. Next, outgoing AIOS President Prof. S. Natarajan detailed his vision and accomplishments for the last year of his presidency, including increasing access to rural eye care and screenings, and the nationwide drive for eye donation. He also detailed collaborations such as with the EYE Research Consortium of India, the Government of Maharashtra,
the Indian Medical Association and more. For those in attendance, the inauguration and transfer of the AIOS presidency from Prof. S. Natarajan to Prof. Dr. Mahipal S. Sachdev was a main highlight. Among his many accomplishments, Prof. Sachdev was awarded Cont. on Page 2 >>
HOTSHOT
Traditional dancers welcome delegates on the first day of AIOC 2020.
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Padamshree by the President of India; is the chairman, medical director and consultant for Centre for Sight Group of Eye Hospitals; and is credited with introducing cuttingedge technology to India. During his presidential speech, Prof. Sachdev recounted the recent accomplishments of AIOS, giving much credit to Prof. Natarajan and the efforts of the Society’s members. “It has been in no small measure due to the efforts, of Prof. Natarajan, that AIOS has made it a mission to screen all diabetics in India for retinopathy through the use of community outreach, artificial intelligence and mega camps,” he shared. This initiative has certainly made significant strides in eradicating preventable blindness in India. Over the last year, AIOS held a record number of webinars, CMEs and surgical skill enhancement capsules – and not only that, the Society challenged current issues including insurance, pricing schemes and tax harassment in various states regarding laser vision correction. Of course, as the incoming president, Prof. Sachdev has the future on his mind. One main initiative? Safeguarding eyecare providers from physical, financial and emotional distress, when the fault lies somewhere else. “Closely related to this subject, is the status and importance accorded to professional societies like AIOS by government agencies,” he continued. “AIOS is the ophthalmic society having the largest number of life members in the world . . .
From L-R: Prof. Dr. Mahipal S. Sachdev, Dr. R. N. Mishra, Sh. Amitabh Kant and Prof. S. Natarajan.
The two Presidents: Prof. Sachdev (incoming) and Prof. Natarajan (outgoing)
it will be our intention at AIOS to make the government of the day aware of the substantial benefit to the nation, which can be gained by involving national professional societies in formulating policies.” During his tenure as president, he also plans to strengthen the Society itself, specifically garnering attention on a global stage. “Towards this end, we will initiate ways and means to encourage foreign ophthalmologists to become members of our society, increasing our international footprint,” said Prof. Sachdev. Moving forward, AIOS plans to set up specialty groups in coordination with national subspecialty organizations to further move toward scientific growth. Under Prof. Sachdev’s leadership, he also plans to make accreditation more realistic and achievable. He also plans to set up a Support for Ophthalmology Start-Up (SOS) cell to help ensure young ophthalmologists and entrepreneurs have the support needed to open a successful practice. In addition, he said that at AIOS, they also plan to develop a HIMS suited to ophthalmology and make it available for AIOS members. By April, the geographical restrictions placed on ethics committee in respect to the projects it can approve are expected to be removed. “This will open the way for AIOS to have its own in-house ethics committee to review and approve ophthalmic research projects. Thus, giving further impetus to research and clinical trials,” explained Prof. Sachdev. In conclusion, Prof. Sachdev recognized the ambition of his upcoming presidency: “It is my humble request to each one of you to help me take this wonderful organization of ours to its rightful place at the top,” he said, adding that he will make himself available and welcomes comments, feedback and constructive criticism. He finished by thanking all those who contributed to his success and his post at AIOS President. After Prof. Sachdev’s remarks, Dr. R. N. Mishra and the late Yashawant M. Paranjpe received the Lifetime Achievement Award from AIOS. Following the Opening Ceremony and Inauguration, delegates were entertained by a cultural show with traditional music with refreshments. Overall, it was an impressive kick-off to what promises to be an even more impressive conference.
CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments
Taking the Bull by the Horns
by Brooke Herron
Highlights from Difficult Cataract Scenarios
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onditions like dense brown cataract, posterior polar cataracts, small pupils and subluxated cataracts are not only challenging for surgeons, they can also potentially threaten vision – making the risks higher both intraoperatively and postoperatively. To learn more about managing these challenging cases, delegates heard from leading anterior and posterior segment surgeons during a session called Take the Bull by the Horns! A Scientific Approach – Cataract Surgery in Difficult Scenarios.
On Posterior Polar Cataracts
Dr. Suvira Jain of The Eye Clinic (Maharashtra, India) began the session, explaining that there are a few things that surgeons should avoid in posterior polar cataracts. “There are a few things you definitely do not do: One, the chamber is shallow and because the tunnel is so short, during I/A there is a constant regressive fluid. Now, this would not happen if you took care to make a nice short incision,” said Dr. Jain. “Even by mistake, the surgeon should never do a hydrodissection, which could open up the posterior capsule,” she continued, adding that when doing a direct horizontal chop, especially for the slightly harder cataracts, you never do a lateral separation. “Other mistake the surgeon makes during a pars plana is trying to save the fragments and bring them out. Any introduction of a needle to try and save the nucleus from going down is going to cause significant damage to the vitreous base, with the propensity of creating holes, tears, detachment and macular edema later,” she concluded.
On Dense Brown Cataract
Next, Dr. Sandeep Nagvekar, ophthalmic surgeon from Mumbai, Maharashtra, India, covered the management of dense brown cataracts. In particular, he mentioned there are three primary concerns: damaging
the posterior capsule, zonular complex and endothelium. Additionally, there are associated comorbidities, including weak zonules, thinned posterior capsule, compromised endothelium, pseudoexfoliation and systemic comorbidities. He emphasized that FLACS (or femtosecond laser assisted cataract surgery) ensures the perfect CCC (continuous curvilinear capsulorhexis), by creating planes of cleavage for easier nuclear disassembly, causing minimal stress to zonules and softening the cataract by using fragmentation mode. Overall, he said that these cases take a lot of patience: “You should take your time, you should do these cases slowly and gently…and then you will get a good result,” he shared.
On Small Pupils
below the incision, while pupil expansion devices stabilize the iris. Overall, for best results, Dr. Heroor said that implanting premium lenses and using devices optimally will result in a happy patient with good visual outcomes.
On Vitreous Loss in Cataract Surgery
“Vitreous loss is the most common complication of cataract surgery, irrespective of the technique,” began Dr. Ashish Vaidya of Netra Retina and Laser Centre (Mumbai, Maharashtra India), adding that high risk factors include young patients, positive vitreous pressure, myopia, pseudoexfoliation, subluxated lenses and posterior polar cataracts. He said at presentation, this can appear as a sudden deepening of the AC, visualization of the rent, peaking of the pupil or loss of followability – which is a very important sign. To manage the complication, he says early detection – followed by adequate vitrectomy is crucial; surgeons should also use a high cutting rate and low vacuum, with infusion to maintain the anterior chamber. In addition, he said it’s vital to implant the appropriate IOL, tightly close the wound and ensure there is no remaining vitreous in the wound. Dr. Vaidya also emphasized that surgeons should not panic: “Do a limited anterior vitrectomy, remove the cortex and place the appropriate IOL,” he said, noting that he prefers to implant PC-IOLs whenever possible.
According to Dr. Anagha Heroor, consulting ophthalmic surgeon at Anil Eye Hospital (Dombivli, India), there are technical challenges when performing phacoemulsification on small pupils. This can include reduced visibility, iris damage, small CCC, retained lens material, IOL placement and PC rupture. “Reduced visibility causes problems at every stage, resulting in a poor visual outcome and an unhappy patient,” she said. She discussed different pupil expansion devices, such as iris hooks, malyugin rings (MST) and B-Hex rings. Dr. Heroor noted that for a successful procedure, Dr. Suvira Jain surgeons should carefully dissect the wound using gentle hydrodissection, reduce the inflow rate, use bimanual I/A (to reduce iris movement) and direct irrigation currents away from the pupillary margins. She also emphasized that iris retractors (in diamond Dr. Sandeep Nagvekar configuration) can be used just
Dr. Anagha Heroor
Dr. Ashish Vaidya
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Pachychoroid Disease Spectrum
Unraveling the Mysteries by Joanna Lee
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achychoroid has come to be known as a phenotype recognized by “focal or diffuse increase in choroidal thickness, accounted for by dilated choroidal vessels in Haller’s layer (pachyvessels), accompanied by thinning of the choriocapillaris and Sattler’s layer with or without retinal pigment epithelium (RPE) abnormalities overlying the pachyvessels”.* All right, that’s quite a mouthful. But more importantly, how can this novel condition be better diagnosed and treated? Continuing the investigations and sharing their findings and experiences were a group of presenters at AIOC 2020 yesterday, looking at pachychoroids from various lenses, attempting to fill the gaps amidst a dearth of information The keynote address of this session was given by Dr. Pavel Volodin from Moscow, Russia, who presented on Spectral OCTangiography in En Face Mode in Detecting of Morphological Changes of the Retinal Pigment Epithelium Before and After Selective Micropulse Laser Exposure in Patients with Central Serous Chorioretinopathy. In looking at more non-invasive methods
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of diagnoses, they’ve found that this navigation laser technology of central serous chorioretinopathy (CSC) treatment offers a precise localization relative to the retinal vascular network, making it possible to have individualized treatment plans as well as to monitor the dynamics of these changes after selective treatment. Dr. Aniruddha Agarwal of Postgraduate Institute of Medical Education and Research, Chandigarh (PGIMER) in Chandigarh, India, then expounded on Uncovering the Unseen: Inception and Etiopathogenesis of Pachychoroid. A substantial proportion of patients with exudative maculopathies in Asian countries are characterized by “pachyvessels”, he concluded, while the characteristics of this phenotype of diseases are certainly different from AMD (age-related macular degeneration). Looking at pachychoroid pigment epitheliopathy (PPE) and focal choroidal excavation (FCE) was Dr. Mahesh Gopalakrishnan of the Department of Vitreoretinal Services, Giridhar Eye Institute (Kochi, Kerala, India). He shared that FCE is an OCT-based diagnosis and has known associations with central serous chorioretinopathy (CSCR) and pachychoroid neovasculopathy. Attempting to find out if pachydrusens are innocuous or not, Dr. Jay Sheth from Surya Eye Institute and Research Center (Mumbai, India) presented his study which uncovered that pachydrusens potentially presents as a potential risk factor for development of disease activity in CSCR. They found
OCULUS & KLB India premieres at AIOC! Be part of the ribbon-cutting ceremony Friday and Saturday at 2.30 pm and 4.30 pm at the KLB booth no. 107 KLB KLB Instruments Co. Pvt. Ltd
that longstanding changes underlying pachydrusens may trigger formation of type 1 CNVM in the form of pachychoroid neovasculopathy (PNV) and polypoidal choroidal vasculopathy (PCV). Meanwhile, peripapillary pachychoroid syndrome (PPS) is characterized by the presence of characteristic abnormalities similar to the pachychoroidal disease spectrum, but found in the peripapillary region. Other features include associated intraretinal edema along with RPE alterations, as explained by Dr. Awaneesh Upadhyay of Sri Sankaradeva Nethralaya (Assam, Guwahati, India) during his presentation on the emerging concepts of PPS. Demystifying CSCR was presented by Dr. George J. Manayath from Aravind Eye Hospital (Coimbatore, India) who shared that choroidal hyper-permeability and increased choroidal hydrostatic pressure is evidenced by EDI-OCT and ICGA which shows thick choroid, dilated outer choroidal vessels, vortex vein and choroidal leakage. OCT-A also suggested underlying inner choroidal ischemia while CSC is now part of the pachychoroid disease spectrum ranging from PPE to PCV. Low-fluence photodynamic therapy (PDT) is the current gold standard for chronic CSCR while subthreshold micropulse yellow or diode lasers are alternate treatments options. He also cautioned that understanding mimickers and OCT biomarkers are important pointers to treatment outcomes. *Cheung CMG, Lee WK, Koizumi H, et al. Pachychoroid Disease. Eye (Lond). 2019;33(1):14-33.
CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments
Seeing Clearer with Phakic IOLs by Brooke Herron
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hakic intraocular lenses can be a valuable tool in the refractive surgeon’s armamentarium. On the first day of the 78th Annual Conference of the All India Ophthalmological Society (AIOC 2020), delegates heard from industry experts on their tips, including selecting the right IOL and patient selection, sizing, anatomical sizing, long-term results and follow-up and more, during a course titled, Implantable Collamer Lenses: A Boon to Refractive Surgeons.
The Keynote Address
The course began with a keynote address by Dr. Aleksei Titov, a renowned refractive surgeon from The S. Fyodorov Eye Microsurgery Federal State Institution (Moscow, Russia), regarding the Correction of Extreme Myopia with Implantation of Posterior Chamber Contact Lenses. He noted several advantages of implantable phakic chamber lenses (IPCLs) “The advantage of IPCL for me is overall, the size. The price is also very important. It costs much less than ICL and of comparable quality.” During his address, he reviewed results from a study where the possibilities of high myopia correction using personalized phakic contact lenses were evaluated. They found that IPCL implantation is “safe, effective, predictable method of surgical correction of high myopia, which offers a rapid recovery and high VA”. He said the advantages of using these lenses were the absence of limitations in the range of myopia, with or without astigmatic component, in combination with preserving one’s own accommodative response. He added that for a successful outcome, careful patient selection is
required, as well as sufficient surgical skill. Continued monitoring of the patients is also necessary.
Why Use Collamer Lenses?
Next, Dr. Krishna Prasad Koodlu, Medical Director of Prasad Netralaya, Super Specialty Eye Hospital (Udupi, India), discussed Collamer, Success with Advanced Phakic IOL Material. He brought up various important points, including the fact that collamer prevents protein deposits. Dr. Koodlu also explained that collamer provides biocompatibility (leading to a quiet eye) and exceptional optical performance – not only that, it’s easy to implant because it unfolds gently in the eye. “If you ask me, this is the best material for phakic IOLs,” he stated, noting that while this lens is ideal for all patients, it’s especially effective for those with diabetes, chronic uveitis, iritis and other AC inflammatory conditions.
Complications and More
“One of the biggest fears in the mind of an ophthalmologist is: Will it cause a cataract?” began Dr. Sanjay Chaudhary, a leading cataract and refractive surgeon and the founder and director of the group of Eye7 Chaudhary Eye Centre (New Delhi, India). He added that in 1,500 cases using the V4c model, they have not had one case of cataract in 5 years. In the V4 model (without the central hole) there were 6 cataracts, in 1,500 cases over 10 years. He continued that the precursor of cataract is the ICL touching the crystalline lens. He described one case where this occurred – they decided to wait to operate. Finally, after 8 years, they did the procedure as the cataract had increased. Halos are another postoperative complication that can occur. “What about halos in an ICL with a central hole? Does it cause halos? Yes, it does. In our experience, whenever we had a central hole, the incidence was around 16% although they decreased over time,” reported Dr. Chaudhary. “The strategy we follow is to tell them ‘Yes, it will go away, use your drops and it will go away’. In about 90% of cases they go away,” he explained. “If not, or if you have a persistent patient, then you have to counsel the patient. The patient is worried about halos because they think something is wrong with the eye.” Dr. Chaudhary says that he believes that counseling is very important and that surgeons should remind patients that it takes time for the brain to adapt – and that “everyone has the capacity to adapt”.
Dr. Sanjay Chaudhary
Dr. Aleksei Titov
Dr. Krishna Prasad Koodlu
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14 February 2020 | Issue #2
Sitting at the Feet of
Laser Gurus
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t was a chance to sit at the feet of the gurus to grasp more practical skills and techniques for a diverse range of retinal conditions. This session, aptly titled Laser Techniques in Vitreoretina: Tips and Tricks from the Masters, started off with a keynote address by one of the few pediatric vitreoretinal surgeons in the Asia-Pacific region, Dr. Manoharan Shunmugam of Malaysia, who spoke on Surgery for Retinopathy of Prematurity. As with his previous presentations, Dr. Shunmugam’s address included highly detailed tips from the assessment of when is a good stage of intervention for premature babies (between Stages 4A and 4B) and predicting who would need surgery. He also touched on management approaches, surgical goals and when immediate sequential bilateral surgery is needed. During his presentation, he also made a case for how laser surgery is statistically one of the most cost effective methods of improving quality of living for babies.
by Joanna Lee
Chair of the session Dr. Deependra V. Singh, ophthalmic surgeon from Eye Q Super Speciality Eye Hospitals in Shalimar Bagh, New Delhi, then gave a lecture - an introduction to laser on Choosing the Right Power, Lenses and Modes of Delivery. From the first attempts of Gerhard Rudolph Edmund Meyer-Schwickerath at laser surgery with sunlight at a rooftop to today’s laser photocoagulation, laser surgery has indeed come a long way. Dr. Singh then brought to mind the common parameters of laser techniques, focusing on power, duration, intervals, aiming of beam intensities, spot size and counter. Useful tips were shared such as power shouldn’t be more than 150% of the duration and avoiding spot sizes larger than 300 microns. He shared a funny tip on how he initiates practice of administering laser precisely: like testing the burns by first pointing the laser on old name cards. He covered also the advantages and disadvantages of both slit lamp delivery and laser indirect delivery, comparing the
Dr. Shashank Rai Gupta
Dr. Manoharan Shunmugam
Dr. Parijat Chandra
Dr. Deependra V. Singh
two methods, sharing tips on settings with general guidelines for panretinal photocoagulation (PRP). Sharing also from his vault of experience was Dr. Shashank Rai Gupta, Chairman and Founder of Delhi Eye Care (New Delhi, India), who gave a comprehensive overview of scatter lasers in diabetic retinopathy and retinal vein occlusion, focusing on focal or grid lasers, their indications (for DME, for instance), delivery systems, preparation of the patients, settings and potential complications. Tips on how to add lasers in between previous laser scars were discussed as with which quadrants to focus on as well as what is subthreshold laser therapy. For predisposed lesions and tears, there’s prophylactic laser. Dr. Ajay Jhinja of Max Vision Eye Care Centre (Vaishali Nagar, Jaipur, India) brought the audience through the various risk factors leading to retinal detachment. He also highlighted that cystoid retinal degeneration – normal ora – is often confused with lattice degeneration while posterior vitreous detachment (PVD) seems to the link between predisposing lesions and retinal detachment, being the cause of tear formations while also giving liquefied vitreous access to retinal breaks and thus, subretinal space. He then shared extensively on the laser settings for slip lamp laser surgeries with tips on avoiding certain spots and also pitfalls of for instance how large areas of intense surgery may lead to vitreous contraction and to the creation of proliferative vitreoretinopathy (PVR). Dr. Parijat Chandra, Professor of Ophthalmology at the Vitreoretinal and ROP Services of Dr. R. P. Centre for Ophthalmic Sciences, All India Institute Of Medical Sciences (AIIMS) (New Delhi, India), continued the discussion on ROP (retinopathy of prematurity) in his talk about Photoablation for ROP with tips on how to laser babies, managing their pain, how to deal with scleral indentation and the challenges of aggressive posterior ROP. He also reminded the audience of the common challenges while administering laser photocoagulation in infants and offered practical tips for optimal laser techniques such as: train on adults first, look out for media haze (caused by dry cornea, fogging of optics, for instance), the speed needed and considering the use of anti-VEGF as part of the treatment.
CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments
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Years of ICO Examinations at WOC 2020 Cape Town
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riving up the standards of eye care around the world” is the philosophy behind the International Council of Ophthalmology’s ICO Examinations. Chair of ICO Examinations, Clare Davey, shares that the prestigious examinations will celebrate their 25th anniversary at the World Ophthalmology Congress® come June 2020 in Cape Town, South Africa. The ICO examinations have so far been administered throughout 135 centers in 80 countries. “This is so that they can go to centers closest to them, making it convenient for them,” Ms. Davey said. The ICO examinations test the knowledge of ophthalmologists against international standards, starting off with the Visual Sciences Examination. “With the test of Visual Sciences, candidates would have a good basis upon which to make good clinical decisions,” she explained. “We also run Optics, Refraction and Instruments so that they know how the eye works.” The Optics, Refraction and Instruments Examination is the second test in its series, leading to the next and third test, the Clinical Ophthalmology Examination. The last examination would
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be the Advance Examination offered to ophthalmologists who have passed exams in the earlier three examinations. This year also marks the first time ICO is holding its general examination papers twice a year under its new program. Besides that, ICO also offers Subspecialty Examinations in subjects like Cornea and Anterior Segment, Glaucoma and other areas. “The Advanced Examination, along with the other three examinations, allows the candidate to sit for the Fellowship of the Royal College of Surgeons of Edinburgh (FRCS) and thereafter also pursue the Fellowship of the International Council of Ophthalmology (FICO),” Ms. Davey said. Other advantages may also follow candidates who undertake the examinations. “If you pass all the ICO exams, you can apply to the ICO fellowships for a 3- to 6-month in-depth time of learning subspecialties as a fellow in order to setup the subspecialties locally to provide something which your country needs.” Another unique feature of the ICO Examination is that its fees are set on a
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Chair of ICO Examinations, Clare Davey
sliding scale according to each country’s Gross National Income Per Capita (GNIPC), making the examinations affordable for ophthalmologists around the world. Ms. Davey also revealed that doctors from India and Egypt make up about 40% of the examinees. They have doctors from Myanmar taking the exams and are now focusing on sub-Saharan Africa, where they see the most need for increased expertise in ophthalmology. The ICO makes no profit at all, as Ms. Davey explained, but their efforts go towards continuously improving the education of ophthalmologists around the world. Ms. Davey invites interested ophthalmologists to visit booth #ST15 right outside the exhibition hall for more information.
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