CAKE & PIE POST (52nd RANZCO 2022 Edition) - Issue 2

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ISSUE

02 | 28 | 22

HIGHLIGHTS presents updates on 08 ORIA cutting-edge studies your practice from 09 Protect cyberattacks! the fight against 15 Inastigmatism and climate change, experts take their stand

Published by

Matt Young

CEO & Publisher

Hannah Nguyen COO & CFO

Can You Handle This?

On Day 2 of RANZCO 2022, AI and Beyonce (references) take the spotlight

by Joanna Lee

Robert Anderson Media Director

Gloria D. Gamat Chief Editor Editors

Brooke Herron Mapet Poso Ruchi Mahajan Ranga Brandon Winkeler International Business Development Writers

Andrew Sweeney Hazlin Hassan Joanna Lee Sam McCommon Tan Sher Lynn Maricel Salvador Graphic Designer

Media MICE Pte. Ltd.

6001 Beach Road, #19-06 Golden Mile Tower, Singapore 199589 Tel. Nos.: +65 8186 7677 | +1 302 261 5379 Email: enquiry@mediamice.com mediaMICE.com

piemagazine.org cakemagazine.org cookiemagazine.org Please note that this is an independent publication of Media MICE Pte Ltd (“Media MICE”) in our role as independent media and is not affiliated with RANZCO. Media MICE is in no way affiliated to or with any person, organization, or entity mentioned in this publication, nor is this publication published in any way intended to convey any such affiliation.

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n case you haven’t heard yet, in ophthalmology, artificial intelligence (AI) is now able to increasingly function unsupervised — as evidenced by the latest studies applying AI to the investigation of corneal topography and imaging, description of the ocular wavefront, ocular biometry, as well as improving the accuracy of the power calculation of intraocular lenses (IOLs).

Case in point: During Day 2 of the 52nd Annual Scientific Congress of The Royal Australian and New Zealand College of Ophthalmologists (RANZCO Brisbane 2022), Dr. Damien Gatinel, the head of the Anterior and Refractive Surgery Department of the Rothschild Foundation, Paris, demonstrated how AI is trained through supervised and unsupervised learning.

In the former, AI is given input by expert ophthalmologists to label individual clinical features and the severity in the images in order to label the AI solutions.

The sophistication of AI in eye care Dr. Gatinel’s study1 has shown how unsupervised AI learning can extract and sort usable data from large unlabeled data sets with minimal human intervention. It was able to perform dimensional reduction from 10,000 values to 3 values and separate the data into dense groups, hence tracing the topography of keratoconus disease.

In another study on gas permeable contact lens fitting for keratoconus, they trained CNN (convolutional neural network) on raw matrices of the actual curvature map to predict Cont. on Page 3 >>

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28 February 2022 | Issue #2

An innovative vision for ophthalmology begins with using our ears At Roche, we believe in order to transform vision outcomes in Australia, our innovation must extend beyond the science that underpins our novel medicines and drug delivery solutions.

Fundamental to our approach is personalised healthcare, harnessing digital solutions and artificial intelligence to improve diagnosis, identify biomarkers, enhance prevention and guide treatment.

Most importantly, we understand that our long-term commitment to ophthalmology has to start with listening to your needs today, to co-create together, for better outcomes tomorrow.

In order to keep you informed, we need your contact information and consent. Scan or click on the QR code to access our online consent form.

Roche Products Pty Limited, ABN 70 000 132 865, Level 8, 30-34 Hickson Road, Sydney NSW 2000.

Medical Information: www.medinfo.roche.com/australia or 1800 233 950. EMVOPH0012 M-AU-00001382 PreparedFeb22

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CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

>> Cont. from Page 1

the lens-based curve. It achieved the mean absolute error of 0.16 mm, which essentially outperformed the manufacturer’s guidelines (MAE: 0.23 mm).

Dr. Gatinel’s team has also designed an algorithm that predicts subjective refraction from the wavefront aberrations.

A test on 350 eyes showed a significant reduction in prediction error.

Meanwhile, their latest effort resulted in an online open-sourced overview of all details and key steps in accurate IOL power computations.2 “This is the first time the details of a modern formula have been disclosed with the aim of sharing knowledge and contributing to improving that formula,” he said, highlighting its significance.

His team’s other latest work, Corneal Edema Visualization with Optical Coherence Tomography Using Deep Learning,3 is a proof of concept in characterizing the disease in corneal imaging. The resulting model which could categorize the eye’s features as having “edema” or “normal” could be used as a local detector of edema on corneal OCT images.

Dr. Gatinel highlighted an interesting feature of deep learning in this study: “Models are so sophisticated that a single model might be able to perform well on images on different devices.” The results could be seen in both the Avanti (Optovue, California, USA) and Anterion (Heidelberg Engineering, Heidelberg, Germany) devices they had used the trained models on.

Honey, are you ready for this (vitreous) ‘gel-ly’?

Update in cataract seems to be singing an interesting tune. “Under pressure, you don’t rise to the occasion, you sink to the level of your training. That’s why we train so hard.” This quote was apparently taken from the Navy Seals, and references to Bootylicious’ lyrics: “Can you handle this?” made for an engaging case toward the use of simulation training for trainee surgeons.

Dr. David Lockington, consultant

ophthalmologist at Glasgow, UK, and national simulation lead at Royal College of Ophthalmologists (New Zealand), shared observations and lessons learned from his role in hopes of encouraging more openness towards adopting the benefits of simulation for better safety during training.

Ophthalmic simulation decreases the subjectivity of guessing if one is ready to handle a real patient while overcoming the various degrees of complexities when it comes to teaching and learning relationships (e.g. challenges arising from varying attitudes toward mentoring, teaching and learning).

Simulations could also help save costs.4 Cost concerns should not be a deterrent as “prevention, rather than management and follow up, of a complication is always more cost-effective,” Dr. Lockington argued.

The use of simulators like the EyeSi (Haag-Streit, Köniz, Switzerland) showed a 38% reduction in complication rates on cataract surgery performed by first and second-year trainees.5 “Furthermore, during the lockdowns, usage of simulators among even experienced surgeons increased and continues to be popular. It also provides for virtual international training opportunities,” he said.

Alarmingly, a study had shown that 47% had never inserted a three-piece IOL and only two trainees (6.5% of the study)6 had ever received training on how to insert one during surgery.

He also advocated for the PCR risk stratification scoring to ensure that the appropriate consultant or surgeon only gets to operate on appropriate patients depending on the risk posed for safety.

“Competence will result in confidence and that will result in good outcomes for the patient and the trainee,” Dr. Lockington emphasized.

In focus: K calculator and toric IOLs for astigmatism The ability to accurately predict astigmatism outcomes has improved since 2006. “However, the increased usage of toric IOLS had effected a most dramatic change in the practice,” Prof.

Graham David Barrett said in the opening of his Norman McAlister Gregg Lecture session.

The consultant ophthalmologist at the Lions Eye Institute and Sir Charles Gairdner Hospital in Perth, Western Australia, uses toric IOLs in about 80% of his patients while targeting less than 0.5 diopter of residual astigmatism.

“It’s a myth to leave any levels of residual astigmatism. Low levels of astigmatism do not assist in intermediate or near vision,” he assured.

His lecture touched on reliable measurements, accurate prediction, and understanding of incisions and precise alignments when it comes to selecting IOLs for patients with pre-existing low levels of astigmatism.

To simplify the process of combining multiple instruments for measurement, Prof. Barrett had incorporated a “K calculator” as part of the online Barrett Toric calculator. It allows users to select the keratometry of up to three devices and provides an integrated K using appropriate vector mathematical calculation. If two devices are selected, the integrated K is the mean of the two devices, for instance.

“The letter measure of central tendency, T, emphasizes outliers and proved to be the most accurate predictor with the lowest prediction error of residual astigmatism for both sphere and toric prediction when I analyze my own patients undergoing IOL implantation using pre-op K’s and actual axis alignments of the toric IOL,” he shared, explaining his long-term use of this method for all his cases. Comparing the IOL Master 700 (Carl Zeiss Meditec, Cont. on Page 12 >>

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E N V I S TA T O R I C I S N O W P R E L O A D E D

Focused on Outcomes. Fixated on Stability.

Aberration-free optic1 | Predictable outcomes1,2 | Smart design1,3,4

For more information contact your Bausch + Lomb Territory Manager or Customer Service 1800 251 150 enVista.toriccalculator.com References: 1. enVista Directions for Use. 2. Data on File. Bausch+Lomb Inc. enVista IOL Comparison Data. 3. Data on File. Bausch+Lomb Inc. 4. Elachchabi A, Martin P, Goldberg E, Mentak K. Nano indentation studies on hydrophobic acrylic IOLs to evaluate surface mechanical properties.

Paper presented at: XXV Congress of the European Society of Cataract and Refractive Surgeons (ESCRS); September 8-12, 2007; Stockholm, Sweden. © 2022 Bausch & Lomb Incorporated. ®/TM denote trademarks of Bausch & Lomb Incorporated and its affiliates.

Bausch & Lomb (Australia) Pty Ltd. ABN 88 000 222 408. Level 2, 12 Help Street, Chatswood NSW 2067 Australia. (Ph 1800 251 150) New Zealand Distributor: Toomac Ophthalmic. 32D Poland Road, Glenfield 0627 Auckland New Zealand (Ph 0508 443 5347) EHTA.0003.AU.22

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

IOL can provide a tolerance to defocus, allowing vision to remain consistent. In addition, the aberration-free optics is uniform in power from center to edge across the principle meridian which means the IOL is less sensitive to the effects of decentration or tilt.

It’s available in a broad range of cylinder powers as low as 1.25 D and can correct <1 D of astigmatism at the corneal plane. enVista® toric is a glistening-free hydrophobic acrylic and has a posterior toric surface with a 6 mm optic.

Get more peace of mind

Astigmatism is No Match for this Toric IOL

by Brooke Herron

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o see the point where cataract and refractive surgery meet, look no further than today’s wide array of intraocular lenses (IOLs). What once was a procedure that primarily focused on replacing the clouded lens (and still is, of course), today’s cataract surgery has evolved along with patients’ expectations for their visual correction.

Thanks to IOLs, this can largely be achieved. And while there isn’t necessarily a one-size-fits-all approach (or IOL) to meet the needs of every patient — there might be a solution for most, including those with astigmatism.

And what better time than the RANZCO 52nd Annual Scientific Congress to take a deep dive into IOLs? Held online this year, attendees now have even more opportunity to visit the virtual exhibition and check out these products themselves.

Here, we cover one of our favorites…

Maximise visual outcomes For most patients, seeing clearly is what

enVista and enVista Toric

matters most. But with IOLs, there is often some “visual compromise” to be made. However, thanks to its aberrationfree aspheric optic design, the enVista® monofocal and toric IOLs from Bausch + Lomb provide both excellent image quality and depth of field.

Patients with astigmatism will be interested to note that the enVista® toric IOL stands out due to its optics design.

With unique aspects that compensate for the eye’s natural imperfections, the

According to its FDA study, the enVista® toric IOL also delivers exceptional rotational stability for precise astigmatism correction: From close-of-case to 180 days, 94.4% of eyes (n=108) had less than or equal to 5 degrees of rotation. No secondary surgical interventions were reported among study participants.

To further complement a safe and efficient IOL implantation, the enVista also features distinctive AccuSet™ haptics. This allows for more extensive interaction with the capsular bag to aid in securing the lens position. It also has a SureEdge™ design, which is a 360-degree square edge, and could help prevent posterior capsular opacification versus its round-edged counterparts.

Surgeons will appreciate the handy preloaded SimplifEYE™ delivery system, which further streamlines loading and makes the surgical process even more efficient.

Plus, the preloaded system greatly reduces the risk of damage to the IOL or cross-contamination.

These features — and therefore, benefits — all coincide at a time when a significant number of cataract patients also have astigmatism. With its applications across a broad range of patients, the enVista® toric IOL can provide a solution for better sight when it’s needed most.

But you don’t have to take it from us: Check out the enVista toric IOL at the Bausch + Lomb Booth at RANZCO Virtual 2022.

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Improving Visual Outcomes with the EVO 2.0 Formula

by Brooke Herron

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oday, cataract surgery looks much different than the procedures of the past — and along with improved safety and new technology, comes the patients’ desire for better visual outcomes.

This is also the outlook of Dr. Nishant Gupta, director at Frankston Eye and Laser Centre (Australia), who shared that “cataract surgery has evolved immensely … nowadays, it’s essentially a refractive surgery with high patient expectations for spectacle independence.”

“Cataract surgery has evolved immensely … nowadays, it’s essentially a refractive surgery with high patient expectations for spectacle independence.”

– Dr. Nishant Gupta, director at Frankston Eye and Laser Centre (Australia) However, achieving spectacle independence isn’t as simple as it sounds — especially in atypical eyes, such as short or long eyes. Thus, central

to achieving good refractive outcomes is selecting the best formula for lens power calculations, explained Dr. Gupta.

But with the various formulas available for intraocular lens (IOL) power calculations, how can a surgeon determine which is best?

To answer this question, Dr. Gupta, along with Dr. Tun Kuan Yeo from Singapore, provided their expert guidance during the RANZCO 2022 Bausch + Lomb Sponsored Symposium, IOL Formulas: The Short and Long of It! Below, we cover their insights on IOL power calculation formulas, with specific detail into atypical eyes.

The EVO formula (briefly) explained Dr. Tun Kuan Yeo, senior consultant and deputy head of cataract, implant and anterior segment at the Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, dedicated his presentation to the “Development and Outcomes of the EVO Formula.”

He shared that the Emmetropia Verifying Optical formula (or EVO), was updated to its 2.0 version in 2019 and encompasses a suite of formulae. These include the EVO IOL formula, the EVO toric formula and EVO for post-myopic refractive surgery.

(Editor’s Note: The soon-to-be-released enVista Toric Calculator (Bausch + Lomb) will incorporate the new generation EVO 2.0 formula.)

EVO is a thick lens vergence formula and is based on the theory of emmetropization. Parameters required include axial length (AL), keratometry (K), anterior chamber depth (ACD), lens thickness (LT) and central corneal thickness (CCT). It also allows for posterior corneal measurements. Dr. Yeo then explained how the formula accounts for the different parameters.

“Axial length is one of the most important variables in IOL power calculations,” said Dr. Yeo. He explained that EVO utilizes a modified sum-of-segments axial length.

“This allows variability of axial length as a function of lens thickness and with this we are actually approaching ‘true axial length’.”

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

He continued: “With utilization of five parameters, the EVO formula is able to achieve a multidimensional capability in prediction and this is achieved using multiple regressions and iterative techniques.

Meanwhile, the EVO toric formula predicts posterior corneal astigmatism, angle alpha and pseudophakic lens position. “At the same time, it models different toric lens geometry based on the toric surface, whether it’s anterior toric, posterior toric or bitoric,” he said. “And finally, the latest version is going to allow the input of measured posterior corneal astigmatism into the calculator.”

The formula is also able to predict for postmyopic refractive surgery eyes, with or without clinical history, continued Dr. Yeo.

The EVO formula: How does it stack up?

As they say, the proof is in the pudding.

Dr. Yeo then shared data from several studies that compared both EVO 1.0 and 2.0 to other formulas. We’ll sum up some of those results here.

Published in JCRS in 2019, Savini et al.1 compared 15 formulas using the AcrySof SN60WF (Alcon, Geneva, Switzerland) in 150 eyes: “This was version 1.0 of EVO and it achieved the lowest mean absolute error and standard deviation. This was followed by Hill RBF, Barrett, Olsen PhacoOptics and Kane,” said Dr. Yeo. Another paper by Hipolito-Fernandes et al.2 compared 13 formulas and found that Kane, EVO 2.0 and VRF-G were the most accurate with no difference between them and across all axial lengths, whether they were short, medium or long eyes, continued Dr. Yeo. Indeed, the authors agreed: “New generation formulas may help us achieve better refractive results, lowering the variance in accuracy in extreme eyes: Kane, EVO 2.0 and VRF-G formulas are promising candidates to fulfill that goal.”

Then Dr. Yeo shared results specific to short eyes. First up, a paper published in JCRS in 2020 by Kane et al.3 “This

was 182 eyes with the SA60AT (Alcon) lens and Kane, followed by EVO 2.0 was most accurate,” he said. According to the authors: “The Kane formula had the lowest prediction error of the formulas studied, which was statistically significant compared with all formulas — except the EVO 2.0 formula.”

Further, a paper published in IOVS in 2021 by Shirke et al.4 looked at 129 eyes and found EVO 2.0 and Kane were the most accurate.

These results are important because as noted by Dr. Gupta: “Short eyes in general are not just surgically challenging but achieving the desired refractive outcomes is another challenge in itself.”

Moving along to the long eye side of the spectrum, EVO 2.0 was also found to be among the most accurate in results from the three papers5-7 shared by Dr. Yeo. Toric predictions were covered next. Dr. Yeo shared data from Patanelli et al.8 showing that the EVO toric v2.0 formula outperformed the legacy calculator in regard to predictions in eyes with low astigmatism. This was echoed by the study’s authors who confirmed: “We thus now have evidence that the EVO Toric Formula v2.0 is not only superior to legacy formulas but is also equivalent to many of the modern toric calculators of present.”

Further, outcomes were similar between the EVO and Barrett toric calculators in another paper which found that both had similar performance regarding astigmatism prediction accuracy.9

Dr. Yeo then shared results from a study he performed using the enVista Toric lens (MX60T IOL; Bausch + Lomb) on 67 eyes.

This study compared the different toric formulas including the Abulafia-Koch, Barrett, EVO and Kane which predict posterior corneal thickness, as well as Holladay I and Fixed Ratio which do not.

Outcomes showed that using EVO, 55.2% were within 0.5; 79.1% were within 0.75; and 91% were within 1.0. “The Barrett and the Abulafia-Koch performed similarly well [to EVO] and with all three formulas the central error was very close to zero,” said Dr. Yeo. The final study Dr. Yeo shared concerned IOL formulas using total keratometry (TK) in eyes with previous myopic refractive surgery. Published in 2020, this included 64 eyes from 49 patients and found that EVO TK was the most accurate, followed

by Barrett TK and Haigis TK.10 In conclusion, Dr. Yeo stated that the EVO 2.0 formula exhibits high accuracy: “It is able to predict for average, short or long eyes with no issues at any axial length.

The toric predictions are similar to the Barrett Toric Formula and the AbulafiaKoch regression, and at the same time, it is able to accurately predict for postmyopic refractive surgery eyes.”

Based on these data, it certainly appears that better visual outcomes are on the way — especially for astigmatic eyes.

Surgeons can find the next generation EVO 2.0 Toric formula included in the upcoming enVista Toric Calculator from Bausch + Lomb.

REFERENCES 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Savini G, Hoffer KJ, Balducci N, Barboni P, Schiano-Lomoriello D. Comparison of formula accuracy for intraocular lens power calculation based on measurements by a swept-source optical coherence tomography optical biometer. J Cataract Refract Surg. 2020;46(1):27-33.

Hipólito-Fernandes D, Luís ME, Gil P, et al. VRF-G, A New Intraocular Lens Power Calculation Formula: A 13-Formulas Comparison Study. Clin Ophthalmol. 2020;14:4395-4402.

Kane JX, Melles RB. Intraocular lens formula comparison in axial hyperopia with a high-power intraocular lens of 30 or more diopters. J Cataract Refract Surg. 2020;46(9):1236-1239.

Sheetal Shirke, Nishant Gupta, Suheb Ahmed; To compare the accuracy of intraocular lens calculation formulas in the prediction of postoperative refraction in eyes with short axial length (<22mm). Invest Ophthalmol Vis Sci. 2021;62(8):563.

Zhang J, Tan X, Wang W. Effect of Axial Length Adjustment Methods on Intraocular Lens Power Calculation in Highly Myopic Eyes, Am J Ophthalmol. 2020;214:110-118.

Mo E, Lin L, Wang J. Clinical Accuracy of 6 Intraocular Lens Power Calculation Formulas in Elongated Eyes, According to Anterior Chamber Depth. Am J Ophthalmol. 2022;233:153-162.

Lin L, Xu M, Mo E. Accuracy of Newer Generation IOL Power Calculation Formulas in Eyes With High Axial Myopia. J Refract Surg. 2021;37(11):754-758.

Pantanelli SM, Kansara N, Smits G. Predictability of Residual Postoperative Astigmatism After Implantation of a Toric Intraocular Lens Using Two Different Calculators. Clin Ophthalmol. 2020;14: 3627-3634.

Pantanelli SM, Sun A, Kansara N, Smits G. Comparison of Barrett and Emmetropia Verifying Optical Toric Calculators. Clin Ophthalmol. 2022;16:177-182.

Yeo TK, Heng WJ, Pek D, Wong J, Fam HB. Accuracy of intraocular lens formulas using total keratometry in eyes with previous myopic laser refractive surgery. Eye (Lond). 2021;35(6):1705-1711.

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Innovation in Action

ORIA presents updates on cutting-edge studies by Hazlin Hassan

“In summary, it is important to get the right diagnosis and treatment to highrisk patients early, as this will prevent blindness,” he concluded.

The distribution of high- and lowrisk individuals to the appropriate professionals (optometrist/general ophthalmologist/glaucoma specialist) also needs to be improved.

A novel treatment for FED For her presentation, Assoc. Prof. Elaine Chong, head of the Department for Ophthalmology at the Royal Melbourne Hospital, Australia, talked about a new treatment for Fuchs’ endothelial dystrophy (FED) without a graft.

S

Unhealthy endothelial cells are removed and the patient’s cornea is encouraged to heal on its own, without corneal transplantation. A small 4 mm area of Descemet’s membrane is removed along with its diseased endothelial cells, without implanting a corneal transplant. This procedure is known as descemetorhexis without endothelial keratoplasty (DWEK), or Descemet’s stripping only (DSO).

aturday’s session on updates from the Ophthalmic Research Institute of Australia (ORIA) proved to be an exciting one, showcasing cutting-edge research with practical implications.

treatment for low-risk patients. “Some of the early findings have been that the age of diagnosis is a decade younger if patients have a high polygenic risk,” explained Prof. Craig.

Prof. Jamie Craig, chair and academic head of the Department of Ophthalmology, Flinders University, Australia, talked about advances made in predicting glaucoma progression in earlystage disease, which may help prevent irreversible blindness.

“In the early paper, we were able to show that optical coherence tomography (OCT) progression was more rapid in high-risk patients and that there’s almost a twofold increased rate of incisional surgery if you have a high genetic risk profile,” he added.

Genetics at play The Progression Risk of Glaucoma: Relevant SNPs with Significant Association (PROGRESSA) prospective clinical data shows that those with a high polygenic risk score (PRS) are more likely to lose visual field despite treatment.

PRS is an estimate of an individual’s genetic liability to a trait or disease.

This helps clinicians start treatment earlier for high-risk patients to prevent vision loss.

It may also reduce clinic burden and

The data will help doctors decide when to initiate and escalate medical therapy and laser, find out who is most likely to need incisional surgery which carries more risk, decide the frequency of review potential for better managing high-risk patients who might be lost to follow up, and to find those people who have a high number of family members likely to be affected.

Prof. Craig also noted that cardiovascular genetic risk factors were also found to be associated with the macular ganglion cell complex. This indicates that hypertensive treatment may be important in preventing longitudinal progression in early glaucoma.

Rho-kinase inhibitor eye drops are used as rescue therapy in certain cases.

Assoc. Prof. Chong presented preliminary results from an ongoing prospective study of 11 patients.

DWEK resulted in improved visual acuity and contrast sensitivity in 81% of patients with moderate to severe Fuchs’ dystrophy.

DWEK is a potential intermediary step in the treatment of FED, before offering corneal transplantation, which can be performed with no issues following DWEK. Further refinement in its technique and prospective studies are required to establish a clear role in the management of FED. “In conclusion, DWEK was successful in 81% of patients with moderate to severe FED with good visual outcomes, and Descemets’ membrane endothelial keratoplasty (DMEK) can be performed successfully if the cornea does not clear following DWEK,” she said.

“There are a few other nuances that we need to look for with further studies. But this is still an ongoing study,” she noted.

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

Know Your Tech Protect your practice from cyberattacks!

by Tan Sher Lynn

Acknowledge your allies To help you keep safe from cyberattacks, Dr. Ha provided an email security checklist, which includes restricting mail access to trusted users; actively monitoring incoming and outgoing mail; enabling domain-based message authentication, reporting and conformance or DMARC (email authentication protocol that protects a user’s domain from unauthorized use); enabling domain keys identified mail or DKIM (which allows a receiver to verify that an email has actually come from a specific domain); and enabling sender policy framework or SPF (which enables a user’s email server to distinguish forged email/spam from legitimate email).

“Further measures include having robust spam filtering, attachment restrictions (so that only certain file types can enter), and a throttling policy. Perhaps, most importantly, the weakest link in the practice may be an individual that inadvertently presses on an attachment he shouldn’t have. Hence, it’s important to ensure there’s adequate employee training to prevent these types of attacks,” Dr. Ha advised.

T

he good news is, in ophthalmology, there are many existing IT systems — in the form of patient administration software, optical coherence tomography (OCT) database, imaging database, shared files and records — available to help keep our practice simplified, organized and up to date. The bad news? All of these are vulnerable to ransomware attacks.

Recognize your foes According to Dr. Marc Sarossy from Melbourne, the key vulnerability of this kind of attack comes through the Windows file-sharing system, a protocol that allows resources to be shared between computers on the network and through a single sign-on at the Windows prompt. This protocol is also used by the Linux and Mac systems.

“Ransomware is malicious software

designed to encrypt user’s files. It targets backup and shadow copies and can evade or shut down antivirus software. It can be deployed through a targeted spearphishing attack,” explained Dr. Sarossy.

“Attacks can be in the form of direct attack, browser-based attack, email attack (which is the most likely vector) and Wi-Fi attack. A decrypter is usually available for a ransom of $50,000 to $100,000, although there’s no guarantee it will work,” he shared.

Next, Dr. Jason Ha from the Royal Victorian Eye and Ear Hospital, Melbourne, discussed about email intrusions and how to build system resilience against cyberattacks.

“Nowadays, there are increasingly sophisticated cyberattacks coordinated internationally to target organizations and encrypt their data until a hefty ransom is paid,” he shared.

Nevertheless, all these measures can only reduce the risk of a cyberattack but never fully mitigate it. According to Dr. Ha, there are other methods that are useful to prevent the propagation of malware once it has entered your practice, such as virtualization, which is the partition of a single physical server into several virtual servers.

“Other risk management techniques include having a written, printed-out disaster plan in case things go wrong, and having a backup system that does not rely on Windows file sharing,” he added.

Ideally, it is good to have the backup stored in the location independent of the main server.

“The ophthalmology community is particularly vulnerable to cyberattacks, and complacency can lead to unwanted attacks. A cyberattack and subsequent recovery can cost a practice considerable time, money and stress. We urge you all to review your cybersecurity setups and speak to your colleagues about the importance of cybersecurity,” he remarked.

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28 February 2022 | Issue #2

TECNIS Eyhance Toric available II soon

TECNIS Eyhance™ IOL • Revolutionary performance that defies monofocal enhanced intermediate vision.1 • Outperforms in low-light conditions, increasing confidence in expected outcomes.

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with TECNIS SIMPLICITY™ Delivery System

Eyhance Toric II IOL TM

• Lock-in visual performance with rotational stability.3

Enhance vision.

Exceed expectations.

References: 1. Data on File, Johnson & Johnson Surgical Vision, Inc. Sep 2018.

DOF2018CT4015. 2. Data on File, Johnson & Johnson Surgical Vision, Inc. 2018.

DOF2018OTH4004. 3. DOF2019OTH4015 - Study NXGT-103-MER3 - Proof of Concept Study for Next-Generation IOL Models MER003 and MER004. Aug. 28, 2019.

For healthcare professionals only.

Please read the Directions for Use for Important Safety Information and consult our specialists if you have any questions. © Johnson & Johnson Surgical Vision, Inc. 2022 AMO Australia Pty. Ltd 507 Mount Wellington Hwy, Mount Wellington, Auckland 1060, New Zealand. Phone: 0800 266 700. PP2022CT4110

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

Eyhance IOL Enhancing cataract patients’ quality of life

by Joanna Lee

C

ataract surgery specialist and aviation ophthalmologist Dr. Dan Black thought his 90-year-old patient would be delighted with her excellent results after her cataract procedure. “Instead, she was disappointed that she couldn’t read. She was even more disappointed that she needed a pair of spectacles to read,” he shared.

Unfortunately, this is not the first time we hear stories like this. Surgeons are aware that increasingly, their cataract patients are demanding presbyopia correction to help them with intermediate distance tasks. However, the “high price” of implantation remains a risk that doctors have been reluctant to take.

An American Society of Cataract and Refractive Surgery (ASCRS) clinical survey recorded that 40% of doctors have raised their concerns over the halo effect resulting in loss of nighttime vision. This was a profound barrier along with other issues, including a significant drop in

contrast sensitivity symptoms.

Just how low can the “price” go?

“Technology is now starting to lower the price,” said the surgeon who, in 2001, pioneered the ultra-small incision cataract surgery in Australia. The noveldesigned TECNIS Eyhance intraocular lens (IOL) is based on refractive technology, which has modified its interior profile to give some degree of presbyopia correction.

According to Johnson & Johnson’s phase 3 trial results, the good news is that there was no statistical difference in the rates of halos, glares, or starbursts observed with the TECNIS Eyhance IOL in comparison with the TECNIS 1-piece IOL. “Similarly, there was no difference or loss of contrast sensitivity when going from the monofocal platform to the Eyhance platform,” Dr. Black explained. No significant loss of

distance visual performance was seen, either.

“There is, however, a good extra line of intermediate vision,” he pointed out.

Essentially, the Eyhance is “a monofocal IOL with intermediate vision” when considering the attributes of contrast sensitivity, good distance vision, and good night vision. “It’s clearly not enough to read, but sufficient to perform those intermediate tasks,” he added.

The Eyhance is best optimized when one minimizes the post-operative sphere and astigmatism levels. So, it is good to correct even low levels of astigmatism.

“Because the Eyhance has a defocus curve of about 0.75 diopters, it could be difficult to reach the endpoint of the refraction at times. My suggestion is to optimize your A constant on a monofocal platform,” Dr. Black advised.

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The other tip is to consider targeting 0.5 diopters of myopia. “Patients can be happy with having 6/7.5 and good intermediate vision rather than be 6/5 and very presbyopic,” Dr. Black said, sharing a story about a military jet pilot who was more than happy to regain his intermediate vision.

Having the benefits of presbyopia correction with refractive optics and uncompromised distant vision quality, which also provides intermediate vision at no cost, is among the top reasons why Dr. Black prefers this lens. “Eyhance is now the default IOL that I use on essentially everybody,” he shared.

Continuing the discussion, specialist ophthalmologist Dr. Ben Connell, one of the first surgeons in Victoria to perform laser-assisted cataract surgery (LACS) using a femtosecond laser, said: “In the T2, the external surface of the haptic has a new frosted appearance. The aim of that is to increase the friction in the internal part of the capsule and to reduce the likelihood of the bend rotating into the bag.” In addition, it also has a shorter unfolding time.

While at it, Dr. Connell also shared his tips on how to minimize rotation instability.

New toric stability

“I always push the lens to the side and I clean underneath the IOL with a cohesive viscoelastic,” he shared. “You could also rotate the lens with the instrument.”

The T1 toric system has undergone a major development recently with improvements to its toric stability.

Dr. Connell has conducted a study to investigate the rotational stability of both Clareon and Eyhance IOLs lenses by

>> Cont. from Page 3

an article that found the Barrett toric calculator having the lowest astigmatism prediction errors. The true-K formula is also accurate for patients who have undergone a myopic laser when the refractive history is known.

Jena, Germany) device for 201 eyes in his study using integrated K, the accuracy of this method was proven.

Accurate methods of prediction are also important when selecting the right toric IOL for pre-existing low-level astigmatism. “My toric calculator is based on a theoretical model of the ellipticity of the cornea to explain why the posterior cornea contributes approximately a half diopter of against the rule cylinder.”

He stressed that it is not populationbased, but calculates a unique theoretical value for each eye using the ocular parameters. In 2017, the Journal of Cataract & Refractive Surgery published

He also explained why it is important to use toric IOLs with low cylinder powers by comparing the outcome of non-toric and T3 implantations with toric IOLs implant results using the calculator.

He said the idea that incisions are preferable in managing low levels of preexisting astigmatism is another myth. “I consider toric IOLs as indispensable for this purpose.”

Compared against the market leader for rotational stability, Eyhance IOLs have almost no rotations within 6 to 24 hours, as well as up to 3 months postoperatively — although there were some early clockwise movements. The absolute or total rotations are quite the same between the two groups.

“In all of these parameters, the absolute rotation was very similar and nonstatistically significant. My study confirms there was no loss of uncorrected distance visual acuity when using the Eyhance IOLs,” Dr. Connell concluded.

in achieving accurate outcomes with toric IOLs, Prof. Barrett has developed the “ToriCAM marker” app as a simple yet precise method for marking toric IOLs. It only requires a phone and a simple marking pen. “The surgeon marks the limbus, aiming for 180 degrees. And then uses the iPhone to identify the actual alignment of those marks,” he said. He also designed a specific marker to be used for the app so that the reference axis on the app can be set independently from the desired toric alignment meridian given by the calculator. However, he still recommends manual markings as routines even when using image-guided systems for reliability and accuracy.

Lastly, in emphasizing accurate alignment

REFERENCES: 1.

checking the results at three time points: intraoperatively, at 6-24 hours (P1) postsurgery, and at 1-3 months (P2). After exclusion criteria, all patients left had visual acuity better than 6/12, and all had refractions.

Zéboulon P, Debellemanière G, Gatinel D. Unsupervised learning for large-scale corneal topography clustering. Sci Rep. 2020;10(1):16973.

2.

Debellemanière G, Dubois M, Gauvin M, et al. The pearl-DGS formula: The development of an open-source machine learning-based thick IOL calculation formula. Am J Ophthalmol.

2021;232:58-69.

3.

Zéboulon P, Ghazal W, Gatinel D. Corneal Edema Visualization With Optical Coherence Tomography Using Deep Learning: Proof of Concept. Cornea. 2021;40(10):1267-1275.

4.

Hind J, Edington M, Lockington D. Maximising cost-effectiveness and minimising waste in modern ocular surgical simulation. Eye (Lond). 2021;35(8):2335-2336.

5.

Ferris JD, Donachie PH, Johnston RL, Barnes B, Olaitan M, Sparrow JM. Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: report 6. The impact of EyeSi virtual reality training on complications rates of cataract surgery performed by first and second year trainees. Br J Ophthalmol. 2020;104(3):324-329.

6.

Guthrie S, Goudie C, Lockington D. Survey of Scottish ophthalmic trainees’ experiences using 3-piece IOLs in cataract surgery. J Cataract Refract Surg. 2018;44(3):409.

Editor’s Note:

Sir Norman McAlister Gregg served in World War I before returning to England to train as an ophthalmologist at Moorfields. He set up his practice in Macquarie Street in Sydney in 1923 and published a landmark paper in 1941, recognizing the consequences of fetal infection with rubella, considered one of the most important contributions to medicine in Australia.

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

implant insertion, and conjunctival and Tenon’s closure.

All About the Retina Rapid Fire session presents the latest advances in AMD treatment

by Hazlin Hassan

Y

esterday, during Day 2 of the 52nd Annual Scientific Congress of The Royal Australian and New Zealand College of Ophthalmologists (RANZCO Brisbane 2022), yet another Rapid Fire session heated up the show. This time it was all about the retina — highlighting the latest in the treatment and management of age-related macular degeneration (AMD).

Promising phase 3 trial results for nAMD treatment Results from the Archway phase 3 trial of the port delivery system (PDS) with ranibizumab for neovascular age-related macular degeneration (nAMD) showed that the PDS was non-inferior to monthly ranibizumab.

The PDS is an investigational drug delivery system designed for continuous intravitreal ranibizumab release through a surgically implanted, refillable ocular implant. The phase 3 Archway trial evaluated the safety and efficacy of PDS for the treatment of nAMD. Patients were randomized 3:2 to treatment with the PDS with ranibizumab 100 mg/ml with fixed 24-week (Q24W) refill-exchanges or intravitreal ranibizumab 0.5 mg injections every four weeks.

Results showed that the PDS Q24W was non-inferior to monthly ranibizumab at W44/48. Over 90% of PDS Q24W patients did not receive supplemental ranibizumab treatment.

The implant insertion procedure has seven key steps: peritomy, implant preparation, scleral dissection, pars plana laser ablation, pars plana incision,

According to Assoc. Prof. Andrew Chang, medical director of Sydney Retina Clinic, PDS Q24W was noninferior to monthly ranibizumab, with vision outcomes for the average of W44/48 consistent with the primary analysis.

The PDS was generally well tolerated, with a favorable benefit-risk profile.

“Adherence to a specific methodology for the implant insertion procedure is key for maximizing optimal outcomes with PDS procedures,” he noted.

Standardized surgical training and ongoing procedural evaluations are important to enhance surgeon proficiency, he added.

Exploring the long-term effects of AMD treatments Meanwhile, Dr. Zhichao Wu from the Centre for Eye Research Australia gave his presentation on an observational extension study to the laser intervention in the early stages of age-related macular degeneration (LEAD) clinical trial.

The purpose of the study was to examine the long-term effect of subthreshold nanosecond laser (SNL) treatment with the Retinal Rejuvenation Therapy (2RT®) device on disease progression in the early stages of AMD or age-related macular degeneration.

The 36-month LEAD trial included 292 participants with bilateral large drusen, who were randomized to receive either SNL or sham treatment in one eye at six-monthly intervals up to 30-months.

The difference in progression to late AMD between treatment arms for these participants was observed.

Overall, the rate of progression over a 60-month period was not significantly different between the SNL and sham group (p = 0.098); a similar finding to the 36-month LEAD study.

“In conclusion, this 24-month observational extension study confirmed findings from the LEAD trial that overall, SNL treatment did not significantly reduce the rate of progression to late AMD,” explained Dr. Wu.

Automating diagnoses of AMD with the help of AI On the other hand, Dr. David Squirrell, from the University of Auckland, New Zealand, showed how the diagnosis of advanced age-related macular degeneration and high-risk intermediate age-related macular degeneration can be automated, based on the Age-Related Eye Disease Study (AREDS) scoring system.

The aim was to develop a deep learning algorithm to detect advanced AMD, and high-risk intermediate AMD based on images extracted from the AREDS dataset.

The AREDS image datasets comprised a total of 118,254 images. An artificial intelligence (AI) system was trained to remove very poor quality images, as well as those with dense cataracts.

From the remaining images, 8,627 were labeled as advanced AMD. A total of 58,249 images had drusen labels (0-4) and 59,165 images had pigmentary labels.

Color balancing, contrast enhancement and image normalization techniques were applied to homogenize the dataset. The data was then split 70/15/15 into training, validation and test sets.

Finally, an ensemble of AI algorithms was trained to detect advanced AMD and high-risk intermediate AMD models.

A “waterfall” of AIs was then trained to automatically reproduce the scoring system in the AREDS Research Group’s report 18.

The results showed that compared to the ground truth provided by the AREDS dataset, the final patient-level accuracy of detecting advanced AMD is 92.75%, with a sensitivity of 94.86%, a specificity of 92.24%, and a negative predictive value of 98.66%.

Compared to the ground truth provided by the AREDS dataset, the final accuracy of detecting high-risk intermediate dry macular degeneration was 97.19%, with a sensitivity of 94.7%, a specificity of 97.31%, and negative predictive value of 99.74%.

“In conclusion, our model was able to accurately identify both advanced AMD and intermediate AMD in this large publicly available dataset. Further validatory trials are required to test its generalisability to other datasets,” concluded Dr. Squirrell.

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Cracking the Cornea A crikeylicious conference at RANZCO 2022

by Andrew Sweeney

Attendees gave their updates on the management of common corneal conditions to improve patients’ vision and comfort.

Prof. Stephanie Watson from the HCF Dental Centre Bondi in Bondi Junction, Australia, was the primary speaker. One of the main thrusts of the symposium, in general, was the effects of COVID-19 on corneal treatment.

We are all aware of the potential side effects and ramifications of the COVID-19 vaccines. And one of the interesting points Prof. Watson discussed was how to deal with patients who have a strong reaction to the jab and whether to consider steroid use during corneal transplantation, as their immune system will be to a degree weakened.

A chock-full of information Another speaker, Dr. Andrew Apel, the founding owner of The Eye Health Centre Brisbane with practices in Brisbane City, Aspley, Wynnum and Booval, focused his presentation on the treatment that patients required after a corneal transplant takes place. He described his preference for the Descemet’s membrane endothelial keratoplasty (DMEK) technique.

He said he preferred DMEK as there is a smaller risk of organ rejection and a lower residual refractive error than with the traditional full-thickness corneal transplant technique, leading to a lesser impact of medication posttreatment.

A

h, cornea, the coolest of ophthalmology’s specialties in this writer’s humble opinion — and something everyone can look forward to learning about at the 52nd Annual Scientific Congress of The Royal Australian and New Zealand College of Ophthalmologists (RANZCO Brisbane 2022).

On the second day of this crikeylicious conference (yes, crikeylicious we went there), we got to sit down and watch the symposium Optimising the Management of Common Corneal Conditions: What Do Corneal Specialists Tell their Patients?

The symposium brought together some of the finest minds in Antipodean cornea procedures, and we couldn’t be happier.

COVID and the cornea The main aim of the session was to examine patients suffering from corneal and external disease, especially those with poor vision and ocular discomfort.

This was one of those online symposiums where we got the best of both worlds, offering both the interesting presentations we like to see and engaging audience’s feedback that we love to watch.

Another interesting presentation was given by Dr. Tanya Trinh, an ophthalmologist trained in Australia and Canada, now based in Mosman, Australia.

Her presentation highlighted the different types of corneal transplants a patient should consider, drawing on her own experience of working with ocular surface regeneration. Dr. Trinh also discussed her work with partial and full-thickness corneal transplantation, stem cell transplantation and amniotic membrane transplantation.

So, if you’re looking for a comprehensive examination of these different techniques, make sure to check this segment out later.

CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

Eye Care Warriors

In the fight against astigmatism and climate change, experts take their stand

by Tan Sher Lynn

F

“It’s simply a myth that there’s any benefit to leaving patients with residual astigmatism. Low levels of astigmatism do not assist near or intermediate vision,” he said.

At the forefront in the battle against astigmatism According to Dr. Barrett, selecting an IOL for patients with low level astigmatism requires reliable measurements, accurate prediction, an understanding of incision and precise alignment. Three instruments are adequate in measuring low-levels of astigmatism: the optical biometer, topographer and keratometer.

calculators has improved astigmatism outcome prediction, and image-guided systems can facilitate accurate alignment.

However, similar accuracy can be achieved with inexpensive smartphone apps and associated markers.

“Leaving a patient with significant astigmatism may have been acceptable in an era when extracapsular cataract surgery was widely practiced. But today, with small incision cataract surgery and phacoemulsification, an attempt to achieve a target of less than 0.5 D in all patients is preferable and could be considered a standard of care,” noted Dr. Barrett.

Taking a step towards a sustainable future Climate change is now an observable

He also noted that the availability of toric

Presenting his talk during the RANZCO Plenary Session on climate change and sustainability, Wellington ophthalmologist Dr. Jesse Gale said that doctors have ethical responsibilities to play in this area, as they have far greater influence than most people.

“As a medical community, doctors should lead decarbonization of health care and advocate for sustainability that supports a healthy planet,” he said.

“In health care, the biggest contributors to the carbon footprint are energy and transport,” Dr. Gale added.

“We can reduce transport emissions by delivering community care close to home and public transport hubs, offering active transport facilities, and reducing low-value visits to the clinics.”

ew innovations in ophthalmology have had as significant an impact as the introduction of toric intraocular lenses (IOLs). Presenting the Norman McAlister Gregg Lecture on Day 2 of the 52nd Annual Scientific Congress of The Royal Australian and New Zealand College of Ophthalmologists (RANZCO Brisbane 2022), Prof. Graham Barrett from the Lions Eye Institute, Western Australia, said that the ability to accurately predict astigmatic outcomes has improved since 2006 and the threshold for considering a toric IOL has reduced.

As a result, toric IOLs are required in approximately 80% of cases undergoing cataract surgery if the desired outcome is less than 0.5 D of residual astigmatism in all patients.

threat around the world, with the rise of global temperature being unprecedented in more than 2,000 years. This is set to pose the greatest risk to human health in the century to come.

He noted that New Zealand has a renewable energy grid, so energy emissions were lower. Nevertheless, the main source of emissions in the country is procurement.

“In ophthalmology, the greatest source of emission is driven by consumption of single-use supplies and excessive packaging. To reduce this type of consumption, it means not opening what you don’t use, reusing as much as possible (gowns, drapes and blades), and recycling the packaging as much as possible,” Dr. Gale enthused.

He added that RANZCO is collaborating with other colleges for joint statements and advocacy and in developing a roadmap of actions to follow.

“We are also leaning on the central office of RANZCO to show leadership in measuring, reducing and offsetting emissions from college activity and investments. And we are always looking for new ways of doing things that improve sustainability without compromising safety and quality,” he concluded.

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