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ISSUE
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cataract • anterior segment • kudos • enlightenment C A K E M A G A ZIN E ’ S D A ILY CO N GR E S S N E W S O N T H E A N T E R IO R S E G M E N T
HIGHLIGHTS
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When NOT to do MIGS and trabs ... glaucoma experts discussed.
solutions, simple 07 Myopia and complex ... read more!
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APACRS Day 1
Glaucoma Oopsies & Cataract Nightmares by Andrew Sweeney
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31 July 2021 | Issue #1
on a virtual platform (as we’ve become accustomed to). Beginning on Friday, July 30, and forcing your correspondent from his bed at a rather unreasonable hour due to his living in Central Europe, the conference began with several highlights of various aspects of the ophthalmology industry. These were then followed by two company highlight events, one being ZEISS’s Driving Outcome & Satisfaction in Cataract and Refractive Surgery, and the second was Santen’s lovely reference to 19th century English literature, Sense and Sensibility of Levofloxacin 1.5%: Reducing Risk of Endophthalmitis After Cataract Surgery.
Whoopsie daisies galore in glaucoma As the day went on the Media MICE squad did its usual perusing of the various symposiums and sessions on offer, and one that caught our eye was SNEC Instruction Course: How (and When) Not to Do MIGS – A Journey Through Complications. Your writer has a particular penchant for sessions about when things go wrong, and this examination of minimally invasive glaucoma surgery (MIGS), as well as comparing this technique to trabeculectomy procedures. The standout segment of this symposium was Not So Minimally Invasive - MIGS Gone Horribly Wrong, given by Dr. Ike K. Ahmed, assistant professor and director of the Glaucoma and Advanced Anterior Surgical Fellowship, University of Toronto, Canada. Dr. Ahmed’s presentation did exactly what it said would do and offered some fantastic case study examples of when MIGS go horribly wrong. In one example, he highlighted a 74-year-old diabetic and obese patient with primary open-angle glaucoma (POAG) as well as cataracts, who while undergoing surgery experienced a large build-up of blood in the Schlemm’s canal. Dr. Ahmed presented footage of this taking place, and reported that the attending surgeon had to “abandon ship,” a decision he agreed with. He then recommended that a reverse Trendelenburg procedure should be considered in these cases.
Now, hopefully you won’t grudge us for a shameless segway into our third and latest magazine COOKIE, as it’s awesome and its focus on optometry is truly unique. The SNEC Symposium: Preparing for the New Wave in Optometry offered some valuable insight into what the future holds for optometry, as well as aspects of ophthalmology, and the lessons learned therein are based on SNEC’s first-hand experience. The session covered everything from the specifics of private practice to ocular surface disease in cataract and refractive surgery. It was this last segment that really got our interest, and was ably presented by Dr. Jean Chai, a visiting consultant at SNEC’s corneal service wing. She reported on hyperosmolarity and how poor management of the tear film can cause changes to keratometry readings, higher-order aberrations, and failed topography and intraocular lens (IOL) calculations. As cataract and refractive surgery can cause dry eye, Dr. Chai recommends high-quality preoperative slit-lamp examinations to monitor eyelid blink and closure, as well as checking the Meibomian glands for evidence of dysfunction.
Does cataract surgery give you nightmares? Posters galore were on offer on Day 1 of the APACRS-SNEC conference and there were certainly clear favorites among the Media MICE staff. A Rare Case of Secondary Angle Closure Glaucoma due to Air Bubble Entrapment following Uncomplicated Phacoemulsification really got our noggins a-scratching as this really was one of those “WTH” moments (and if you don’t know what that means, go ask one of your kids). Pediatric Cataract’s Delayed Presentation and its Surgical Difficulties: A Case Report also got us hooked, as the condition studied in the poster is obviously very unusual among children. But for the writer of this article, there was one real stand-out poster — that was Posterior Polar Cataract Surgery – No More a Nightmare, submitted by Drs. Meghali Bhattacharjee and
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 [Hanita Lens]. Media MICE is in no way affiliated to or with any person, organization, or entity mentioned in this publication, [including (APACRSSNEC], nor is this publication published in any way intended to convey any such affiliation.
Aniruddha Mahindrakar from India. Their research focused on what they described as “the most dreaded form of cataract,” and studied 18 eyes with posterior polar cataract who underwent phacoemulsification. The Vasavada and Raj technique of inside-out hydrodelineation was applied, where a trench is first sculpted, and a rightangled cannula is used to direct the fluid perpendicular to the lens fibers. Of 18, 17 eyes were treated using this technique successfully, with the one aberrant eye experiencing a small posterior capsular rent, which they say was managed well. The doctors concluded that more gentle maneuvering to avoid chamber collapse or overinflation; low parameters; avoidance of hydrodissection; nucleus rotation; posterior capsule polishing; and excessive, intraocular lens manipulation during surgery should not be performed with the same techniques as standard cataract surgery. Finally, pointing to the study’s success, they recommended the use of the Vasavada and Raj technique. While we can’t sip gin and tonics at Raffles or watch the sunset from the Marina Bay Sands complex, we can look forward to tomorrow’s sessions. Make sure you follow the Media MICE team on our social media to stay on top of the latest APACRS events and visit our CEO Matt Young’s LinkedIn page for the top insights around. Till tomorrow!
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CAKE Magazine’s Daily Congress News on the Anterior Segment
Before Cataract Surgery
IOL Selection and Ocular Surface Management by Tan Sher Lynn
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n ophthalmology, cataract surgery is always a hot topic: From choosing the “right” intraocular lens (IOL) to preoperative considerations like dry eye, surgeons have a lot to think about before the procedure even begins. These topics and more were discussed on Day 1 of the 33rd Asia-Pacific Association of Cataract and Refractive Surgeons and Singapore National Eye Centre 30th Anniversary virtual meeting (APACRSSNEC 2021).
Mono versus multifocal IOLs Dr. Ryan Tay, an optometrist at Tan Tock Seng Hospital in Singapore, talked about the types of IOL used in cataract surgery. “Monofocal IOLs have a single optical zone and they provide patients with a distinct single focus. When this type of lens is indicated for cataract surgery, the surgeon usually discusses with the patient whether to target the eye for distant or near vision. If distance is chosen, the patient will need reading glasses for near vision. “On the other hand, multifocal IOLs are able to provide both distant and near focus. But they are not necessarily superior to monofocals. Due to their optical design with multiple zones, these IOLS can come with side effects like halos. They also provide a less distinct single focus compared to monofocal IOLs, especially in less than ideal lighting conditions,” he said. He noted that one of the newer IOLs are extended depth of focus (EDOF),
which use diffractive optics to create an elongated focus. These usually give good distance and intermediate vision. “Monofocal IOLs have been the staple in the past and will continue to be so in the present and future. New IOL profiles are continuously researched and improved to create new IOLs. The future will see new iterations and we may need to reevaluate the way we manage IOLs and patients,” he concluded.
Phakic IOL for high myopia Presenting on phakic intraocular lenses (PIOLs), Clinical Associate Professor Mohamad Rosman from Singapore National Eye Centre, said that PIOLs are actually contact lenses within the eye. “The main advantage is the ability to correct a larger range of refractive error: -3 to -23D for myopia, up to 6D for astigmatism and +3 to +21D for hyperopia. These lenses are used in cases where surface ablation is not suitable, such as when the cornea is thin or suspicious.” He noted that among the few types of PIOLs, namely angle supported, irisfixated and posterior chamber PIOLs,
posterior chamber PIOLs are more popular due to good safety profile and efficacy, as well as low complications. The STAAR Surgical Visian Implantable Collamer Lens (ICL; California, USA) is the most commonly used PIOL for the time being. “Phakic IOLs offer an alternative correction in patients with thin cornea and high myopia. For people with lower myopia and thicker corneas, its use is more controversial due to the risk of complications. Long-term follow up is required, and the optometrists should know how to examine the PIOL using a slit lamp, monitor for any sign of cataract or glaucoma, and understand the cause for sudden change in astigmatism in PIOL patients,” he said.
Managing dry eyes in cataract and refractive surgery Dr. Jean Chai from the Singapore National Eye Centre noted that a healthy ocular surface is important to ensure accurate preoperative measurements and avoid suboptimal visual outcomes postsurgery. “Cataract and refractive surgery can cause or worsen dry eye disease due to corneal nerve disruption, tear instability, Meibomian gland dysfunction or inflammation, which increases tear osmolarity. The approach for patients with dry eye disease, before proceeding with cataract and refractive surgery, is to identify the underlying cause, and defer ocular surgery until the surface stabilizes. “For patients with dry eyes, SMILE or advanced surface ablation (PRK, LASEK, epiLASIK) may be better than femtosecond LASIK due to less disruption to the surface and corneal innervation. During cataract surgery, making a smaller incision may be less likely to induce dry eye, and monofocal IOLa are preferred over multifocal IOLa. Postoperatively, you may want to consider prescribing preservative-free eye drops as those with preservatives may worsen dry eye. Lastly, the patient needs to be counseled on the need for postoperative, long-term management of their condition,” she said.
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Signs
When Not to Do MIGS and Trabs by Sam McCommon
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inimally invasive glaucoma surgery (MIGS) has become increasingly popular recently, and as such is earning dedicated discussions regarding its use. However, just like any treatment, knowing when not to use it is just as important as knowing when to use it. Such was the focus of a discussion during the first day of the 33rd Asia-Pacific Association of Cataract and Refractive Surgeons and Singapore National Eye Centre 30th Anniversary virtual meeting (APACRS-SNEC 2021). If you’re looking for some context in which to place MIGS, this is a great place to start.
eye drops, the less compliance there will be. Eye drops used long-term can cause prostaglandin associated periorbitopathy (PAP), as well as other conditions like blepharitis and dry eye syndrome associated with BAK, a preservative commonly found in eye drops. Additionally, Dr. Markornwattana reckons that around half of glaucoma patients will require surgery at some point, despite medications.
We’ll start by looking at the headline of the talk.
So, that’s a bit of background. MIGS has its place, and as Dr. Markornwattana noted there’s no “no” in glaucoma treatment — every case is unique and requires case-specific treatments.
When NOT to do MIGS?
There’s a gap between laser surgery and traditional glaucoma surgery that’s well filled by MIGS. For Dr. Markornwattana, the treatment options look like a sliding scale, from least serious to most: eyedrops, laser treatments, MIGS and finally, more invasive surgery.
When not to perform glaucoma surgery is a different topic, but one suggestion from the doctor stands out — some materials may not be appropriate for Muslim patients, so a doctor should speak with a patient about their religious views if it seems like they may be pertinent. Dr. Makornwattana had some valuable take-home messages for us. First, and perhaps most important, is that there’s no such thing as an ideal glaucoma surgery. Trabeculectomy isn’t a magic bullet, and MIGS is still not a standard of care in glaucoma. Developing skills in MIGS requires time on the learning curve for surgeons. Additionally, needle revision and postoperative care will be much different between trabeculectomy patients and MIGS patients.
When NOT to do trabeculectomy Here’s another “not to” lecture, with some equally valuable takeaways. We’ll wrap this one up quickly, though we’d love to expand on it in another, full article. This talk was brought to you by Dr. Graham Lee, a professor of ophthalmology at the University of Queensland, Australia. He’s one of the few specialists in the world who have completed both corneal and external diseases as well as glaucoma fellowships — so our ears perk up when he speaks. According to Dr. Lee, non-ideal patients for trabeculectomy include:
Dr. Manchima Makornwattana gave us some excellent takeaways to ponder when considering MIGS treatment. She’s the holder of numerous prestigious Thai titles including professor of ophthalmology at Thammasat University Faculty of Medicine, just outside Bangkok, so she’s a titan in the Thai ophthalmic community (no pun intended). Before we dive in, we need to establish a bit of context first.
Now, with our context, we can dive into the doctor’s advice for when to avoid MIGS. For Dr. Markornwattana, some specific ocular conditions can mean MIGS are a no-go. These ocular conditions include:
As Dr. Makornwattana pointed out, even when patients are totally educated, informed, brought up to speed and so on — patients will “definitely 100% go for eye drops because it is most available, most understandable and most acceptable.”
• Long-term exposure to BAK
• African or Asian patients, or patients with tight orbit syndrome
• Challenging eye, a deep socket or a prominent orbital rim
• Patients who have used long-term multiple topical medications
• Small interpalpebral fissure or PAP
Thanks to the above doctors for their insights, and as always we look forward to hearing more from them and their colleagues.
• Conjunctival hyperemia • Previous ocular surgery or conjunctival scar
• Shallow chamber However, the longer a patient uses
• Patients with a scarred conjunctiva or thin sclera, including from previous surgeries like trabeculectomy/ goniotomy, vitrectomy and extra- or intra-capsular cataract extraction • Patients with secondary glaucoma, including uveitic, neovascular or aphakic patients
CAKE Magazine’s Daily Congress News on the Anterior Segment
Getting the Best Outcomes in Cataract Surgery by Hazlin Hassan
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enowned surgeons shared their top tips for getting excellent results in cataract surgery during a session on Managing the Posterior Segment in Cataract Surgery, on Day 1 of the 33rd Asia-Pacific Association of Cataract and Refractive Surgeons and Singapore National Eye Centre 30th Anniversary virtual meeting (APACRS-SNEC 2021).
Screen for coexisting conditions “Prior to the cataract surgery, it is really important to screen for any coexisting eye disease, for retinal diseases specifically, to optimize cataract surgery outcomes,” said Associate Professor Daniel Ting, consultant, Surgical Retina, Singapore National Eye Centre. Coexisting retinal diseases include diabetic retinopathy (DR) and diabetic
macular edema (DME), age-related macular degeneration (AMD), epiretinal membrane (ERM), macular hole, vitreomacular traction, and retinal tear or detachment. For patients with diabetes, surgeons should preoperatively co-manage with internists to optimize the vascular risk factors to ensure that blood pressure and cholesterol levels are well controlled prior to the cataract operation. If a patient has severe non-proliferative diabetic retinopathy or proliferative diabetic retinopathy, then retinal laser is offered first. Once the condition is stable, then cataract surgery may be considered the day after. Also, if a patient has vitreous hemorrhage, retinal laser or a vitrectomy may be conducted first, if required. For patients with DME, the condition
needs to be stabilized first with antiVEGF or steroids, he said. In patients with epiretinal membrane or vitreomacular traction, the severity needs to be assessed if they need to undergo vitrectomy. Further, systemic conditions such as previous stroke or heart disease that require blood thinners need to be known. “It is not an issue actually, most cataract operations are done under topical [anesthetic]. If there is a need, however, for combined phaco and vitrectomy, we may need to consult the internist about stopping the blood thinners preoperatively if deemed fit,” he said. Postoperatively, the patients need to be monitored for worsening of DR or DME. For patients with AMD, they need to treat the active disease first in cases of wet AMD, and to proceed with counseling of a guarded visual prognosis for dry AMD.
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In instances of retinal breaks or retinal detachment (RD), the retinal breaks or RD need to be treated first before proceeding with the cataract operation three months later.
Choosing the right lens Associate Professor Danny Cheung, consultant, Surgical Retina Department, Singapore National Eye Centre, discussed the matter of cataract surgery and lens choice in the presence of ERM and vitreo-macular interface disease. He presented a case of a 68-year-old man with moderate nuclear sclerotic cataracts, moderate myopia and no significant corneal astigmatism. He noted that both cataract and ERM are common age-related eye diseases and that this patient was interested in spectacle independence. But there are issues in planning for cataract surgery in the presence of ERM and other vitreomacular interface abnormalities. “In summary, vitreomacular interface abnormalities or diseases such as ERM are increasingly detected in patients with cataract and it has now become a common scenario for us to deal with in clinical practice. The best surgical approach is yet to be determined, but cataract surgery alone may provide sufficient improvement in vision for some of the patients with ERM. Preoperative careful counseling and assessment of patient expectations are critical in the management of these patients,” he said.
Set the right expectations Dr. Anna Tan, senior consultant, Medical Retina, Singapore National Eye Center, has a tip for surgeons performing cataract surgery on patients with AMD: “Under-promise and over-deliver.” She shared that all eyes with any stage of AMD should also have preoperative OCT to assess the status of the outer retina. Counseling should be given, and surgeons would do well to manage the expectations of AMD patients undergoing cataract surgery, explained Dr. Tan, adding that microperimetry can assess visual potential more accurately. She noted that there is no clear current evidence that cataract surgery significantly affects AMD progression.
Patients with intermediate or dry AMD should be advised on a possible risk of conversion to wet AMD. There should be increased vigilance in monitoring within three months post-cataract surgery, she added. For patients with nAMD, they should be given a preoperative [anti-VEGF] intravitreal injection (IVT). Cataract surgery should be avoided in the first six months of commencing IVT therapy or until the patient is stable on maintenance treatment. She continued that injection intervals should be maintained or even shortened immediately after cataract surgery. Postoperative cystoid macular edema (CME) needs to be differentiated from AMD exudation by multimodal images, concluded Dr. Tan.
Special considerations During a presentation on Cataract surgery after retina surgery: considerations and techniques, Professor Caroline Chee, head, Vitreoretinal Service, Department of Ophthalmology, National University Hospital, Singapore, said: “Vitreoretinal surgery is more common now than ever before. As we all know, cataract formation increases after retinal surgery, particularly if gas or silicone oil is used.” If the onset of the cataract is very rapid (within weeks), there is a strong possibility of an iatrogenic breach in the posterior capsule which will have an impact on surgery. If there was a retinal detachment or diabetic traction
detachment, she said to wait until the retina is well reattached, for at least three months or longer if there was PVR (proliferative vitreoretinopathy) or giant tear. “The principle is to allow the healing to be complete and inflammation to settle,” explained Prof. Chee. In young patients, loss of accommodation needs to be balanced against reduced vision — if there is mild visual loss, surgery may be deferred a little longer. Unlike in older patients, the fellow eye will not need cataract surgery for a long time. Other suggestions provided by Prof. Chee included that, in general, a monofocal or monofocal toric is usually preferred over a multifocal IOL. This is because a loss of contrast sensitivity and glare in multifocal IOLs is compounded by retinal pathology. Also an acrylic IOL should be used instead of a silicone IOL; if there is a presence of silicone oil in the eye or potential future need for silicone oil in surgery, there is a high risk of condensation and hazing of optic. Additionally, surgeons should aim for at least mild myopia. The IOL position may be more posterior than usual due to an absence of vitreous support and weak zonules. The final refraction tends to be more hyperopic, thus a higher powered IOL may be chosen to reduce the risk of hyperopic surprise, which Prof. Chee suggested increasing by +0.50 to +1.00 D.
CAKE Magazine’s Daily Congress News on the Anterior Segment
Myopia Simple and Complex Solutions to a Nearing Problem by Sam McCommon
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t’s hard to overstate just how big of a problem myopia is and is projected to be in the future. Myopia rates range around the globe, affecting 15-49% of the adult population and 20-90% of children and adolescents. If you’re thinking, “wow, 90% of children are myopic in some places?” then you’re getting the right idea. What’s more, studies estimate that by 2050, some 50% of the world’s population — or 4.7 billion people — will be affected by myopia. Of those, 10% (1 billion) will suffer from high myopia, less than or equal to -5.00 diopters. Those statistics came from Dr. Li Lian Foo, who shared updates from a number of myopia trials. We’ll get back to her talk in just a moment, but starting off with some jaw-dropping statistics is a reliable way to get attention. Preventing myopia and identifying any potential external causes is a crucial step in the right direction, and that’s what kicked off the discussion. So, join us as we start there.
Environmental influence in myopia and management strategies Dr. Seang-Mai Saw, head of the myopia unit at the Singapore Eye Research Institute (SERI) led us down a fairly straightforward but eye-opening path (no pun intended) into environmental influences in myopia. The short story? What your mom said about not staring at screens too much, and about getting out to play — it turns out she was right for more than one reason, and the data backs her up. To start with, we should note that the presence of myopia and high myopia
in young adults is very high in urban Asia. This is especially true in South Korea and Singapore, where kids don’t get much outdoor time at all. Just for reference, a study in South Korea identified 96.5% of young adults (average age 19) with myopia, and 21.6% with high myopia. In Singapore, those numbers were around 80% with myopia and 13-14% with high myopia, depending on varying ages and cohorts. For comparison, in Israel the numbers were in the 20% range, with high myopia as low as 2%. So, it’s a serious problem in East Asia, and one that commands a lot of attention. As Dr. Saw pointed out, a lack of outdoor time and low exposure to sunlight have been implicated in myopia onset. In fact, outdoor time has been the only modifiable factor found to protect against the onset of myopia in nonmyopic children. The body’s reaction to sunlight is complicated, after all, and some studies suggested that exposure to high light levels in sunlight releases dopamine, which acts as a stimulator of choroidal thickness and scleral remodeling, preventing globe elongation. In addition to a lack of sunlight, lots of time spent with near work — reading, writing, screen time and the like — is also an environmental cause of myopia, which can be modified. And yes, there may be a genetic component, but it may also not be as much of a player in the situation as one might think. Dr. Saw shared a study that compared students of Chinese ethnicity in Sydney, Australia and Singapore. The students in Sydney had a myopia rate almost 10% that of the Singapore kids — 3% to 29%, respectively. The biggest difference? The Sydney kids spent an average of 13.75 hours per week outside, whereas the Singapore kids
spent only 3 hours a week outdoors. So, her suggestion? Encourage kids to spend more time outdoors. That’s likely to be a strong educational focus in Singapore in the near future. We hope so, for the kids’ sake.
Medical treatments for myopia In addition to outdoor time, some medical treatments are showing promise. Dr. Li Lian Foo, with the Singapore National Eye Centre (SNEC), shared a study that demonstrated atropine 0.01% may slow myopia by 50-60%, with effects stronger in the second year than the first. The treatment had few side effects, and a sustained effect at five year follow-up. As she noted, 20-30% of children need higher doses for myopia control, and 10% of children do not respond well to even high-dose atropine. Dr. Audrey Chia, head and senior consultant of pediatric ophthalmology at SNEC backed up the dose-related efficacy of atropine but noted individual response may be unpredictable, with poorer responses in those under 8-years-old. An additional study showed DE-127 0.005% and 0.01% to be significantly efficacious for reducing myopia progression compared to placebo. We’re running out of space here, but we’ll have to explore these studies in greater detail in one of our web articles. You can look forward to that, just like we look forward to Day 2 of the 33rd Asia-Pacific Association of Cataract and Refractive Surgeons and Singapore National Eye Centre 30th Anniversary virtual meeting (APACRS-SNEC 2021).
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