ASIA-PACIFIC’S FIRST MAGAZINE ON THE POSTERIOR SEGMENT
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magazine
ANTERIOR & POSTERIOR CROSSOVER ISSUE September/October 2017 www.piemagazine.org
posterior segment • innovation • enlightenment
Ice Cream on a Cone, Dumbbells and Biceps, Burgers and Fries, Fish on Hooks, Wine and Cheese, and Milk and Cookies, Like
the Anterior and Posterior Segments are...
Bet ter Together Page 18
APVRS Kuala Lumpur to Host Retina Specialists Worldwide Page
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Where, oh Where, has my implant gone? Page
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Spotlight on Women in Ophthalmology Page
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Inside this issue...
Posterior Segment
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APVRS 2017 Preview: Kuala Lumpur to Host Retina Specialists Worldwide
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ASRS Post-Show Coverage: 3D Imaging, Stem Cells and Anti-VEGFs
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EURETINA 2017 Coverage: Posters Rock at EURETINA Barcelona!
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COVER STORY
Better Together: Crossing the Line Between Segments The anterior and posterior segments occasionally intersect – and much can be learned from those doctors who straddle the segments. Whether the crossover arises from a complication or a surgeon’s interest … we know that the segments are better together.
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Cover Section
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Matt Young
CEO & Publisher
Hannah Nguyen CFO
Gloria D. Gamat Chief Editor
Brooke Herron Associate Editor
Ruchi Mahajan Ranga Project Manager
Timmo Gunst
Publications & Digital Manager Graphic Designers
Winson Chua Patalina Chua Writers
April Ingram Olawale Salami Editorial Assistants
Mary J. Cristobal Irene S. Janer Leilani C. Yu www.piemagazine.org Published by
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6001 Beach Road, #19-06 Golden Mile Tower, Singapore 199589 Tel: +65 8186 7677 Fax: +65 6298 6316 Email: enquiry@mediamice.com www.mediaMICE.com
Beyond Amazon: The Next Big Thing in Drug Delivery Systems
Enlightenment
34 36 38
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Solving the Puzzle of Postoperative Inflammation
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A Window Through which to Prevent Blindness: Clinical Applications of Retinal Oximetry
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Hold On, It’s Slipping! Prevent Intraocular Foreign Body Slippage with IOL Scaffold
Innovation
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On Meditation and Mindfulness: Unplugging for Work-Life Balance
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Job Hazards in Ophthalmology: Back Pain
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Emerging Trends in Female Authorship in Ophthalmology
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Dropping it Like it’s Hot on the eyeVLOG
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MSO Helps Ensure Timely Diagnosis of Diabetic Retinopathy with Eye Photo Service He can’t stop, won’t stop, rapping.
Extras
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page Media MICE Pte. Ltd.
Where, oh Where, has my Implant Gone? Management Approaches for Dexamethasone Implant Migration
Breaking the Vicious Cycle of Severe Dry Eye Disease (DED): New Perspectives in Diagnosis and Treatment
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ESCRS Symposium Preview: OCT & OCTA Innovations Discover the New Gold Standard with Optovue
Artisan Aphakia IOL: Applicable to Both Chambers of the Eye
We are looking for eye docs who can contribute articles to PIE magazine. Interested? Let's talk! Send us an email at enquiry@mediamice.com.
To place an advertisement, advertorial, symposium highlight, video, email blast, or other promotion in PIE magazine contact CEO Matt Young at matt@mediamice.com.
PIE MAGAZINE LETTER TO READERS Do You Like Broccoli Ice Cream?
T
hat’s the name of a music video on YouTube that I watch often, thanks to my 2-year-old daughter. The song verses are as follows: Do you like broccoli? Yes I do, Yes I do. Do you like ice cream? Yes I do, Yes I do. Do you like broccoli ice cream? No I don’t. Yucky!
After the hundredth time listening to this song, I finally learned what my daughter probably knew many months earlier. Some things are better together, and some things aren’t. And just like sushi and wasabi, or burgers and fries, the anterior and posterior segments are certainly better together than apart. Nature says so, for one. The anterior segment and posterior segment are not geographically or medically defined by nature. There’s just the eye. There’s not a piece of posterior segment stuck all over the anterior segment in a funky, broccoli-on-ice-cream kind of way. It’s a flawless melding of anatomical structures. Meanwhile, experts within this issue of PIE Magazine also note the many ways that there is commonality between the anterior and posterior segment. LASIK and cataract surgeons exist in their own right, as do retinal specialists. But there’s a lot that should bring everyone together. PIE Advisory Board member Dr. Gemmy Cheung, MBBS (Lond), FRCOphth(UK), Deputy Head and Senior Consultant of medical retina, Singapore National Eye Centre, makes this point especially in our Cover Story (page 18). Inflammation, after all, knows no boundaries between the front and back of the eye. Meanwhile, many surgeons have crossed over from one segment to the other in the course of their career, and we interviewed them to find out why. We then packaged that with some example “crossover” stories that involve both segments in our cover section. Essentially, this is why we’re publishing PIE 3 at the ESCRS Lisbon. We had plenty of opportunity to publish at EURETINA Barcelona, or another retina congress in Asia, but we didn’t. It’s important to take a stand on this issue, and say to anterior segment and posterior segment surgeons and industry, “let’s work more closely together.” Let’s arm ourselves with knowledge from the other segment, so that we can form the best picture about what’s happening for all eye care patients. Thus, although ESCRS and EURETINA are separate conferences this year, we were present at EURETINA to provide coverage here for ESCRS delegates who missed it (page 14). We also covered ASRS in Boston, which really is America’s premier retina congress (page 10). Meanwhile, we’re really piling on the enlightenment this time, where we look at women authorship in ophthalmology (page 36), meditation (page 34), back pain (page 39) and a new style of ophthalmic reportage called the eyeVLOG (page 40). Overall, if you don’t believe a word you’ve read here, but are still up for trying broccoli flavored ice cream, consider yourself enlightened. And think about the other segment the next time you see inflammation, or consider career advancement. All the best,
Matt Young CEO & Publisher PIE (Posterior Segment-Innovation-Enlightenment) Magazine
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PIE MAGAZINE ADVISORY BOARD MEMBERS Dr. Gemmy Cheung, MBBS(Lond), FRCOphth(UK) Dr. Cheung currently serves as deputy head and senior consultant of the medial retina service for Singapore National Eye Centre (SNEC), as well as senior clinician investigator for the Singapore Eye Research Institute (SERI). Her research interests include the study of risk factors and clinical features of macular diseases that may be unique in Asian populations. Dr. Cheung has published more than 150 articles, mostly regarding age-related macular degeneration, including polypoidal choroidal vasculopathy, and conducted several clinical trials in anti-vascular endothelial growth factor therapies. Dr. Cheung has also been actively involved in training and education, and has served as an instructor on Asia-Pacific Academy of Ophthalmology (APAO) and American Academy of Ophthalmology (AAO) courses and many other educational programmes. In addition, she is also a volunteer faculty member for the ORBIS Flying Eye Hospital Programme. Dr. Cheung has received a number of prestigious awards, including the Macula Society Young Investigator Award (2017), APAO achievement award (2017), APAO Nakajima Award (2014), APAO Outstanding Service in Prevention of Blindness Award (2013), the Bayer Global Ophthalmology Research Award (2012), the Roper-Hall Medal (2005) and the Elizabeth Hunt Medal (Royal College of Ophthalmologists, UK). [Email: gemmy.cheung.c.m@singhealth.com.sg]
Prof. Mark Gillies, M.D., Ph.D. Dr. Gillies presently holds a number of positions including: director of research and director of the Macula Research Group for the Save Sight Institute; foundation fellow for the Sydney Medical School; professor in the Department of Clinical Ophthalmology at the University of Sydney; head of the Medical Retina Unit at the Sydney Eye Hospital; deputy chair for the Ophthalmic Research Institute of Australia; and director of Eye Associates in Sydney. Dr. Gillies has served as a principal investigator or associate investigator in more than 70 clinical trials, and his research regarding macular degeneration and drug safety and efficacy has been published in 188 journals. He has also received a number of grants to study treatments for age-related macular degeneration, retinal disease and Muller cell dysfunction – among other treatments and studies. Dr. Gillies has also appeared in national media on numerous occasions, including the evening news of all major networks, on ABC radio as a local expert, as well as in print media. His dedication and research has resulted in multiple awards. Most recently, he received Gerard Crock trophies for the best papers at the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Annual Scientific Meeting (2013 and 2015), an achievement award from the Asia-Pacific Academy of Ophthalmology (APAO) in 2014, and an achievement award from the American Academy of Ophthalmology (AAO) in 2015. [Email: mark.gillies@sydney.edu.au]
Dr. Vishali Gupta, M.D. Dr. Gupta currently serves as a professor of ophthalmology at Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh in India. Throughout her career, she has completed original work in the fields of intraocular tuberculosis, optical coherence tomography, diabetic retinopathy, and fungal endophthalmitis. In addition, she is actively studying vitreoretina and uveitis diseases. She has been published in 65 per-reviewed journals, and has authored 17 book chapters and four complete books. Dr. Gupta also holds a US patent for the development of multiplex PCR for uveitis. In addition, she is a sought after speaker, and has made more than 350 presentations in various national and international meetings. Dr. Gupta has received several awards for her work, including the first JN Pahwa award from the Vitreo Retinal Society of India, the first NA Rao Award from the Uveitis Society of India, and the first NA Rao award from All India Ophthalmological Society (AIOS). [Email: vishalisara@yahoo.co.in]
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POSTERIOR SEGMENT APVRS 2017 PREVIEW
Kuala Lumpur to Host Retina Specialists Worldwide at Upcoming
APVRS 2017
by Gloria D. Gamat
APVRS is a leading “society representing retina specialists in Asia-Pacific region, and our annual congress is a meeting of great quality.
”
- Prof. Dennis Lam, Secretary General, APVRS
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ll ophthalmologic roads will lead to Malaysia, when the AsiaPacific Vitreo-retina Society (APVRS) meeting comes to Kuala Lumpur for the first time. With support from local organizer, the Malaysian Society of Ophthalmology (MSO), the 11th APVRS Congress (APVRS 2017) will be held at the world-renowned Kuala Lumpur Convention Center (KLCC) from December 8 to 10. As the burden of myopia and diabetes is increasing worldwide, retina is becoming one of the more popular subspecialties in ophthalmology. In the Asia-Pacific region, both retina specialists and trainees look forward to
the APVRS meeting each year for the latest updates in clinical procedures, tools and technologies related to the eye’s posterior segment. “APVRS is a leading society representing retina specialists in AsiaPacific region, and our annual congress is a meeting of great quality,” said Prof. Dennis Lam, Secretary General of the APVRS. Some of the highlights to look forward to at APVRS 2017 are the four keynote speakers and their notable presentations on crucial topics in retina. The prestigious Tano Lecture will be delivered by Dr. Taraprasad Das, M.D., FRCS, DSc, the President
of APVRS. Dr. Das is currently the Vice Chairman of the L V Prasad Eye Institute (LVPEI), a comprehensive eye health facility network in India, whose main campus is located in Hyderabad. Aside from his affiliation with LVPEI, Dr. Das is a Professor of Ophthalmology at the Sun Yat-Sen University in Guangzhou, China; an Adjunct Professor of Ophthalmology at University of Rochester Medical School, Rochester, New York, USA; and Fellow of the National Academy of Medical Sciences (NAMS), India. During the Tano Lecture at APVRS 2017, Dr. Das will talk about decoding evidencebased best practices in the prevention
and treatment of post-cataract surgery endophthalmitis. A prominent lecturer at every APVRS meeting, Prof. Andrew Chang, MBBS(Hons), Ph.D.(Syd), FRANZCO, FRACS, will give the Keshmahinder Singh Lecture this year. A vitreoretinal ophthalmologist of the Sydney Retina Clinic & Day Surgery in Sydney, Australia, Prof. Chang is strongly committed to international ophthalmology through his leadership – not only to the APVRS, but also to the Asia-Pacific Academy of Ophthalmology (APAO) and The Royal Australia and New Zealand College of Ophthalmologists (RANZCO). For the Keshmahinder Singh Lecture at APVRS 2017, Prof. Chang’s presentation is entitled “Vitreoretinal Surgery – An Unexpected Adventure.” APVRS 2017’s International Award Lecture will be delivered by Prof. Neil Bressler, M.D., Chief of the Retina Division and Professor of Ophthalmology at the Johns Hopkins Wilmer Eye Institute, Baltimore, Maryland, USA. He will discuss the revolution in diabetic retinopathy management and why it is considered “a race against time.” Prof. Bressler has been a member of the Wilmer Eye Institute’s faculty since 1988. His research interests include diabetic retinopathy and macular degeneration. Prof. Bressler has previously chaired the National Eye Institutes (NEI) Data and Safety Monitoring Committee for intramural clinical trials and the Food and Drug Administration (FDA) Ophthalmic Devices Panel. Currently, he is the editor-in-chief of JAMA Ophthalmology. The fourth keynote speaker at APVRS 2017 will be Dr. Timothy Lai, M.D., MBBS, FRCSEd, FRCOphth, Associate Professor in the Department of Ophthalmology & Visual Sciences, The Chinese University of Hong Kong, Hong Kong SAR, The People’s Republic of China. With clinical and research interests in the management of macular diseases, particularly choroidal neovascularization (CNV),
polypoidal choroidal vasculopathy (PCV), central serous chorioretinopathy, visual electrophysiology and genetics of retinal diseases, Dr. Lai has published more than 140 papers in international peer-reviewed journals, co-authored and edited seven textbooks and has delivered more than 50 invited lectures worldwide. At the APVRS 2017, he will give the Constable Lecture and will present on “Management of Choroidal Neovascularization Due to Uncommon Causes: What We Know and What We Don’t Know.” With four strong keynote presentations and 176 international speakers, the APVRS Secretariat and Organizing Committee headed by the MSO, is assuring attendees of a robust scientific program this year. But lest we forget, retina experts from east and west alike converge at APVRS each year to share their knowledge, especially with young ophthalmologists. The intent to impart practical clinical pearls of wisdom to young ophthalmologists is emphasized even more strongly for APVRS 2017. “This year, there are special sessions tailored specifically for general ophthalmologists and non-retina
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POSTERIOR SEGMENT APVRS 2017 PREVIEW
Kuala Lumpur Convention Center
specialists to update themselves on important issues such as pathological myopia, polypoidal choroidal vasculopathy (PCV) and posterior segment issues in cataract surgery,” said Dr. Ken Fong, Congress President of the 11th APVRS Congress and Secretary General of MSO. The Masterclasses at APVRS 2017, according to Dr. Fong, are especially aimed at retinal trainees. “They will be educated on tips and tricks in managing trauma, retinal detachment, diabetic retinopathy, PCV, as well as learning about retinal imaging and electrophysiology,” he explained. Furthermore, world leaders in
the field of gene and stem cell therapy will be present in various sessions at APVRS 2017 to discuss the latest findings in this exciting field. The symposium on Retinal Imaging in the 21st Century will cover the latest imaging devices available today, while the symposium on When Front and Back Collide: Managing Anterior Segment Surgery Complications, will cover posterior segment issues that occur during anterior segment surgeries. APVRS 2017 will be held at the KLCC, Kuala Lumpur’s most popular convention center, located right beside the iconic Petronas Twin Towers.
Outside of the scientific program at APVRS 2017, the social program is promising delegates an enjoyable experience as well. The Presidential Dinner on December 8 (Day 1) will be held at the Grand Salon of the Grand Hyatt Kuala Lumpur, just a 3-minute walk from the congress venue. The Congress Party on December 9 (Day 2) at the KLCC Grand Ballroom will allow delegates to experience Malaysian food and culture under one roof. For this event, the KLCC Grand Ballroom will be transformed into a magical venue under the lights of the Petronas Twin Towers, where delegates will be treated to dinner and entertainment, in authentic Malaysian style. Malaysia, a melting pot of culture and a top tourist destination in the heart of Asia-Pacific has a lot to offer every visitor, not just in Kuala Lumpur, but in other cities too including Melaka, Penang and Sabah, among others. “On behalf of the Malaysian Society of Ophthalmology, we are honored to host this prestigious meeting for the first time in Malaysia. You are welcome to visit this beautiful country and we look forward to seeing you all in Kuala Lumpur on December 8, 2017,” concluded Dr. Fong.
Keynote Speakers
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Dr. Taraprasad Das APVRS 2017 Tano Lecture Decoding Evidence-Based Best Practice in Post-Cataract Surgery Endophthalmitis Prevention and Treatment 10.20 - 10.40 am December 8, 2017 (Day 1) Banquet Hall, KLCC
Prof. Neil Bressler APVRS 2017 International Award Lecture Revolution in Diabetic Retinopathy Management – A Race Against Time 10.20 - 10.40 am December 9, 2017 (Day 2) Banquet Hall, KLCC
Prof. Andrew Chang APVRS 2017 Keshmahinder Singh Lecture Vitreoretinal Surgery – An Unexpected Adventure 10.00 - 10.20 am December 9, 2017 (Day 2) Banquet Hall, KLCC
Dr. Timothy Lai APVRS 2017 Constable Lecture Management of Choroidal Neovascularization Due to Uncommon Causes: What We Know and What We Don’t Know 10.00 - 10.20 am December 10, 2017 (Day 3) Banquet Hall, KLCC
Asia-Pacific Vitreo-retina Society Congress (APVRS) 2017 8th - 10th December 2017 Kuala Lumpur Convention Centre, Malaysia http://2017.apvrs.org
For enquiries, please contact the Central Secretariat
Organised by
APVRS Secretariat c/o Department of Ophthalmology & Visual Sciences The Chinese University of Hong Kong 4/F, Hong Kong Eye Hospital 147K Argyle Street Kowloon Hong Kong Phone: (852) 3943-5827 Fax: (852) 2715-9490 E-mail: secretariat@apvrs.org Supported by website: http://2017.apvrs.org
POSTERIOR SEGMENT ASRS 2017 COVERAGE
3D Imaging, Stem Cells and Anti-VEGFs Discussed at by Olawale Salami
ASRS 2017
A 3D Approach to Vitreoretinal Surgery
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n recent years, the ophthalmic world has witnessed remarkable enhancements in the surgical management of vitreoretinal diseases, mainly because of the development and availability of digital imaging systems, such as the Digitally Assisted Vitreoretinal Surgery (DAVS) 3D system (Alcon, Fort Worth, TX, USA). Digital imaging systems provide enhanced visualization, and permit adjustments in image light intensity and depth of field, making it possible to operate in very low light conditions. Furthermore, a wide variety of settings allow the surgeon to customize lighting conditions and image filters for each procedure, which is an added value in routine clinical practice. At the recently held American Society of Retina Specialists Annual Meeting (ASRS 2017) in Boston, USA, Dr. Marco Mura, M.D., Associate Professor of Ophthalmology at the Wilmer Eye Institute, Johns Hopkins University School of Medicine in Baltimore, Maryland, USA and Chief of the Retina Division at the King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia, shared recent insights into the role of digital 3D imaging in the surgical management of vitreoretinal disease. In an effort to provide supportive data on quantifiable parameters associated with the performance and use of the 3D DAVS viewing system by ophthalmologists in routine clinical practice, Dr. Mura and colleagues performed a subjective, prospective evaluation, utilizing a set of
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Ophthalmologists not actually required to wear 3D glasses during surgery.
questionnaires administered to surgeons across different levels of training (two consultants and five fellows). The study was conducted in standard surgical settings in two teaching hospitals and compared standard PPV 23-, 25- and 27-G with digital channels. Cameras used in the study were the Leica M844 and M822 at 175-200 mm focal lengths and an aperture of approximately 35%. Intra-ocular illumination was tangential and direct, with brightness, hue and gain adjusted with color channels (i.e. vitreous
removal, diabetic, and macula filters). Study participants were asked if the procedure was easier, same, worse, much worse or better with the surgical filters. The study team included 398 patients over the 3.5year follow-up period, and these patients were homogenously distributed among the fellows and consultants. A majority of the surgeons (60%) found the procedure better or much better than standard settings (without filters). Furthermore, with the diabetic
Aflibercept Treatment PERMEATEs Better in DME and RVO
(UWFA) and optical coherence tomography angiography (OCTA). Dr. Ehlers presented the 6-month interim data analysis for the 26 patients who had completed their month 6 visits. The mean age of subjects was 67 years, and majority (62%) were men. There was an even patient distribution between diabetic macular edema and retinal vein occlusion. The baseline mean visual acuity was 20/80 and baseline mean central subfield thickness was 505 µm. Dr. Ehlers highlighted that excellent outcomes of visual acuity were seen at 6 months, with mean score of 20/40, and 38% of eyes gaining 3 lines. From an anatomic standpoint, he noted significant improvements at month 6, with mean CST of 265 µm, 54% of eyes achieving dryness via OCT, and 100% of eyes with no sub-retinal fluid. When they assessed qualitative data, they found significant reductions in leakage, micro-aneurysms, macular and peripheral ischemia at month 6, when compared to baseline. Quantitative leakage assessment revealed an overall 47% reduction at month 6 compared to baseline, especially marked at the posterior pole (83%) and mid-peripheral area (87%). The leakage index at month 6 was 1%. Furthermore, analysis of the evolution of micro aneurysms revealed an overall 10% reduction
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t the recent ASRS 2017 meeting in Boston, Dr. Justin Ehlers, M.D. from Cleveland, Ohio, USA, presented data from the PERMEATE (Peripheral and Macular Retinal Vascular Perfusion and Leakage in DME and RVO) study, which was designed to characterize longitudinal retinal vascular dynamics with an angiographic quantitative assessment tool for both diabetic retinopathy and retinal vein occlusion. The study included male and female patients ≥ 18 years of age, with foveal-involving retinal edema secondary to DME or RVO, and E-ETDRS bestcorrected visual acuity of 20/25 or worse in the study eye. Patients with any prior or concomitant therapy to treat DME or RVO in the study eye, prior laser treatment for retinal disease, prior vitrectomy, trabeculectomy, other filtration surgery or history of retinal detachment in study eye were excluded. Patients with significant vitreous hemorrhage obscuring view of macula or retinal periphery and patients unable to undergo fluorescein angiography were also excluded. All patients received initial monthly treatment of aflibercept (Eylea, Bayer, Leverkusen, Germany), quarterly ultra-wide field fluorescein angiography
filters, 70% of surgeons found the procedure either better or much better. When asked about the depth of field filters compared to standard optical microscopes, 100% preferred the depth of field filters. Based on their findings, Dr. Mura and colleagues concluded that, “the 3D DAVS enhances surgical maneuvers and makes them easier to perform through increased depth of field. The possible use of these color channels offers superior ergonomics and a better teaching environment.”
Quantitative “segmentation of ultra wide field angiography may provide unique opportunities for understanding of important underlying changes in retinal vascular dynamics, such as leakage, micro-aneurysms and ischemia.
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- Dr. Justin Ehlers when compared to baseline, which was notable at the posterior pole (54%). The ischemia index, assessed at month 6, showed an overall 53% reduction when compared to baseline. Based on their findings from this treatment naive cohort study, Dr. Ehlers and colleagues concluded that aflibercept therapy resulted in significant improvements in visual acuity and reduction in macular edema. Furthermore, he proposed that “quantitative segmentation of ultra wide field angiography may provide unique opportunities for understanding of important underlying changes in retinal vascular dynamics, such as leakage, micro-aneurysms and ischemia.”
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POSTERIOR SEGMENT ASRS 2017 COVERAGE Can preoperative anti-VEGF administration reduce postoperative vitreous hemorrhage and cystoid macular edema?
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ars plana vitrectomy (PPV) is the treatment of choice for nonresolving vitreous hemorrhage (VH), and preoperative anti-VEGF is effective in reducing intraoperative bleeding by reducing neovascularization, but is washed out during vitrectomy. Postoperative vitreous hemorrhage (POVH) is one of the most common adverse events following vitrectomy for non-resolving VH. The incidence of postoperative cystoid macular edema remains poorly documented, and possible associated factors include diabetic macular edema or postoperative inflammation following surgery or peripheral panretinal photocoagulation (PRP) endolaser. In order to elucidate the role of preoperative anti-VEGF administered intraoperatively during vitrectomy for vitreous hemorrhage, Dr. Manish Nagpal MBBS, MS (Ophthalmology), FRCS(Edinburgh, UK) from the Retina Foundation & Eye Research Centre (Ahmedabad, India) and colleagues reviewed data from 312 eyes from 224 patients with non-resolving vitreous hemorrhage, and their findings were presented at the recent ASRS 2017 meeting in Boston, USA. In this
Stem Cell Therapy for Ophthalmic Disorders: The Good, the Bad and the Ugly
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t the ASRS 2017 meeting in Boston, USA, Dr. Mark Humayun, M.D., of the USC Roski Eye Institute (Los Angeles, California, USA) led a panel discussion on stem cell therapy and its potential application in treating ophthalmic disorders. In his introduction, Dr. Humayun stated that the commercialization of unproven stem cell therapies has become popular in recent years. The
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Much like anti-VEGF struggling to not be washed away during vitrectomy...
retrospective comparative study, the patients were divided into two groups: group A (165 patients who did not receive anti-VEGF; [control]) and group B (147 patients, who received antiVEGF). Patients were followed up on 1st, 30th, 90th and 180th postoperative day. Postoperative vitreous hemorrhage was defined as vitreous hemorrhage occurring between 1 and 6 months from the date of surgery. Patients included in the study needed to have non-resolving vitreous hemorrhage, no traction on USG, no prior anti-VEGF received in the last 3 months and no prior eye surgery. Postoperatively, the incidence of POVH was significantly lower in group B, which received anti-VEGF (9.5%)
when compared to group A, which did not receive anti-VEGF (21.8%) (p=0.01). Furthermore, Dr. Nagpal and colleagues found reduced incidence of vasculitis and venous occlusion in patients who received anti-VEGF. When stratification based on prior laser treatment was done, group A patients still had a higher incidence of POVH. Furthermore, when the study team measured central foveal thickness (CVT) they found lower CVT measurements in group B patients, who were treated with anti-VEGF. Dr. Nagpal and colleagues concluded that “preoperative anti-VEGF treatment reduces the incidence of POVH and more likely to reduce cystoid macular edema.�
unproven stem cell therapy industry is estimated at up to $2.4 billion, and involves over 60,000 patients per year, who pay out-of-pocket up to $40,000 per treatment. In terms of the regulatory approach to stem cell therapy, there is a tiered, risk-based framework for human cells or tissues that are intended for implantation, infusion or transfer. The biggest success has been in orthopedic diseases. There are strict regulations under the Public Health Service (PHS) Act for highly processed or manipulated tissues, used for other than their normal
function, combined with non-tissue components or used for metabolic purposes. Demonstration of clinical safety and effectiveness is mandatory and these require pre-market review. Conventional tissue grafts undergo little processing. For example, skin grafts, and when used for their normal function are identified as lower risk, and regulated by section 361 of the PHS Act, which specifies guidelines on prevention of communicable diseases. For conventional tissue grafts, premarket review and approval are not required.
Dr. Humayun discussed stromal vascular fraction of adipose tissue (SVF), which is a rich source of pre-adipocytes, mesenchymal cells, endothelial cells, progenitor cells, B cells, T cells and adipose tissue macrophages. Collecting the SVF is very simple and can be performed in less than 60 minutes. It involves minimal manipulation of adipose tissue, and the cells obtained can be injected quickly back into the same patient. Three cases of vision loss after intravitreal stem cell injection were presented and discussed by the panelists. All patients underwent intravitreal injection of 0.1cc autologous adipose tissue-derived stem cells. The average cost of the procedure was $5,000. Patients signed consent forms for the procedure, but no study consent,
A Revolution in the Management of Advanced Maculopathies
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t the recently held ASRS 2017 meeting in Boston, USA, researchers from Italy reported that the IOL-VIP (intraocular lens for visually impaired people) revolution system is safe, well-tolerated, and effective in improving best-corrected visual acuity (BCVA) in patients with low vision due to advanced maculopathies.
Like stem cells, it appears fidget spinners can also be anything they want ... like the biggest trend of 2017.
even though they were aware of study listing on ClinicalTrials.gov, a registry and results database of publicly and privately supported clinical studies of human participants conducted around the world. Potential causes of vision loss in these patients include contamination
In a paper entitled Intraocular Telescopic System IOL-VIP for Advanced Maculopathies, Dr. Fabio Patelli, M.D., shared findings of a retrospective, multicenter evaluation of the IOL-VIP system. Patients were diagnosed with AMD or other macular diseases, with BCVA >0.3 and with preserved visual field at baseline. Postoperative VA and safety data were collected after two
of cells with toxic substances, use of trypsin or collagenase during stem cell isolation and effect of growth factors and cytokines in the vitreous and blood, driving undifferentiated stem cells to mesenchymal cells. According to the panelists, stem cell treatment for ophthalmic disorders has great potential. However, the methods utilized in isolation of these cells and the delivery methods need to be scrutinized to minimize risks to patients enrolling in clinical trials. Furthermore, patients and physicians must be aware of potentially devastating outcomes of intravitreal stem cell therapy provided by private, non-FDA approved facilities which are not affiliated with medical centers, even if these studies are IRB approved and/ or listed on clinicaltrials.gov.
years of follow-up. Out of the 82 eyes from 64 patients, preoperative BCVA was <0.1 in 58 eyes; 56 (96.5%) of these eyes achieved postoperative BCVA of >0.1, and these patients now use optical magnifiers. As noted by Dr. Patelli, the IOL-VIP system has several advantages. Firstly, the eye movement can be controlled with the field of view and its 1.3X magnification allows a stable increase of visual acuity, both for distance and for near vision. In addition, its prismatic effect facilitates deviation of images into the preferred retinal locus. It is also available as a binocular implant. The research team concluded that the IOP-VIP Revolution system is safe and well-tolerated. Surgery is not difficult, and BCVA results are equal to, or better than, predicted BCVA simulation tests. Furthermore, visual field reduction is minimal (between 7-10%) and comfortable for patients, and the binocular implant is well-tolerated. Finally, in most cases, patients can use an optical magnifier instead of electronic CCTV.
No, dog. This is not the same kind of "binocular" implant.
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POSTERIOR SEGMENT EURETINA 2017 COVERAGE
t a k c o R s r e t s Po
EURETINA Barcelona!
Retinopuncture: A Lowinvasive Technique in the Treatment of Macular Subretinal Hemorrhages
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n recent years, retinal surgeons have shown keen interest in minimally invasive methods of treating macular subretinal hemorrhages. At the recently held EURETINA 2017 Congress, Dr. L. N. Boriskina and from Volgograd, Russia, and colleagues shared their experience in this emerging field in a paper entitled “Results of retinopuncture in treatment of macular subretinal hemorrhages.” The team followedup with nine patients presenting with macular subretinal hemorrhages of different etiologies, such as posterior contusion syndrome with ruptured choroid (3 cases), idiopathic macular hemorrhage (3 cases), age related macular degeneration (2 cases) and hypertensive disease (1 case). The team performed retinopuncture using the Nd:YAG laser LPQ 3106 Super Q Lazerex (Ellex, Adelaide, Australia), at a wavelength of 1064 nm, focusing
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on the most prominent point of neural epithelium detachment. The resulting hemopthalmos in these patients responded to treatment by medication. This technique resulted in reliable improvements in visual acuity of up to 0.54± 0.1. Dr. Boriskina concluded that “retinopuncture performed in the early onset period is a highly effective, low invasive method of treatment of subretinal hemorrhages of various causations, and provides a significant improvement in visual function.”
OCTA, A Useful Tool in the Assessment of PCV Patients
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urrently, there is limited data on the use of OCT angiography in assessing patients with polypoidal choroidal vascular (PCV) lesions. Therefore, Dr. Eung Suk Kim from the Department of Ophthalmology, Kyung Hee University Hospital, Seoul, Korea, and colleagues conducted a retrospective study aimed at elucidating the OCTA findings before and after treatment of patients with PCV. These patients received either monotherapy with intravitreal anti-VEGF
or in combination with photodynamic therapy. This was a retrospective study which included data from 16 eyes diagnosed with treatment-naïve PCV using indocyanine green angiography (ICGA). In this study, Dr. Kim observed that the branching vascular networks (BVNs) showed more clearly on the OCTA, when compared to the ICGA, while polyps were better visualized using the ICGA. However, the OCTA remains an important, non-invasive tool for detecting vascular changes in PCV. Presenting findings at the recently held EURETINA 2017 Congress in Barcelona, Spain, Dr. Kim concluded that “OCTA patterns of the polypoidal lesions and the BVN are helpful in understanding the pathology of polypoidal choroidal vasculopathy and therapeutic outcomes.”
3D Bioprinting: Let’s Print Some Retinal Cells!
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D bioprinting technology can be used to generate in-vitro 3D tissue models for biomedical applications with great accuracy and efficiency. These tissue models mimic cell
arrangements in native tissue and organs, allowing increased flexibility in experimental mechanistic evaluation of diseases as well as evaluation of possible therapeutic targets of new drugs. At the recent EURETINA 2017 Congress, Dr. Augustinus Laude from Singapore, presented data of a study which explored the use of 3D bioprinting to precisely deliver cells and biomolecules at fixed point levels as a precursor to micro-tissues, microorganisms and extracellular models for potential applications in retinal diseases. The research team set out to bioprint a 3D retinal tissue model, composed of human retinal pigmented epithelial cell line (ARPE19) and human retinoblastoma cell line (Y79 cells). Both these cells lines could be bioprinted to discrete places with precision to stimulate key aspects of native disease tissue components with verified quality. The bioprinting process did not involve any scaffolding materials, yet the printed cells managed to survive to 14 days and develop some cellular features with tissue-like distribution and density. Based on these findings, Dr. Laude concluded that “bioprinting technology can be used to generate retinal bilayer constructs which show excellent cell viability and functionality up to 14 days of co-culture.” However, more work will be needed on longer-term survival and cell differentiation potential of these 3D bioprinted cells.
Long-term Efficacy and Safety of Photodynamic Therapy on Central Serous Chorioretinopathy
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r. Young Joo Park, Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea, and colleagues investigated the long-term efficacy and safety of photodynamic therapy on central serous chorioretinopathy (CSC). To do this, they conducted a retrospective case
series, which included patients treated with verteporfin photodynamic therapy (PDT) at the Seoul National University between March 2005 and March 2017. The measured BCVA and central foveal thickness at baseline and assessed response rates, recurrence and complications. In total, the team studied 77 eyes of 74 patients (32% female) over a mean period of 57 months. Mean baseline refractive error was -0.46±1.50. Nine percent of the patients were hypertensive, and 13% had received previous CSC treatment. Total PDT count per person was 1.2 ± 0.4. Following PDT, recurrence rate was 18%, and retreatment using additional PDT resulted in excellent response rates of 83.3%. During the recent EURETINA 2017 Congress, Dr. Park reported that “verteporfin PDT for treatment of CSC showed good efficacy and visual anatomical outcomes, as well as good safety profiles in the long term follow-up.”
There's detachment. And then there's detachment.
Analysis of Cases that Develop Rhegmatogenous Retinal Detachment after Secondary Cataract YAG Capsulotomy
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t the recent EURETINA 2017Congress in Barcelona, Spain, Dr. N. Pomytkina from Russia, presented a paper from her research group which analyzed cases of development of rhegmatogenous retinal detachment in patients after secondary cataract YAG capsulotomy. For this, they conducted a retrospective analysis
of patients’ records from 2013 to 2016. Nineteen cases of retinal detachment were identified (26% female) with a mean age of 63 years. Dr. Pomytkina reported that YAG capsulotomy of secondary cataract is a risk factor for retinal detachment. In addition, in the immediate period following YAG capsulotomy, the development of retinal detachment is caused by formation of valvular ruptures. Therefore, Dr Pomytkina emphasized that thorough examination of the retinal periphery and implementation of limiting laser coagulation of the retina plays a pivotal role in the prevention of retinal detachment after secondary YAG associated capsulotomy.
25-Gauge Sutureless Scleral Fixation of Posterior Chamber Intraocular Lens Implant
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ntraocular lenses (IOLs) provide better vision in patients who have had cataract extraction or dislocated lens. However, posterior chamber IOL implantation remains difficult, especially in the absence of capsular support. At the recent EURETINA 2017 Congress, Dr. Muhammed Amer Awan from Shifa International Hospital, Islamabad, Pakistan, and colleagues set out to study the outcome and safety of the 25-G suture-less scleral fixation of posterior chamber IOL. This was a retrospective, single hospitalbased interventional case series that included eyes with inadequate or no capsular support. In these cases, patients received a 25-G, 3 ports pars plana vitrectomy. All eyes(14) had improvements in vision. There was no significant pre- or postoperative complication reported. Based on findings, Dr. Awan concluded that the 25-G suture-less, sclera fixation of PCIOL is an excellent technique to achieve better visual outcomes on eyes with inadequate or absent capsular support.
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POSTERIOR SEGMENT EURETINA 2017 COVERAGE Key Takeaways from the Aflibercept Symposium
at
EURETINA 2017
Takeaway #1: Aflibercept and the Role of a MultiTarget Approach to Retinal Disease Based on a presentation by Prof. Francine Behar-Cohen, Professor of Ophthalmology and Vitreoretinal Surgeon, Assistance Publique â&#x20AC;&#x201C; HĂ´pitaux de Paris, France
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flibercept (Eylea, Bayer, Leverkusen, Germany) is the only approved intravitreal anti-VEGF (vascular endothelial growth factor) targeting different VEGF receptor ligands: VEGF-A, VEGF-B, placental growth factor (PLGF) and galectin-1, with greater affinity than the natural receptor. Furthermore, the aflibercept molecule has been optimized to have a high binding affinity for VEGF-A; 100 times more potent than ranibizumab (Lucentis, Novartis, Basel, Switzerland). This results in a prolonged intraocular VEGF-A suppression with a half-life of about 9 days. In a study of 7 patients who interrupted use of aflibercept and ranibizumab, and subsequently had quantification of intraocular aflibercept levels, the duration of suppression of VEGF-A was found significantly longer, as compared to ranibizumab. To summarize VIEW 1 and VIEW 2 study data, notable findings demonstrate that giving monthly or bimonthly injections result in similar visual gains, and that administering multiple anti-VEGF injections has become an issue for many patients. In one study presented, patients with central retinal vein occulsion (CRVO) who were receiving multiple anti-VEGF injections were switched to aflibercept. This resulted in an extended duration of intervals between injections, with a gain of 0.5 lines after 6 months, and a gain of 3 lines after one year. Switching patients to aflibercept allows for extended interval between injections, which would mean less frequency of injections for patients. Another important message is the binding of aflibercept to galectin-1. Galectin-1 has been shown to potently
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stimulate endothelial cells and induce neovascularization by binding to VEGFR-2 and preventing endocytosis of the receptor, potentiating cellular activation and inflammation. This has been shown in mice deficient in galectin-1, which develop less neovascularization, and a reduced area of hypoxia in a model of retinopathy of prematurity (ROP) as compared to wild type. Aflibercept efficiently inhibits galectin-1 mediated activation of VEGFR-2.
Takeaway #2: Innovative Imaging with Aflibercept Based on a presentation by Prof. Giovanni Staurenghi, Professor of Ophthalmology, Chair of the University Eye Clinic, Director of the University Eye Clinic Department, Luigi Sacco Hospital, Milan, Italy
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n important question in clinical trials evaluating efficacy of new retinal drugs is: What is the retinal thickness we need to measure and how do we measure this? Also, how much can we relate that to visual acuity (VA)? It is important is to be able to demonstrate that thickness is related to VA as this is a critical measure of reduced inflammation. In optical coherence tomography angiography (OCTA) imaging, the main advantage is that for the first time we can study images of different depths. This is of key importance in patients with diabetic retinopathy where there is a need for depth analysis to identify microaneurysms. An important technique today is ultrawidefield imaging, which becomes a key technology for studying peripheral lesions associated with perfusion. And it has been used to demonstrate the ability of aflibercept to reduce the unperfused areas of the retina. Imaging also has been used to evaluate retinal function and there are series of possibilities with microperimetry and contrast sensitivity. These techniques evaluate the function of the eye and are important parts of clinical trials where geographic atrophy
and microperimetry are critical end points. However, functional tests are difficult to perform in routine clinical care. New emerging technologies, particularly OCTs, will allow better understanding of results of clinical trials.
Takeaway #3: Emerging Clinical Evidence with Aflibercept Based on a presentation by Assoc. Prof. Gemmy Cheung, Senior Consultant Ophthalmologist at Singapore National Eye Centre (SNEC) and Clinician Investigator at the Singapore Eye Research Institute (SERI), Singapore
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ew clinical trials have allowed us to learn more about extensions and modifications in clinical indications for aflibercept. A wealth of data has already demonstrated that aflibercept monotherapy is effective in improvement of vision and regression of polyps in patients with polypoidal choroidal vasculopathy (PCV), a disease characterized by abnormal choroidal vascular lesions which end in polypoidal dilatations. The PLANET study, a randomized, double blind, placebo controlled multicenter phase 3 study evaluated the effect of aflibercept on PCV with or without rescue photodynamic therapy (PDT). The study showed that aflibercept resulted in anatomical improvement in over 80% of patients and 40% had achieved complete regression of polyps. Importantly, aflibercept monotherapy led to significant gains in visual acuity in patients with PCV. The ALTAIR study, a phase 4 trial designed to demonstrate efficacy of aflibercept in a treat-and-extend protocol, showed VA gains of 8 to 9 letters from baseline to week 52. It also demonstrated that up to 50% of patients achieved a treatment interval of 12 weeks or more, with no safety signals. The CLARITY study was designed to study the efficacy and safety of aflibercept in the treatment of proliferative diabetic retinopathy (PDR). At the end of the study, aflibercept therapy resulted in significantly superior disease regression and improved vision in patients with PDR as compared to standard of care.
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COVER STORY
Better Together
Crossing the Line Between Segments by Brooke Herron
While most conditions affecting the eye could be categorized as anterior or posterior issues, there are times when the two segments intersect: A disease in the anterior can travel and cause issues in the posterior, or as is often the case, a complication during surgery can affect the other segment. The anterior and posterior segments can also intersect via the surgeons themselves – whether it’s because the doctor has a keen interest in both segments, or because their patients require care in both areas. Whatever the cause of this “crossover,” these instances have resulted in versatile surgeons who have the knowledge and expertise to treat a variety of anterior and posterior conditions.
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Crossover Conditions and Complications
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r. Gemmy Cheung, MBBS(Lond), FRCOphth(UK), Deputy Head and Senior Consultant of medical retina for Singapore National Eye Center (SNEC) and PIE Magazine advisory board member, notes two examples of when a condition or treatment is focused on one segment, but then causes complications in the other. “If someone has inflammation in the front of the eye, it can lead to complications in the back,” she said. For example, diseases like anterior uveitis can lead to macular edema. “Uveitis can go from the front to the back – that’s the main issue.” “Cataract surgery can also lead to posterior problems,” noted Dr. Cheung. “If the lens is tilted or not positioned properly in the capsular bag, it can cause chronic
inflammation. It doesn’t have to rupture from the capsule – it can be more subtle.” When this occurs, ophthalmologists who specialize the anterior segment could consult with a posterior specialist, or if they have the tools and skills, they can provide treatment themselves (and vice versa). Dr. Cheung says that this crossover depends on the severity of the condition. “Most doctors have a basic, general training that encompasses both segments – so, they would have an inkling of what the possible diagnosis could be,” she explained. “For example, if an anterior surgeon sees that a patient’s visual acuity is not as good as expected, they would begin to think that something else is wrong,” said Dr. Cheung. “Today, non-invasive OCT is easily done and many anterior surgeons are comfortable ordering a OCT scan of the posterior – but many would prefer to work with a posterior surgeon for surgery, especially if it’s invasive.” According to Dr. Cheung, there are certain posterior treatments (like anti-VEGF injections) that can be safely given by anterior doctors, as long as they do the following: ensure the diagnosis is correct; provide adequate counseling and expectations of treatment; and if response behavior is abnormal, consider consulting with a posterior doctor. The same principles apply to doctors in developing countries. “The injection procedure is not complicated, as long as the facility is adequate and clean – if it’s not clean, I would stop there,” said Dr. Cheung. “I think we understand that there are challenges in rural areas, and that they provide the best care to their ability, and to what the local system can support. Often anterior doctors in these areas can go for short, but intensive, courses in the posterior segment.”
Crossover Surgeons Sometimes the two paths cross because of the surgeon’s passion and interest in particular area. Dr. Anil Arora, MBBS
(Syd), M.Med (Ophthal.), FRANZCO, FRACS, Ophthalmic Surgeon for Central Coast Eye Specialists and Medical Director of the Laser Vision Clinic Central Coast in Sydney, NSW, Australia, began his career as a general ophthalmologist, but after three years of gaining experience, he decided to pursue a subspecialty training in vitreoretinal surgery. “I had always been fascinated with the retina and with many of the procedures that vitreoretinal surgeons performed,” he said. After finishing his training, he joined a practice that served a large population. There, he was able to use his newly acquired retinal skill set and knowledge, but also continued to see patients with other eye conditions and concerns. “There was a large patient base of elderly people who not only had retinal pathologies such as age-related macular degeneration, but who also had visually significant cataracts that required treatment,” said Dr. Arora. “The demand for ophthalmic surgical care was high and I began carrying out reasonable volumes of cataract surgery.” At this point, Dr. Arora became interested in trying to achieve spectacle independence for patients undergoing cataract surgery. This lead to a keen interest in multifocal intraocular lenses, which he cautiously begin implanting in selected patients. He notes that results were generally very favorable, so his multifocal intraocular lens practice grew. At the same time, Dr. Arora continued to carry out vitreoretinal surgical procedures such as vitrectomies and scleral buckling surgery, as well as intravitreal anti-VEGF injections. It soon became clear to Dr. Arora that if he was going to use these lenses frequently, eventually he was going to run into a refractive complication – resulting in an unhappy patient. As a solution, he enrolled and finished a postgraduate course in refractive surgery at the University of Sydney. In 2010, Dr. Arora, along with some colleagues, established the Laser Vision Clinic Central Coast (Sydney, NSW, Australia)
Most doctors have a “basic, general training that encompasses both segments – so, they would have an inkling of what the possible diagnosis could be. - Dr. Gemmy Cheung
”
to provide laser vision correction surgery, as well as treat complications from cataract surgery. He was also an early adopter of small incision lenticule extraction (SMILE) – he performed his first SMILE procedure in 2014, and was the second center in Australia to offer the treatment. “I enjoy being an ophthalmic surgeon who is able to carry out a full range of eye procedures from the front to the back of the eye,” said Dr. Arora. “I have one or two operating lists a week which typically consist of a mixture of cataract surgery and vitrectomy surgery, and I have fortnightly laser vision correction lists where I carry out standard LASIK and SMILE.” In another example of crossing over, Dr. Arora said: “I have a family of patients in which there are three generations involved: an elderly lady, her middle-aged son and his 23-yearold daughter.” His elderly patient had a dropped nucleus after cataract surgery (that had been performed elsewhere) and Dr. Arora carried out vitrectomy surgery to remove this. He performed cataract surgery on the middle-aged son, using a toric multifocal intraocular lens and that patient is now completely spectacle independent. Dr. Arora also
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COVER STORY
I enjoy being an “ophthalmic surgeon who is able to carry out a full range of eye procedures from the front to the back of the eye.
”
- Dr. Anil Arora
carried out LASIK on the 23-yearold daughter to eliminate her myopic astigmatism. “Despite moving across to cataract and refractive surgery I still enjoy my retinal surgery. I also have a large medical retina practice and carry out procedures such as fluorescein angiography and intravitreal anti-VEGF injections,” added Dr. Arora. For other surgeons, like Dr. Somsran Watanachote, who is Director of the eye center at Bangkok Hospital, her crossover from posterior to anterior was inspired by her colleagues. Dr. Somsran began her career in the posterior segment at the Children’s Hospital in Bangkok, where she treated conditions like retinopathy of prematurity (ROP), squint and complications from cataracts. From there, she spent three years at Tohoku University in Japan, performing procedures like pars plana vitrectomy (PPV), scleral buckling, extracapsular cataract extraction (ECCE) and treating idiopathic orbital inflammatory disease (IOI). She then returned to Bangkok and became the head of the vitreoretina unit at Rajavithi Hospital. During this time, two of her colleagues began to step away from doing posterior segment surgeries,
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and instead, devoted their practices to cataract and refractive procedures. Dr. Somsran was encouraged by her colleagues and soon crossed into the anterior segment. “I looked around, and many of my colleagues had begun shifting their practice to the anterior segment,” said Dr. Somsran. “I followed them and began to do refractive surgeries, too.” Today, Dr. Somsran still works in both segments. “I still do intravitreal injections (IVT), laser, pan retinal photocoagulation (PRP) and medical retina,” she said. “And I still do examinations with posterior specialists, helping to ensure my patients are being treated by the right specialist for the best outcome.”
Cross training for better patient outcomes As with any field, the more you know, the better. And because there are conditions and complications that can affect both segments, being confident and skilled in both areas can lead to innovation in treatment and better patient outcomes. Dr. Arora reveals a time when his training in different ophthalmologic subspecialties came in handy: He used a posterior segment instrument in an anterior segment procedure. “I was managing a case of epithelial ingrowth in the pocket of a patient who had undergone SMILE laser vision correction. I used the instruments that I would normally use in a vitreoretinal procedure to peel an epiretinal membrane: a 25-gauge diamonddusted membrane scraper and 25-gauge end-grasping ILM forceps.” During the procedure, he approached the epithelial cell nest in the SMILE pocket in the same way that he would approach an epiretinal membrane. Dr. Arora used the diamonddusted scraper to loosen the epithelial ingrowth and then used the ILM forceps to grasp it and remove it from the SMILE pocket. “It worked extremely well and
was minimally invasive,” he added. In addition to being able to use multipurpose instruments, cross training makes surgeons more versatile. Dr. Arora notes his dual skill set helps when he encounters complications like a dropped nucleus, or a dislocated intraocular lens. “Another example is in the management of an anterior capsulotomy that starts to run out towards the periphery. A good means of salvaging this is to use 23- or 25-gauge vitreoretinal scissors that can be passed through a limbal paracentesis incision to redirect the capsulotomy centrally,” he added. And while there are many advantages to practicing in both segments, the transition to another subspecialty involves planning and hard work. Dr. Arora says: “It is never too late to change or crossover – however, it does become very difficult when trying to manage an already established practice.” The takeaway from this: You must be (or must learn to be) very good at managing your time and prioritizing. Dr. Somsran adds that it’s important to not forget your roots: “When you are able to perform these difficult surgeries, it’s a gift and skill you have conquered. As long as you are working, try to balance your given skill and keep practicing – it is worth it to be able to work in both the anterior and posterior.”
When you are able to “perform these difficult surgeries, it’s a gift and skill you have conquered.
”
- Dr. Somsran Watanachote
COVER SECTION IMPLANT MIGRATION
Where, Oh Where, Has My Implant Gone?
Management Approaches For Dexamethasone Implant Migration by April Ingram
T
he Ozurdex implant (Allergan, Dublin, Ireland) offers sustainedrelease dexamethasone and has been used to effectively treat various vitreoretinal diseases including macular edema associated with retinal vein occlusion, non-infectious uveitis, and diabetic macular edema. Although the sustained delivery of dexamethasone has been a valuable asset to the arsenal of retinal medicine, shortly after becoming available, a few reports of the implant migrating into the anterior chamber began to emerge. This can lead to potentially complicated corneal edema with permanent damage to the corneal endothelium, decreased vision and requires immediate removal. If implant migration has occurred, moving or removing the rogue implant may further complicate the changes that occur in the implant over time. Attempts to grasp the implant in an effort to surgically remove or reposition, can lead to its fracture, and aspiration could cause dispersion of the material. Some clinicians have tried to carefully push the implant back into vitreous, but the likelihood of it returning to the anterior chamber is high. A recent publication in Graefes Archives of Clinical and Experimental Ophthalmology, describes the clinical course, and individualized management approaches of patients with migration of a dexamethasone implant into the anterior chamber. They reviewed a total of 924 intravitreal dexamethasone injections and identified four cases in which anterior migration of the implant occurred. In all four cases, the eyes were pseudophakic, one with a PC-IOL in a post-YAG laser capsulotomy state, two eyes with a sulcus IOL, and one eye with an iris-fixated retropupillary IOL. All the cases had a prior vitrectomy with no posterior lens capsule and had previous, uneventful Ozurdex injections. Two of the eyes
He’s looked near and far, but still cannot find the implant...
required surgical removal of the implants. Repositioning of the implant back into the vitreous cavity was successful in the two other cases. One of the study authors, Dr. Min Kim, M.D., from the Gangnam Severance Hospital and Yonsei University College of Medicine in South Korea, provided some insight: “Repositioning the implant may be considered as an option in cases involving the first episode with no significant corneal endothelial decompensation.” Why are these implants migrating in the first place, and can we predict which ones will move? The authors suggest that previously vitrectomized eyes may facilitate the migration, because they are missing the scaffold that holds the implants in place. Additionally, they point out that because the vitreous cavity is filled with aqueous fluid after vitrectomy, any change in fluid dynamics could contribute to the movement of the implant.
The paper concluded that when the differences within and across cases was carefully considered, neither repositioning nor removal was a strong predictor of treatment outcomes. They advise clinicians to carefully consider both the advantages and disadvantages of repositioning the implant in the eye. As well, they note that not all patients need to have the dislocated implants removed, and repositioning them back into the vitreous cavity might be the first option to consider, in the absence of severe corneal decompensation. “Considering potential anterior segment complications and the loss of drug effectiveness together, our results suggest that instead of always removing the implants immediately, an individualized approach is recommended to obtain the best treatment outcomes and to minimize the risk of corneal complications,” Dr. Kim explained.
Reference: Kang H, Lee MW, Byeon SH, et al. The clinical outcomes of surgical management of anterior chamber migration of a dexamethasone implant (Ozurdex®). Graefes Arch Clin Exp Ophthalmol. 2017; doi: 10.1007/s00417-017-3705-y. [Epub ahead of print]
About the Contributing Doctor Dr. Min Kim is an Assistant Professor and Vitreoretinal Specialist in the Department of Ophthalmology at Gangnam Severance Hospital and Yonsei University College of Medicine in Seoul, South Korea. He is an active member of the American Society of Retinal Specialists (ASRS), the Asian Pacific Vitreoretinal Society (APVRS), the Korean Retinal Society and the Korean Uveitis Society. [Email: minkim76@gmail.com]
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COVER SECTION IOL SCAFFOLD TECHNIQUE
Hold On, It’s Slipping!
by April Ingram
Preventing Intraocular Foreign Body Slippage with IOL Scaffold
Experience is key when working with scaffolding.
A
n intraocular foreign body (IOFB) lodged in the posterior segment can be disastrous, and remains a major cause of visual loss, primarily in young adults. The presence of a posterior segment IOFB poses significant surgical challenges, and the management varies depending on the location and size of the IOFB, and overall severity of injury. Removal of the IOFB has been done with lens sparing vitrectomy, although it’s not usually recommended when there is a coexisting cataractous lens, traumatic cataract, or phacodonesis. Often, the planned procedure for better intraoperative visualization and prevention of lens-induced uveitis, includes a pars plana vitrectomy (PPV), removal of the IOFB with forceps and then cataract extraction, all in a simultaneous procedure. But how and where, exactly will the IOFB come out? Previously, Dr. Amar Agarwal, MBBS, MS, FRCS, FRCOphth[Lon], and the team from Dr. Agarwal’s Group of Eye Hospitals in India, introduced an intraocular lens (IOL) scaffold maneuver in order to prevent nucleus drop in eyes with intraoperative posterior capsular rupture during phacoemulsification. It has since been used and revised for other procedures. In a recent article
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in Retinal Cases & Brief Reports, Dr. Agarwal and colleagues present this IOL scaffold technique and its effectiveness during IOFB removal in preventing the intraoperative drop or slippage of the FB back into the retina. Dr. Agarwal explains how this IOL scaffold method differs from existing direct IOFB removal techniques: “Here, an IOL is placed prior to the IOFB removal and the IOL optic acts as a scaffold on which the IOFB can be held and removed. This would prevent it from the recurrent drop into the vitreous or on the retina.” He adds that this isn’t as simple as it sounds and experience is key: “As
the prerequisite, the surgeon has to be well-trained in the IOL scaffold procedure and glued transscleral IOL implantation technique (in cases of defective capsules) to follow the technique.” The technique and applications are discussed in greater details in their previous publications in the Journal of Refractive Surgery in 2012, Ophthalmology in 2013 and the Journal of Cataract and Refractive Surgery in 2013. The current publication is a case report that describes the removal of a 4mm IOFB, that was lifted to the anterior chamber with intravitreal forceps and then set on the iris. After decreasing the infusion and extending the main corneal wound, a 3-piece posterior chamber IOL was placed in the sulcus and used as a scaffold. The IOFB was retrieved through the main corneal wound using forceps, and the IOL was centered, and the wound closed. Dr. Agarwal explains his groups’ experience with the procedure: “We have used this method in retrieving IOFBs and have found to have good surgical outcomes.” He adds that there are other uses for this technique: “IOL scaffold can also be used to prevent IOL parts dropping into the vitreous during IOL exchange and the capsular remnants drop during the soemmering’s ring removal.”
Reference: Agarwal A, Ashok Kumar D, Agarwal A. Intraocular Lens Scaffold to Prevent Intraocular Foreign Body Slippage. Retin Cases Brief Rep. 2017;11(1):86-89.
About the Contributing Doctor Dr. Amar Agarwal is the Chairman and Managing Director of Dr. Agarwal’s group of Eye Hospitals (www.dragarwal.com), which include 75 eye hospitals globally, as well as the Eye Research Centre in Chennai, India. He serves as the Secretary General for the Indian Intraocular Implant and Refractive Society (IIRSI) and Past President of International Society of Refractive surgery (ISRS). Dr. Agarwal has pioneered numerous surgical techniques and is at the forefront of the design and application of new technologies in ocular surgery. Dr. Agarwal has performed more than 150 live surgeries at various conferences and his videos have won many awards at the film festivals of ASCRS, AAO and ESCRS. He has also written more than 60 books which have been published in various languages: English, Spanish and Polish. He also trains doctors from all over the world in his center on phaco, glued IOL, lasik and retinal surgeries. [Email: dragarwal@vsnl.com]
COVER SECTION POSTOPERATIVE INFLAMMATION
Solving the Puzzle of
Postoperative Inflammation by April Ingram
E
ven with all the advances in surgical techniques and drug formulations, the prevention and management of postoperative ocular inflammation still remains a challenge. To better understand antiinflammatory drug use, Prof. Florent Aptel, M.D., Ph.D., and colleagues at the University Hospital of Grenoble in France, published their systematic review of the literature and a Delphi survey of 28 international experts in the British Journal of Ophthalmology. Prof. Aptel explains the purpose for initiating this study: “Interestingly, despite the very large number of cataract surgeries performed worldwide, and large number of clinical trials performed, there is no consensus, neither established guidelines for the prevention and treatment of the postoperative ocular inflammation to date.” From their results, the group noted the variability of management regimens, particularly, regarding the agents and drugs: “Some physicians used corticosteroids or NSAIDs alone, whereas others combined these two therapeutic classes.” “Regarding the duration, some studies reported the prophylactic use of anti-inflammatory agents during a few weeks, whereas others reported in similar conditions the use of the same
agents during two or three months,” Prof. Aptel added. The study goes beyond the standard drops of corticosteroids and NSAIDs for postoperative inflammation, and includes a review of recent publications that highlights new molecules with new targets and novel delivery technique. Prof. Aptel adds that they reviewed, “new delivery systems that were recently reported, such as sustained release dexamethasone inserted in the canaliculus of the eyelid, in the anterior chamber or in the vitreous, and a biodegradable intrascleral betamethasone implant.”
So, were they able to find any sort of agreement or consensus? The review of the literature and the Delphi survey did lead the researchers to conclude that the same anti-inflammatory treatment could effectively be used to manage inflammation following cataract surgery and non-complicated pars plana vitrectomy for epiretinal membrane and macular hole. However, the work also highlighted the need for a more prolonged and more powerful treatment after glaucoma surgery. Specifically related to vitreoretinal surgery, the study found discrepancies and lack of recommendations in both the preferred treatment and perception of the eye’s inflammatory status by experts for retinal detachment repair and for combined vitreoretinal/cataract surgeries. It was agreed that need certainly exists for trials to establish treatment guidelines. Based on their findings, Prof. Aptel suggests that the solution to the inflammation puzzle may be: “Effective, safe and locally acting antiinflammatory treatments of long-lasting duration administered by the surgeon immediately at the end of surgery could remove the need for patients to instil frequent eye drops and over a relatively long period of time, solve compliance uncertainty and limit side effects.”
Reference: Aptel F, Colin C, Kaderli S, et al; OSIRIS group. Management of postoperative inflammation after cataract and complex ocular surgeries: a systematic review and Delphi survey. Br J Ophthalmol. 2017; pii: bjophthalmol-2017-310324. [Epub ahead of print]
About the Contributing Doctor Prof. Florent Aptel is currently Professor and Head of the Anterior Segment and Glaucoma Unit at the University Hospital of Grenoble, France and affiliated with the Lab Hypoxia and Physiopathology and the French National Institute of Health. He received a Master of Science from the University of Paris, his Medical Degree and a PhD from the University of Lyon. He achieved the European Board of Ophthalmology certification in 2008. His clinical and research interests focus on glaucoma, with a particular emphasis on the monitoring of the 24-hour IOP fluctuations, angle-closure pathogenesis, and the applications of high intensity ultrasound in ophthalmology. Prof. Aptel held a PhD in the field of high intensity focused ultrasound and his doctoral and post-doctoral works led to the development of a new device for treating glaucoma based on the selective coagulation of the ciliary body. This device has now a CE marking, and is being evaluated in several international clinical trials. [Email: Afaptel@chu-grenoble.fr]
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Breaking the Vicious Cycle of Severe Dry Eye Disease (DED) New Perspectives in Diagnosis and Treatment
D
ry eye disease (DED) has been described as a vicious cycle of hyperosmolarity, inflammation and tear film instability. The pathophysiology of this disease causes symptoms that wreaks havoc on the eyes of sufferers and lowers their quality of life, especially in severe cases. Because there are three main factors that contribute to the pathophysiology of this disease, determining which to treat – or which is the root cause – has been hotly debated by those in the ophthalmic community. However, we do know that inflammation is one of the key factors responsible for the severity of the disease – and we know that in order to treat the disease, the cycle must be broken. “It is well established that inflammation has a significant role in the pathophysiology of DED, and promoting symptoms of irritation and ocular surface damage,” said Dr. Andrea Leonardi, who serves as a Professor of Ophthalmology at Department of Neuroscience, Ophthalmology Unit
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and Faculty of Medicine at the University of Padua, Italy. “Factors that somehow adversely affect tear film stability and osmolarity can induce, even minimally, ocular surface damage and initiate an inflammatory cascade that generates innate and adaptive immune responses.” He noted that an adaptive inflammatory process – similar to what may occur in systemic autoimmune diseases – should sustain chronic DED, as shown in animal model of dessicating ocular surface stress. “A persistent stress on the ocular surface may promote an activation of antigen presenting cells responsible for priming naive T cells, and leading to the expansion of autoreactive CD4+, TH1 and TH17 cell subsets. This may explain the chronicity of inflammation in the severe form of DED,” Dr. Leonardi explained. In addition, another study recently found that DED is an autoimmune disease of the ocular surface and that
inflammation plays the key role in determining its progression and resolution1-4, corroborating Dr. Leonardi’s assertions. Dr. Leonardi further explained how inflammation may induce changes on the ocular surface, like corneal nerve morphology and sensitivity – and how those changes may lead to neuropathic corneal hypersensitivity or hyposensitivity, symptoms that influence tear production and tear film stability. “The roles of the neurosensory system and neuroinflammation have received increased attention in the past few years, but we don’t currently have the tools available to understand these phenomena. Several observations suggest that dry eye patients suffer from neuropathic corneal mechanical hypersensitivity induced by ocular surface inflammation,” added Dr. Leonardi. Based on this evidence, we can extrapolate that inflammation is an underlying cause, and it has directly contributed to the severity of the disease. DED is not simply a lack of tears, Dr. Leonardi further noted, but a complex ocular surface disease
in which the tear film is unstable and no longer provides sufficient nourishment or protection to the ocular surface, which then becomes inflamed and damaged. This damage can be caused by hyperosmolarity, secondary to tear flow insufficiency, or by immune reactions. In all cases, inflammation is a key component of DED and a main target for topical treatments. In the article below, we will discuss a new available treatment option that has been shown to effectively treat inflammation in patients with severe DED… thus, breaking one chain in this vicious cycle.
It is well established that “inflammation has a significant role in the pathophysiology of DED, and promoting symptoms of irritation and ocular surface damage.
”
– Dr. Andrea Leonardi
DED Versus Severe DED in Asia
H
ow much of DED is considered severe? And of those sufferers, how many live in Asia? With limited published data and research on the topic, we spoke with doctors “on the ground” in Asia to determine its prevalence among the population in countries like Singapore, Thailand, Korea and Hong Kong. According to Dr. Vishal Jhanji, who serves as a clinical professor at The Chinese University of Hong Kong, with its increasing population density, industrialization and contact lens use, severe dry eye prevalence is on the rise in Asia. This could be a result of increased “screen time.” “Use of electronic devices is more popular in Asia, than in other parts of the world,” explained Dr. Jhanji, noting an inverse correlation between daily hours of computer use and Schirmer’s test scores. “A statistically significant difference in Schirmer’s test scores has been reported in individuals who use computers less than three hours daily compared to those who use them more than three hours per day,” reported Dr. Jhanji.
And though the incidences of DED are on the rise, the treatment options have remained relatively static, as noted by Dr. Louis Tong, MBBS(S’pore), FRCS(Edin), DM(Nott), PhD(S’pore), Senior Consultant, Cornea and External Eye Disease Service, Singapore National Eye Center (SNEC): “There is a definite unmet need for medical care for severe dry eye.” In addition, highlighted Dr. Tong, there are limited resources for reliable statistics regarding the prevalence of the disease. In Korea, a 2014 nationally representative study found that 10.4% of participants reported that they have been diagnosed with DED, and an additional 17.7% reported that they had symptoms of DED.5 And in Thailand, estimated cases of DED are even higher: in a hospital-based study conducted in 2006, 34% of patients reported significant symptoms of DED,6 while a population-based study estimated 14%. Dr. Vilavun Puangsricharern from the Department
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ADVERTORIAL of Ophthalmology Chulalongkorn University Hospital in Thailand, noted those two prevalence studies and added that the number of those cases at an out-patient department (OPD) that are severe is estimated at 10 to 15%. According to Dr. Jhanji, a recent study published in the Hong Kong Journal of Ophthalmology showed that the prevalence of dry eye in Hong Kong was close to 8%. In addition to this, the prevalence was higher in older patients. Noting the 10% prevalence in symptomatic DED in Malaysia, Dr. Tong estimates that 1-2% of the population in Singapore suffers from severe DED; and of all DED patients, it is estimated that 10 to 20% of those cases are severe.7 With the lack of exact data on the epidemiology of dry eye severity, it is challenging to determine how many people are actually affected by the disease...but that may be changing. “Before we had the Ocular Surface Disease Index (OSDI) in our clinics, the majority of the dry eye assessment was not objective,” said Dr. Jhanji. However, many clinics are adopting new protocol to better document DED. “If a clinician is managing dry eye patients, it is recommended that every patient fill in the OSDI chart at each follow-up – and other useful questionnaires such as SPEED and SANDE are now commonly being used,” explained Dr. Jhanji. “University and teaching hospitals have set up special dry eye clinics in order to better understand the epidemiology of dry eye syndrome. Likewise, refractive surgery centers are trying to adopt a practice of documentation of incidence of dry eyes after flap-based surgeries and surface ablations.” Another potential and important group of patients comes from rheumatology and immunology clinics, Dr. Jhanji further noted. “These patients have moderate to severe dry eyes depending upon the severity of their systemic disease,” he added.
lot of recent research on dry “eyeA pathogenesis and treatment, both in the laboratory as well as in the clinics, is indirect evidence of DED getting the increased attention it deserves.
”
– Dr. Vishal Jhanji
However, experts agree that with more attention and better assessment, comes better treatment. “In general, the acceptance rate of dry eye as a well-defined syndrome is increasing not only among the ophthalmologists, but with patients as well, “ said Dr. Jhanji. “Dry eye is no longer regarded as a trivial condition that can be neglected until it starts affecting patients’ daily lives. A lot of recent research on dry eye pathogenesis and treatment, both in the laboratory as well as in the clinics, is indirect evidence of DED getting the increased attention it deserves.” However, even with more awareness, lack of access to treatment options remains a problem for many in Asia. “Severe dry eye in Asia, especially in Thailand, is still an unsolved problem,” added Dr. Puangsricharern. “The patients with severe dry eye are really suffering from the chronicity of this debilitating disease. They suffer from dryness, irritation, inability to open their eyes, decreasing vision and also, decreasing quality of life.” To illustrate the need, Dr. Tong added that 30 to 40% of DED patients at his clinic are severe cases. Regarding treatment options, he said: “Most patients are quite despondent here, there is no access to scleral lenses, among other things. Patients on antidepressants or with neurotrophic pain are the most unresponsive to treatment, or most disappointed with their treatment.”
Most patients are quite despondent here, there is no access to “scleral lenses, among other things. Patients on antidepressants or with neurotrophic pain are the most unresponsive to treatment, or most disappointed with their treatment.
”
– Dr. Louis Tong
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Next Generation of Cyclosporine Treatment: Ikervis
W
hile there are numerous treatment options of varying efficacy available for DED, there are fewer solutions for patients symptoms of severe inflammation from DED. Historically, different formulations of topical cyclosporine have been used to treat severe DED – but with conflicting results. “In the past, I’ve treated moderate-to-severe DED patients with the pharmacy made formulation of CsA [cyclosporine A] at 0.5-1% with great success,” said Dr. Leonardi. “But in my clinical experience, CsA takes more time to reduce symptoms than signs, therefore it may not be well accepted by both patients and doctors.” For better treatment of severe keratitis associated wtih DED, Santen Pharmaceutical Co., Ltd., a specialty company dedicated to the ophthalmic field, has released Ikervis – a new 0.1% cyclosporine cationic emulsion (CE) eye drop. According to Dr. Leonardi, this new formulation has a better “delivery system” of the lipophilic drug cyclosporine, and therefore allows the drug to be better absorbed into the conjunctival and corneal tissues. Dr. Leonardi highlighted that the standardized formulation – and its stability and safety in the single dose product – makes Ikervis (CsA CE or CsA cationic emulsion) unique for the treatment of inflammation from severe DED..
Recent studies have confirmed the drug’s efficacy for those with severe keratitis from DED, as well as for those with Sjogren’s syndrome. “Ikervis has been proven to be effective in significantly improving corneal fluorescein staining, which has been considered a ‘biomarker’ of corneal involvement in DED,” said Dr. Leonardi. “The same improvement was demonstrated in both SICCANOVE and SANSIKA studies, either in patients with or without Sjogren’s syndrome.” In the first SANSIKA study, the proportion of patients achieving ≥2 grades improvement in corneal fluorescein staining (CFS) and a 30% improvement in symptoms (Ocular Surface Disease Index [OSDI]) by month 6 was 28.6% with CsA CE (Ikervis) versus 23.1% with vehicle (p = 0.326) (primary endpoint).8 “Even though symptoms were not statistically or significantly improved (in both studies) compared to vehicle – they equally improved over time, compared to the baseline. Thus, resulting in a significant improvement of symptoms and keratitis,” said Dr. Leonardi. Further, Dr. Leonardi revealed that Ikervis treatment in particular, was significantly effective in the improvement of corneal damage expressed by CFS scores (mean adjusted CFS change from baseline to month 6 [-1.764 vs -1.418,
27
ADVERTORIAL p = 0.037]), in the reduction of inflammation expressed by the inflammatory marker HLA-DR at month 6 (p = 0.021)8 and in the reduction of one of the key factors involved in the inflammatory initiation: hyperosmolarity. “These clinical data demonstrated the effect of CsA CE on the signs and key factors of DED, which by alone was clinically relevant as it helps control the inflammatory process and prevents disease progression,” he said. The SANSIKA 2 and SICCANOVE studies continued testing Ikervis versus vehicle for safety and efficacy and also found favorable results. According to the SICCANOVE study9: “0.1% Cyclosporine A CE (Ikervis) was well-tolerated and effectively improved signs and symptoms in patients with moderate to severe DED over 6 months, especially in patients with severe disease, who are at risk of irreversible corneal damage.” “We also explored patient outcomes and how they related to using Ikervis as a first-line treatment of the treatment of inflammation from severe DED. While concerns
regarding topical CsA treatments vary country-by-country, many involve cost (and costs for the national health system), as well as efficacy,” added Dr. Leonardi. He says that patients prefer to be treated with topical CsA compared to topical corticosteroids. This is mostly due to the potential side effects of corticosteroids in the short- and long-term course of treatment. In terms of safety and toxicity, he noted that different formulations of CsA ophthalmic emulsions did not show ocular or systemic toxicity with long-term ocular administration. These data were replicated also in the Ikervis studies. Dr. Leonardi concluded that cyclosporine is a known immunosuppressant and anti-inflammatory agent and the mechanism of action has been well documented in the scientific literature. As inflammation has been shown to be key to the pathology of DED and has been postulated to be part of a vicious cycle leading to a self-sustained disease state, it is plausible that anti-inflammatory therapies could be effective in the treatment of DED.
Patient Compliance and Managing Side Effects
S
uccessful management of most ophthalmic conditions depends heavily on patient compliance. Ophthalmologists have been emphasizing this fact for a long time. For example in glaucoma, it is well known that management is severely hindered by non-compliance with eye drops.10 Also, it has been estimated that 10% of glaucomatous visual loss is due to poor compliance.11 According to a survey study published as early as 1998, dry eye patients who are recommended to regularly use tear lubricants often discontinue (47%), while in those recommended with ointment, 53% stopped using the treatment.12 In general, patient compliance boils down to several factors: cost, convenience, disease severity and adverse side effects. Most of the treatment protocols for DED are based on guidelines from the Dry Eye Workshop (DEWS) – and these differing treatments are often based on the severity of the disease. For example, “mild-to-moderate dry eye patients need preservative-free artificial tear drops, while patients with more severe dry eye require punctal plugs,” explained Dr. Jhanji. “Very severe dry eye disease usually requires auto serum eye drops. Inflammatory dry eye syndrome is managed with corticosteroids, cyclosporine, oral doxycycline and lid hygiene.” In many instances, cyclosporine is the first line of treatment for DED. Its most common complaint stems from one primary side effect: a stinging sensation when the cyclosporine eye drops are applied. According to Dr. Jhanji, for mild to moderate DED, lower doses of
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cyclosporine (0.05%) are prescribed, often paired with topical corticosteroid eye drops to help reduce the stinging sensation. Once the patient acclimates to using cyclosporine, the corticosteroid can be tapered off. For moderate to severe DED, the dose is increased to 0.1% or 0.5%, and in some cases 2% for very severe cases. He notes that preservativefree artificial teardrops can also be helpful for reducing the stinging sensation. Although cyclosporine is the most commonly prescribed antidote to alleviate DED symptoms, its use can also be the hardest to enforce. The stinging sensation can be very off-putting for some patients, thus reducing patient
compliance. “Most patients experience burning or stinging,” acknowledged Dr. Tong. “However, this reaction varies from patient to patient. Some are unable to continue [treatment], and some are not bothered by it.” “In addition, a good doctor-patient relationship is another key to compliance,” said Dr. Puangsricharern. “If patients trust their doctor, they will listen. Patients also have to understand the chronic nature of DED, and that improvement will only occur with continued treatment.” Both Dr. Puangsricharern and Dr. Tong advise that patients should be warned about the stinging sensation, and that the beneficial effect (or reduction of symptoms) takes time to kick in. “Sometimes, using artificial tears five minutes before the cyclosporine helps,” said Dr. Tong. “Also, some patients are more willing to persevere if they know that corticosteroids are the next step, should the cyclosporine treatment fail.” Other than stinging, the cyclosporine drops have fewer side effects compared to corticosteroids. “The lack of adverse side effects – like raised intraocular pressure and glaucoma – is a major plus for cyclosporine,” he continued. According to Dr. Jhanji, cyclosporine eye drops can potentially be used up to four times per day as a first-line treatment for management of DED. He agrees with Dr. Tong: “Additional use of corticosteroid eye drops and artificial tear substitutes for an initial 4-6 weeks is recommended for better compliance.” The combination of eye drops helps to reduce the stinging sensation. Dr. Tong has also found another way that patients increase compliance
(on their own), and that’s by reducing the dose. Dr. Puangsricharern has also noticed this: because of the cost, some patients will use one vial over two days. Ultimately this reduces the effectiveness of the treatment – and is not recommended. Dr. Jhanji added that a good formulation of cyclosporine would improve compliance, though it seems there isn’t much alternative. This is where Ikervis steps in. “If Ikervis only requires a once per day instillation, it would increase compliance and convenience, and possibly have less adverse side effects,” concluded Dr. Tong. [Editor’s note: Ikervis is indicated for once daily use to treat severe keratitis in patients with DED.] It’s also important to remind patients that cyclosporine treats the underlying cause of DED – inflammation – so it’s critical to continue treatment in order to reduce the symptoms. Unfortunately, there is no current cure for DED, but with new drugs emerging to treat the disease and its symptoms, there’s hope for those who suffer from it. Using Ikervis as a once per day treatment should not only increase compliance, but improve the quality of life for patients too.
A good doctor-patient “relationship is another key to compliance. If patients trust their doctor, they will listen. Patients also have to understand the chronic nature of DED, and that improvement will only occur with continued treatment.
”
– Dr. Vilavun Puangsricharern
This supplement has been supported by an educational grant from Santen.
References: 1. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report (2017). Ocul Surf. 2017;15(3):575-628. 2. Stevenson W, Chauhan SK, Dana R. Dry eye disease: an immune-mediated ocular surface disorder. Arch Ophthalmol. 2012;130:90–100. 3. Pflugfelder SC, Stern ME. Immunoregulation on the ocular surface: 2nd Cullen Symposium. Ocul Surf. 2009;7:67–77. 4. Chen Y, Chauhan SK, Soo Lee H, et al. Chronic dry eye disease is principally mediated by effector memory Th17 cells. Mucosal Immunol. 2014;7(1):38-45. 5. Um S-B, Kim NH, Lee HK, et al. Spatial epidemiology of dry eye disease: findings from South Korea. Int J Health Geogr. 2014; 13: 31. 6. Lekhanont K, Rojanaporn D, Chuck RS, et al. Prevalence of dry eye in Bangkok, Thailand. Cornea. 2006;25(10):1162-1167. 7. Yu J, Asche CV, Fairchild CJ. The economic burden of dry eye disease in the United States: a decision tree analysis. Cornea. 2011; 30(4):379-387. 8. Leonardi A, Van Setten G, Amrane M, et al. Efficacy and safety of 0.1% cyclosporine A cationic emulsion in the treatment of severe dry eye disease: a multicenter randomized trial. Eur J Ophthalmol. 2016;26(4):287-296. 9. Baudouin C, Figueiredo FC, Messmer EM, et al. A randomized study of the efficacy and safety of 0.1% cyclosporine A cationic emulsion in treatment of moderate to severe dry eye. Eur J Ophthalmol. 2017; 20:0 [Epub ahead of print] 10. Buller A, Hercules BL. Should patients choose their own eyedrops? Acta Ophthalmol Scand. 2006;84(1):150-151. 11. Taylor SA, Galbraith SM, Mills RP. Causes of non-compliance with drug regimens in glaucoma patients: a qualitative study. J Ocul Pharmacol Ther. 2002;18:401–409. 12. Swanson M. Compliance with and typical usage of artificial tears in dry eye conditions. J Am Optom Assoc. 1998;69(10):649-655.
For Medical and Healthcare Professionals Only. For full prescribing information, please contact your local Santen representative. 29
INNOVATION DRUG DELIVERY SYSTEMS
BEYOND AMA
The Next Big Thing in Retinal Drug Delive
by Brooke Herron
R
etinal degenerative diseases are a leading cause of irreversible blindness and loss of vision worldwide. And although there have been considerable advances in clinical equipment, pathological analysis and surgical procedures, anatomical and physiological barriers make it difficult to deliver treatment to the posterior segment of the eye in a non-invasive manner. In addition, many retinal diseases are chronic, resulting in a frequent need for treatment at a high cost to the patient. Various ophthalmological drug delivery systems (DDS) targeting the retina have been developed, and below, we explore current treatments available for clinical use, as well as other devices in various stages of trials.
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The Current DDS Landscape Ophthalmologists have various DDS options to treat retinal diseases – each with its pros and cons. Conventional treatments like topical installation (of intraocular pressure lowering agents) and intraocular injections (of antiVEGF agents) are often the standard of care for some diseases – but they are not without complications. Poor patient compliance and successful drug delivery to the posterior segment, are the two biggest obstacles for topical installation. Intraocular injections have their own set of complications: they are invasive; they can cause serious complications; and repeated injections are often necessary.
There are also various intraocular and periocular implant DDS in clinical practice and trials. Intraocular implants have the ability to entrap and release drugs over a period of time, which may lower the frequency of surgery in some patients, while periocular implants allow for localized delivery of drugs and are less invasive than intravitreal administration – making them a viable and attractive option for treating retinal disease.
Coming Soon: The Latest in DDS The ideal DDS device for treating retinal degenerative diseases would deliver drugs to target sites in a noninvasive manner to maximize therapeutic outcomes and minimize side effects.
ranibizumab over a period of months, and is easily refilled in an office setting. It is currently in clinical trials. Another refillable device, which is intended for implantation into the lens, is in the preclinical phase. In this device, bevacizumab is loaded with a PVA matrix and release is controlled through a semi-permeable membrane on the side, with silicone check valves to refill the reservoir. In addition, because of its placement in the lens, this DDS could deliver drugs to both the anterior and posterior segment of the eye (depending on the device orientation).
AZON
ery Systems
Below we explore the new wave of DDS devices â&#x20AC;&#x201C; including refillable devices, micro electro mechanical system (MEMS)-based devices, cellbased bioreactors, and self-deploying devices â&#x20AC;&#x201C; most of which are currently undergoing clinical or preclinical trials.
Refillable Devices Refillable devices, like the port delivery system developed by ForSight Vision4 Inc. (Menlo, CA, USA) require a surgical procedure but can be used over several years without additional surgeries. Like the scleral plug, the port DDS is placed through the pars plana on the outside of the sclera and delivers drugs into the vitreous cavity through a small tube reservoir. This particular device was designed to deliver
Micro Electro Mechanical System (MEMS) Another refillable device uses MEMS technology and an active drug delivery pump. When a drug dose is required, an electrical current is passed between electrodes, and the gas generated by electrolysis of the water increases the pressure in the reservoir to push the drug solution out through the cannula and into the eye. Further testing will reveal if this approach could enhance drug delivery to the posterior segment of the eye. In addition, implant devices equipped with electrodes and power sources might also be applicable to electrical stimulation therapy in ophthalmic diseases, which has emerged as a potential neuroprotective strategy.
Cell-Based Bioreactors A living cell is a highly efficient bioreactor and any gene encoding a therapeutic protein can now be engineered into cells. Renexus (formerly NT-501), developed by Neurotech (Cumberland, RI, USA) is a human RPE cell line that is genetically modified to secrete ciliary neurotrophic
factor (CNTF). The engineered cells are encapsulated into semipermeable capsules that facilitate the diffusion of nutrients and proteins, but prevent attack by the host immune system. This capsule device is surgically implanted into the vitreous body through a tiny scleral incision and is anchored by a single suture. Several clinical trials using the device have been conducted.
Self-Deploying Devices Another DDS being explored is a self-deploying device that uses the transscleral route by subconjunctival or subtenon injection. Transplanting a self-deploying device in a less invasive manner could be possible with the use of a flexible sheet-type device that can unfold in the body and attach to tissue surface following injection from a needle. For example, the nanoporous film device, with its thin film, can be furled to fit inside and then deployed by a syringe. However, when administering drugs through the transscleral route, self-deployment and tight attachment of the device on the sclera following injection from a syringe would be favorable to facilitate drug diffusion to the retina, while reducing drug elimination by conjunctival clearance. As has been reviewed by Kaji and colleagues*, there are numerous DDS options for physicians treating retinal degenerative diseases â&#x20AC;&#x201C; some of which are already available, while others are in clinical trials or being investigated. As we search for the ideal DDS for the posterior segment, combining new technology, like MEMS and cell encapsulation, with current devices (like periocular implants) would be optimal to increase the bioavailability of released drugs. In addition, developing devices that can be implanted in a less-invasive manner should also be an important objective.
Reference: *Kaji H, Nagai N, Nishizawa M, Abe T. Drug delivery devices for retinal diseases. Adv Drug Deliv Rev. 2017; S0169-409X(17)30099-6. [Epub ahead of print]
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INNOVATION RETINAL OXIMETRY
A
Window Through which to Prevent Blindness Clinical Applications of Retinal Oximetry
by April Ingram
A
lthough poets have long said that eyes are the window to the soul, research is showing us that the eyes, more specifically the retinas, are actually windows to the body and brain. The imaging and analysis of retinal blood vessels has lead to the discovery of new biomarkers in retinal diseases such as diabetic retinopathy, central retinal vein occlusion, retinitis pigmentosa, and glaucoma. Beyond ocular diseases, because retinal blood vessels are part of central nervous system vasculature, biomarkers for diseases of the brain, such as Alzheimer’s disease are also being uncovered. This work is being done using retinal oximetry and is based on spectrophotometric fundus imaging which measures oxygen saturation in arterioles and venules in the retinal vasculature, retina, and optic nerve head.This non-invasive, quick, safe technique can detect changes in oxygen metabolism, including those that result from ischemia or atrophy. In a recent special issue of Investigative Ophthalmology & Visual Sciences, Dr. EinarStefánsson, M.D., Ph.D., FARVO, and colleagues discuss the clinical applications of retinal oximetry and the latest discoveries of biomarkers in retinal and brain diseases. Dr. Stefánsson explains, “Retinal oximetry adds a new dimension to diagnostic imaging of the eye, which previously has been limited to structural functional/electric imaging. Retinal oximetry is metabolic imaging.
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Many retinal diseases have metabolic foundations and involve ischemia and/ or atrophy.” In ischemic/hypoxic retinopathies such as diabetic retinopathy, neovascular, age-related macular degeneration, and retinal vein occlusions, retinal oximetry measures retinal hypoxia directly or indirectly. Retinal hypoxia is the main stimulant for production of vascular endothelial growth factor (VEGF). As we know, VEGF is the primary treatment target in these diseases and also the predominant cause of retinal edema and neovascularization, resulting in reduced vision. Dr. Stefánsson explains, “Hypoxia is ideal as a biomarker in these diseases as it relates so closely to VEGF which is central in the pathophysiology and treatment.”
“Since retinal hypoxia is closely linked to VEGF production, this biomarker is likely to be useful for determining the need for anti-VEGF treatment or hypoxia relieving treatment such as laser and vitrectomy,” he added. Both laser and vitrectomy influence retinal oxygen metabolism, an effect that can be detected by retinal oximetry. Retinal photocoagulation destroys photoreceptors and adjacent tissue and reduces oxygen consumption of retina, reducing hypoxia and VEGF production. “Retinal oximetry evaluates the outcome of such treatments in terms of the pathophysiology process rather than waiting for structural and functional damage which comes later,” explained Dr. Stefánsson. Additionally, in atrophic retinal diseases, such as retinitis pigmentosa and other retinal dystrophies, glaucoma and atrophic age related macular degeneration, retinal atrophy leads to reduced oxygen consumption, which can also be detected by retinal oximetry. Therefore, retinal oximetry offers a non-invasive method to measure the progression of these diseases and the need for, or response to treatment. The response to treatment can also be valuable in the assessment of new therapies, as Dr. Stefánsson describes, “Retinal oximetry can also be used to determine the improvement from new and experimental therapies in terms of new viable cells consuming oxygen.”
Reference: Stefánsson E, Olafsdottir OB, Einarsdottir AB, et al. Retinal Oximetry Discovers Novel Biomarkers in Retinal and Brain Diseases. Invest Ophthalmol Vis Sci. 2017;58(6):BIO227-BIO233.
About the Contributing Doctor Dr. Einar Stefánsson is Professor and Chair of the Department of Ophthalmology, and Vitreoretinal Surgeon at the National Hospital Reykjavik, part of the University of Iceland. He also serves as Editorin-Chief of Acta Ophthalmologica. Dr. Stefánsson’s research has made significant contribution to ophthalmic care and advanced our understanding of ocular physiology. Among his accomplishments, he and his colleagues uncovered the “Holy Grail” of ophthalmic pharmacology, developing the first eye drops to reach the posterior segment. He pioneered the field of vitreous physiology and helped demonstrate the biological and clinical effect of retinal photocoagulation. Dr. Stefánsson also collaborated with engineers, physiologists, and computer programmers to develop a reliable retinal oximeter, (www.oxymap.com), which has revolutionized retinal oximetry imaging and clinical research in this field. In addition to publishing more than 300 peer reviewed papers, 400 abstracts, numerous book chapters and patents, he was knighted by the President of Iceland in 2007. Dr. Stefánsson has been married to Bryndis Thordardottir MSW for 37 years and they have 5 children and 6 grandchildren. [Email: einarste@landspitali.is]
Corneal Cross-Linking The latest 2017 PXL Systems are out now! Made in Switzerland by PESCHKE
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Highlights: Variable energy level settings Continuous, individually customable pulsed and LASIK radiation modes Self-calibrating and self-adjusting Colour touch screen The PXL Platinum offers: Eye tracking with adjustable real time camera view Bluetooth communication interface + treatment report creation Ultrasound contact Pachymeter optional CXL treatments are easy to perform, safe for the patient, and can be combined with other medical therapies. SAFE – EFFECTIVE - FLEXIBLE CXL – The Experience In recent years corneal cross-linking has become the standard procedure for treating patients with progressive keratoconus and other ectatic corneal diseases because of its effectiveness and lack of serious side effects. A large number of major clinical studies has proven the effectiveness of CXL and the lack of serious side effects. More than 85%of eyes treated with CXL showed a significant increase in BCVA. Six months after the procedure cylinder was reduced in the majority of patients. CXL is the only effective nonThe PXL systems come in a sturdy transport case invasive treatment to stop progressive Keratoconus and other ectatic disorders (such as PMD and iatrogenic ectasia) and has a regularisation effect on corneal topography. In addition to its role in treating ectatic corneal diseases, CXL has an established place in the Ergonimic, flexible table mount management of infectious keratitis. UV light has long been known for its ability to kill different microorganisms (such as bacterial and fungal ones). Since keratitis in humans is an important cause of blindness, and antibiotic resistance is an increasing problem worldwide, CXL proves to be an extremely valuable possibility to manage the condition with a satisfactory outcome…….Contact Peschke to learn more! PESCHKE Trade GmbH Boesch 73 · 6331 Huenenberg · Switzerland Phone +41 41 784 9460 · Fax +41 41 784 9462 info@peschketrade.com · www.peschketrade.com
ENLIGHTENMENT WORK-LIFE BALANCE
On Meditation and Mindfulness Unplugging for Work-Life
Balance
by Ruchi Mahajan Ranga
I
n today’s fast-paced society, if you aren’t feeling stressed, you are in the minority. On its website, the Global Organization for Stress has compiled a list of statistics to illustrate that fact: In major global economies, stress levels are rising, with 6 in 10 people experiencing increased workplace stress – China has had the greatest increase at 86%. In Australia, 91% of adults feel stress in one area of their lives.1 With these statistics, it’s no surprise that many people struggle to balance their personal and professional
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lives. And for healthcare professionals – many of whom are on-call 24/7 – finding that balance is even more difficult. So, until we devise a magical pill to cure stress, we’ll have to find ways to manage it. Learning to set limits is an important part of reducing stress. In a digitally driven world, we can get lost in our routines and forget that time to relax is vital to our wellbeing – in fact, studies have shown that productivity actually decreases with high levels of stress. There are various stress-reducing strategies people adopt to look after
their mind and body. For some, finding a work-life balance is a matter of scheduling and prioritizing, while others may take a more holistic approach to wellness. And while it may sound simple, finding a balance continues to be a daunting task for many. Dr. Vandana Jain, a practicing cornea, cataract and LASIK surgeon in Mumbai, India, has found a stress reducing release through meditation. We talked with her to learn how meditation has changed her life, and helped to her to find that elusive balance.
Meditating the stress away Dr. Jain shares that meditation has played a pivotal role in helping her adopt the right mindset at different phases of her life. She was introduced to meditation by one of her colleagues when she was experiencing tremendous pressure during the first year of her startup. And while there are different styles of meditation, Dr. Jain practices Vipassana, one of India’s most ancient meditation techniques. “Vipassana helped to me gain the right perspective and to shed my overcritical attitude toward myself,” said Dr. Jain. Dr. Jain admits that she is a perfectionist by nature – and that practicing meditation has given her more acceptance of herself and of the people around her. “Doing meditation routinely in the morning is like a habit for me now. With its help, I have learnt to focus on the bigger picture, both in business and in my personal life, and that eased up a lot of stress,” she said. “The acceptance of things, both at the professional and personal level, is an important lesson that has been unveiled to me through meditation.” For people who experience agitation or anger, along with stress, Dr. Jain says meditation can work wonders. For her, regular meditation practice has helped her achieve a higher level of satisfaction with her life – it soothes her agitation, spreads vibes of relaxation, and enables her to effectively communicate at every level. “By minimizing one’s indulgence in negative emotions, meditation helps bring out inner youth – and that’s reflected in the face,” shares Dr. Jain, who says she often gets complimented for her rejuvenated look after making daily meditation part of her life. While mindfulness and awareness are the most common benefits reported from meditation, it also provides us with the much-needed ability to combat stress after a hectic workday –
“
The acceptance of things, both at the professional and personal level, is an important lesson that has been unveiled to me through meditation.
”
– Dr. Vandana Jain before the build-up of stress begins to negatively impact our health, life and relationships. The goal is to approach everything we do in a mindful manner.
For Dr. Jain, meditation helped to lower her stress levels and find a balance between her work and personal life. Of course, there are other paths to reach the same goal: some people swear by yoga, while others prefer traditional exercise. Either way, taking time out for yourself each day is vital to maintaining physical, mental and emotional health. And for those hectic days, when there’s just not enough time – that’s when you need it most. Take a step back, breathe, implement your desired strategy (whether its meditation or another practice), and return revitalized and ready to tackle any challenges that head your way.
Mediation tips for beginners In order to quiet the mind, follow these simple steps to begin a meditation practice. Begin by practicing daily for five minutes, and gradually work your way up to 20 minutes. 1. Find a comfortable seat. Generally, this is sitting cross-legged with a straight back. However, if that is not appropriate for you, sit against a wall or in a chair. (Remember, if you’re not comfortable, you won’t be able to sit still!) 2. Rest your palms on your knees. Close your eyes. Sit still. 3. Let the breath come naturally. As thoughts arise, notice them and let them go. 4. You may concentrate on the breath or use the words “let go,” to help calm the mind.
Reference: Global Organization for Stress. Stress Facts. Available at www.gostress.com. Accessed on Sept. 13, 2017.
About the Contributing Doctor Dr. Vandana Jain is the Medical Director and co-founder of the multispecialty Advanced Eye Hospital & Institute in Navi, Mumbai, India. She is also a co-founder of a medical device business: Clear Ear, Inc. in California, USA, and is an adviser to many healthcare start-ups. She has received numerous awards in her career, including an Incredible Journey award and a Women Achievers award, among others. Dr. Jain is also co-owner of several international patents. As an ophthalmologist, she has worked and spent time at prestigious institutes like L.V. Prasad Eye Institute (Hyderabad, India) and Massachusetts Eye and Ear Infirmary, Harvard (Boston, USA). Dr. Jain has numerous advocacies as well. She started One Vision Health & Research Foundation, a NGO that provides free surgeries and eye check-ups, and offers various skill-based training programs like optometry and OT technician. Several large drives benefitting children’s eye care and eye donation are also organized by the Foundation every year. Recently, she co-founded and is working with a start-up called Fitterfly (www.fitterfly.in), a company that educates parents about fitness and nutrition for their children. [Email: drvandana.eye@gmail.com]
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ENLIGHTENMENT WOMEN IN OPHTHALMOLOGY
Female Authorship
Emerging Trends in by Ruchi Mahajan Ranga
T
he word “gender” makes its way frequently into ophthalmic literature. But the gender of authors themselves rarerely comes up. Now, gender is in focus. In order to evaluate trends in the prevalence of women authors in ophthalmology over recent years by authorship, position, and field of research, Dr. Noa Geffen, M.D., from Sackler Medical School at the Tel Aviv University (Israel) presented study findings at the American Society of Cataract and Refractive Surgery (ASCRS) 2017 meeting in Los Angeles, California, USA. In this observational study, trends in the gender distribution of authors in six ophthalmology journals between January 2002 and December 2014 were reviewed. The study sought to investigate the proportion of women authors in different time frames, and to identify any trend that increased this proportion through time in different categories. Findings suggest that the contribution of female authors remained
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in Ophthalmology
below the 50% mark (in all categories). Female authorship was observed to be at 34.7% in clinical journals, 36.8% in basic science journals, and 30.6% in subspecialty journals. Observing the trends from year 2002 to 2014 produced interesting results. For example, a steeper rise in the first authorship was observed as compared to the last authorship in terms of female contribution (p<0.001). However, there was no significant rise over the years for last authorship in subspecialty journals. For all three authorship positions, female contribution was observed to be consistently higher in general ophthalmology as compared to subspecialty journals (p<0.0001). Where no significant rise in female authorship was observed over the years in the last authorship category in subspecialty journals, a steep rise in percentage of first female authorship was observed for general journals. While the study showed
consistency in the overall increase of women’s contributions to the field of ophthalmology, the findings demonstrated that at the same time, a gap still exists in roles of clinical practice and scientific leadership. Though the rising graphs are predictive of gender equality in authorship in the coming future, the identified gaps warrant some scrutiny. In this regard, we have asked two notable female ophthalmologists in India to help us shed some light on the matter. Part of the reason we see less authorship by female ophthalmologists could be because of a lack of involvement in the business aspects of ophthalmology, like investing. “Somehow in Indian society, investment and technology intensive specialties, like ophthalmology and radiology, witness more set-ups by male professionals than female professionals,” said Dr. Vishali Gupta, a professor of ophthalmology from the Postgraduate Institute of Medical Education and Research (PGIMER) in Chandigarh, India. “There is a dire need for such specialties to stay up-to-date with whatever is latest in the field to provide the patients with the most advanced form of treatment modalities.” “Someone training at a smaller facility doesn’t get access to newest technology. So, in order to keep oneself abreast with latest in the field, one has to opt for an advanced training facility, and there are only a few in the country,” she added. After completing their degree in ophthalmology, men can easily go to multiple training centers. But it’s not the same for women, who play a central role in responsibility for their families. “Women are committed in whatever they do, and they rise at it. When it comes to women authorship,
we shouldn’t expect the same number as we have far more male ophthalmologists in the field,” Dr. Gupta explained. Dr. Gupta believes in the “gogetter” attitude to make the best of available opportunities. “The field of ophthalmology is driven by technology, which in turn is driven by commerce, so things move very fast and get obsolete in a span of few years. One has to be up-to-date with the most recent developments, even if there are no resources to acquire the same,” said Dr. Gupta, who believes in staying well-equipped with knowledge in order to deal diligently with patients. Dr. Sheetal Brar, a practicing ophthalmologist at Nethradhama Superspeciality Eye Hospital in Bengaluru, India, says she put a lot of thought into choosing ophthalmology as her chosen career: “Ophthalmology offers a good combination of clinical and surgical exposure, it does not have too many emergencies or risk to life, it provides a good work-life balance, and it’s rewarding too.” On the role of gender in ophthalmology, Dr. Brar continued: “There was a time when patients used to doubt the competency of female ophthalmologists and would prefer a male ophthalmologist for consultation or surgery.” However, she says that now more women are taking up ophthalmology, causing this trend to shift in India: “With women as leading ophthalmologists in many institutes and societies, the projection has improved to a vast extent.” When asked about her mantra to cope with tough competition in this ever-changing field as a female ophthalmologist, Dr. Brar said: “In this highly competitive world, I think it is very important to be focused on your goals, to stay tuned to recent advancements and to try to make the best use of every opportunity you get. If you are able to do so, it doesn’t matter if you are man or a woman.”
Before joining Nethradhama Eye Hospital, Dr. Brar worked with a medical college in North India where the department was dominated by male ophthalmologists. She shares that as a woman ophthalmologist, she was denied surgical opportunities, was made to take classes for undergraduate students, and had to see patients in the outpatient department. Ultimately, the lack of encouragement, coupled with fewer facilities to do clinical research and the unfavorable environment to grow further, forced her to take a leap and quit the facility. Dr. Gupta had the opposite experience of Dr. Brar. “Even though the field of ophthalmology is said to be dominated by men, I have never felt a difference at the workplace as an ophthalmologist,” she said. Dr. Gupta finds herself fortunate to have had the environment and colleagues that allowed her to do what she wanted to do without any gender bias. For Dr. Brar, leaving an unfulfilling job opened doors to the opportunity to be mentored by Dr. Sri Ganesh, Chairman & Medical Director at
Nethradhama Group of Hospitals. Dr. Ganesh not only helped her attain excellent clinical and surgical skills, but also gave her ample opportunities to perform clinical research and present her work at national and international platforms. Dr. Brar believes in utilizing every single opportunity in the best possible way in order to achieve the desired goal. “Don’t let failures dishearten you. Surround yourself with positive people who encourage you and guide you to make the right decision at the right time.” For aspiring women ophthalmologists, Dr. Gupta provides this final advice: “We should always stand up for the decisions we make. We should try to make the best of what we have. Learning is not bound by time – you can always take charge and do it when you feel the time is right, perhaps once your kids are grown. Complaining and playing the blame-game gets doesn’t get us anywhere. Keep yourself abreast with the latest in the field. You always get what you deserve, not what you desire.”
Reference: ASCRS 2017 Eposter #32343-0235: Trends in Authorship of Papers in Major Ophthalmology Journals By Gender, 2002 – 2014 by Dr. Noa Geffen, M.D., Israel
About the Contributing Doctors Dr. Sheetal Brar is a practicing ophthalmologist at Nethradhama Superspeciality Eye Hospital, Bengaluru, India. She completed her MBBS in 2005 and chose to specialize in ophthalmology. Later on she had a chance to be mentored by Dr. Sri Ganesh, Chairman & Medical Director, Nethradhama Group of Hospitals, Bangalore. She has presented her research work at both national and international levels and has won many national and international awards. In a span of four years, Dr. Brar published 22 clinical papers in peer-review journals. She believes in dreaming big, meeting successful people and learning from their success stories. [Email: brar_sheetal@yahoo.co.in] Dr. Vishali Gupta is a professor at Advanced Eye Center at the Post Graduate Institute of Medical Education and Research in Chandigarh, India. She specializes in the retina, vitreous, and uvea. She has been published in 65 peer-reviewed journals, and has authored 17 book chapters and four complete books. Dr. Gupta also holds a US patent for the development of multiplex PCR for uveitis. In addition, she is a sought after speaker, and has made more than 350 presentations in various national and international meetings. Dr. Gupta has received several awards for her work, including the first JN Pahwa award from the Vitreo Retinal Society of India, the first NA Rao Award from the Uveitis Society of India, and the first NA Rao award from All India Ophthalmological Society (AIOS). [Email: vishalisara@yahoo.co.in]
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ENLIGHTENMENT EYE PHOTO SERVICE
MSO Helps Ensure Timely Diagnosis of
Diabetic Retinopathy with Eye Photo Service by Ruchi Mahajan Ranga
D
iabetes (type 1 and 2) causes a host of health problems, including diabetic retinopathy, which leads to vision loss. In fact, diabetes is a leading cause of blindness in working-age adults. While type 1 diabetes is an autoimmune disease diagnosed in childhood, type 2 – sometimes called “adult-onset” diabetes – emerges later in life and is often a result of physical inactivity and obesity. Diabetes is now a global epidemic, and while the rates are highest among the elderly, prevalence rates continue to rise among the younger and productive sections of the population in developing countries. Asia alone has 60% of diabetics in the world.1 Currently, Malaysia has the highest rates of diabetes and obesity in Southeast Asia, with more than 3.5 million people suffering from the disease – ranking them among the highest in the world. In 2015, the Malaysian Health Ministry estimated that 1 out of 6 persons (17.5%) aged 18 years and above has diabetes.2 Given that more than 45% of Malaysians are obese or overweight, the rapid rise of diabetes is not surprising. According to a study published in The Lancet, 44% of men and 49% of women in Malaysia were found to be obese or overweight.3 To reduce the risk of complications, or to prevent them from worsening, diabetics must carefully manage and monitor their symptoms. Failure to screen for diabetic retinopathy is the major cause of vision loss in diabetic patients – vision loss that could have been prevented with timely intervention, as the most effective time to treat diabetic retinopathy is when the patient is still asymptomatic.
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Because conditions like diabetic retinopathy can be devastating to quality of life, it’s imperative that every diabetic has a retinal examination. This examination is generally carried out by an ophthalmologist or by a primary care physician using direct ophthalmoscopy. To help primary physicians screen patients for diabetic retinopathy more confidently, the Malaysian Society of Ophthalmology (MSO), offers Eye Photo – a non-profit initiative that makes community-based retinal photography more effective and efficient. MSO is a professional organization that represents medical doctors specializing in the field of ophthalmology in Malaysia. Using Eye Photo, MSO’s nonmedical staff members take highresolution retinal photographs for patients, which are then used by primary physicians to look for any signs of sight-threatening diabetic retinopathy. With Eye Photo, MSO hopes to prevent vision loss in the diabetic community that remains under-screened due to lack of awareness, lack of access to
other means of screening, or both. (This service is not meant to replace any medical eye care that patients may already be receiving.) To use this service, patients with a referral note from a primary physician can walk-in during clinic hours at: Klinik Kesihatan Jeram, 45800 Jeram, Selangor, Malaysia. The Eye Photo staff can be reached at: +603-32640720, and the clinic is open from 8 a.m. to 5 p.m. (Monday to Friday).
References: 1. Hu FB. Globalization of diabetes: The role of diet, lifestyle, and genes. Diabetes Care. 2011;34(6):1249-1257. 2. Tee ES, Yap RWK. Type 2 diabetes mellitus in Malaysia: current trends and risk factors. Eur J Clin Nutr. 2017;71(7):844-849. 3. NCD Risk Factor Collaboration (NCDRisC). Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 populationbased measurement studies with 19·2 million participants. Lancet. 2016;387(10026):1377-1396. 4. MSO Website. Eye Photo Project. Available at: http://mso.org.my/index.cfm?&menuid=6. Accessed on September 21, 2017.
ENLIGHTENMENT MANAGING BACK PAIN
Job Hazards in Ophthalmology
Back Pain by Brooke Herron
O
phthalmologists often spend long hours working in awkward positions, and unfortunately, these necessary job functions cause many doctors to suffer from neck and back pain. In fact, a recent survey of ophthalmologists in India showed that symptoms of neck and back pain are common, with 70.5% of respondents suffering from symptoms. According to the survey, 49% of respondents experienced low back pain, followed by neck pain at 33%, and upper back pain at 16%. In addition, of those with back pain, 86.6% reported that up to 5 hours per week was lost due to persistent backache. This study by Drs. Ramesh Venkatesh and Sumit Kumar, which surveyed members of the All India Ophthalmological Society (AIOS), is the first time the prevalence between ophthalmologists and work-related back and neck pain has been investigated in India.*
Analyzing the risk factors This survey explored a number of factors leading to neck and back pain among ophthalmologists in India. According to the survey, 61% of respondents felt that their back pain was exacerbated while working: Performing surgery was main culprit of back pain (45.9%), seeing patients in the OPD/doing procedures came in second (32.6%), followed by using retinal lasers/indirect ophthalmoscopy (25.5%).
Interestingly enough, ophthalmologists in certain specialty branches experience more neck and back pain than others. Doctors specializing in cataract, general ophthalmology, cornea and refractive surgery, glaucoma, and medical retina were found to have a higher rate of reported symptoms, while those working in pediatric ophthalmology, neuro-ophthalmology, oculoplasty, and surgical retina showed lesser risk of having back pain. The study’s authors note that this could be due to the lesser volume of ophthalmic work and cases in these subspecialties.
Try it at home: Gentle yoga poses to alleviate back and neck pain. Cat and Cow Poses Cat and Cow poses are a gentle way to stretch an achy or sore back.
Do it: Start on your hands and knees. On an inhale, move into cow pose by dropping your belly toward the floor and bringing your gaze up (don’t crunch your neck). On an exhale, move into cat pose by rounding your back and bringing your gaze toward your navel. Repeat 10 times, flowing smoothly with your breath between the poses.
Managing back and neck pain This study also asked respondents about their methods to alleviate symptoms of back and neck pain. Of all respondents with pain, 74.3% reported they were doing some form of exercise/ yoga, 32.5% were taking non-steroidal anti-inflammatory drugs, 9.37% had received physiotherapy/treatment from a chiropractor, and 0.87% had undergone surgery. In addition to exercise, the authors made other suggestions to help reduce pain. For example, making minimal modifications in instrumentation, like adjustments to the height of the slit-lamp, operating table and/or microscope eyepieces, will help to keep the neck and back in a neutral position (this helps avoid unnecessary extension or flexion). Increasing the doctor-topatient ratio would also help by reducing the workload and hours worked.
Child’s Pose This pose elongates the back and promotes relaxation – so it’s perfect to do before bed, or at the end of a long day.
Do it: Kneel on the floor, with your big toes touching, and sit on your heels. Spread your knees apart, but keep your big toes touching. Sit tall to lengthen the spine, and on an exhale, drape your body between your knees. Rest your forehead on the floor, and stretch your arms in front of you, palms facing down. Hold for five to 10 breaths, and repeat as needed for a soothing stretch.
Reference: *Venkatesh R, Kumar S. Back pain in ophthalmology: National survey of Indian ophthalmologists. Indian J Ophthalmol. 2017; 65:678-682.
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ENLIGHTENMENT eyeVLOG
Dropping it Like It’s Hot…
on the eyeVLOG
by Matt Young PIE Magazine CEO & Publisher
“O
MG, almost forgot about OCT.” That rap line keeps rattling around my head. It was a line I wrote up while in a taxi headed to my lakeside destination in Hangzhou, China’s storied beautiful city. Donned in my typical conference uniform, I strolled around the lakefront – or rather hopped, and dropped it like it was hot. My ophthalmology rap, that is. Why rap about ophthalmology? Well, when I wrote my first ophthalmic sentence in 2003 for an anterior segment magazine, I found the subject to be exceedingly dry. If you’re not an ophthalmologist, reading about ophthalmology is dry. If you are an ophthalmologist, it’s still dry. Perhaps as an ophthalmologist, you find that mental sparks fly when considering whether to use a 25- or 27-gauge needle. But surely, from time to time, having read through 13 pages of a peer-reviewed journal, you might nod off. We’re all human, after all. We all know what’s overtly scintillating, and what’s not. PIE Magazine’s eyeVLOG came upon me one weekend while watching Casey Neistat, my favorite YouTube Vlogger. Casey is a whiz at producing beautiful, entertaining and informative
vlogs. And I’m sure he knows nothing really about the human eye. But I do. And I admire Casey’s style. So I set about creating a big of a Casey-esque vlog for ophthalmology. What it lacks in production value, it – hopefully – makes up for in humor. If you’re a follower of the eyeVLOG, you’ll notice I’m not against waking up, or even singing on camera. The life we lead, after all in ophthalmology, is a life. We go to conferences, we learn new things, and we laugh along the way – often to inside jokes that aren’t readily told publicly. Why this all has to be cloaked in a supreme suit and tie affair is beyond me. Believe me, I know how to live. I’m simply inviting others – doctors and industry
About the CEO and Publisher Matt Young, M.S.J., is CEO and Publisher of PIE Magazine, and Founder and Director of parent company Media MICE Pte Ltd. Media MICE was founded in 2009 as a medical publishing and innovative content marketing company based in Singapore, serving both Asia-Pacific and international markets. The company allies with major ophthalmic societies, key opinion leaders and corporations to support this mission. Mr. Young has worked based in the United States, China, Vietnam, Malaysia and Singapore as a journalist, technologist and serial entrepreneur, and has been in ophthalmology since 2003. His work also has appeared in The Wall Street Journal, The Washington Post, CNET.com, NPR, Asia Times Online, Beijing Review and many other publications. He holds awards from the American Society of Business Publication Editors (ASBPE), Awards for Publication Excellence (APEX), and China International Publishing Group (CIPG), among others. He holds a master’s degree in journalism from the Northwestern University, Chicago. Mr. Young speaks English, Mandarin, Spanish and a smattering of Vietnamese. [Email: matt@mediamice.com]
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professionals alike – to recognize the human side of what we do and how we learn, and to enjoy that part of the ride as well. When I peer into the future of our industry, this is what I see: I see millennials coming up in our field, which is why we have successful meetings now called things like Millennial Eye. I saw one instance of virtual reality communication in 2014 – at the Alcon booth at EURETINA – and this year I saw it take over booth communications at ASRS in Boston, with an example of mixed reality as well using Microsoft Hololens. Our own experience providing ophthalmic communication through Google Glass with Bayer and through Augmented Reality with Abbott showed the magic that happens – also intellectually – when new communication methods partner with scientific content. I see skits like X-Rounds at ASCRS, where a flashy session combined with ophthalmology’s top speakers, makes for entertaining and scientific fun. And I notice what people wear, namely myself, and experience how people come out of the woodwork to have meaningful ophthalmic conversations. We connect through our humanity, and our common
desire to grow, not through our armor and cynicism. Yes, the eyeVLOG is experimental. And I’m not expecting for anything to go viral anytime soon, since I cover ophthalmic innovation rather than cats playing keyboards. If I sang and all the ophthalmologists in the world watched, I sadly still wouldn’t make the Billboard Hot 100. On the upside, show-stopping innovation is shown on the eyeVLOG and in quick spurts, so you don’t have to drool through booth lectures or even be present to get some interesting insights into ophthalmic innovation show floors globally. So I hope you youngster ophthalmologists and industry professionals – and hipsters at heart – enjoy my take on ophthalmic meeting reporting. Even if you don’t, know that through this and other efforts, we at PIE Magazine are looking at ways to make ophthalmology fresh, creative and constantly relevant to our evolving audience from been-there-done-that to … wow! Most of all, I have to say I’m proud to be doing it in Asia. Our region is full of humor, is immensely vibrant, and has only begun to lead the way on innovation. So, the next time you feel put off – by one of my rap lyrics or some absurd dress – consider that my world is one that exists in 2050 and beyond. Always thinking about the future of content in our industry, essentially, I come to you from it. And, I come in … peace! Don’t miss the eyeVLOG on YouTube: Search for “Pie Magazine” to visit our channel and view our vlogs!
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Applicable to Both Chambers of the Eye
I
n today’s clinical practice, there are many IOLs to choose from. Many lenses are versatile, and some are more forgiving than others, allowing IOLs to have a range of applications. The Artisan® Aphakia intraocular lens (Ophtec, Groningen, Netherlands) is a truly versatile lens that is designed for primary or secondary implantation for the visual correction of aphakic eyes. “Artisan Aphakia intraocular lens (IOL) is indicated for primary implantation in lens subluxation or dislocation, which may be hereditary or traumatic; and for secondary implantation in aphakic patients with inadequate capsular support; or pediatric aphakia due to congenital cataract; or after the removal of dislocated IOL that may be spontaneous or traumatic,” explained Dr. Chien-Liang Wu, M.D., Director, Ophthalmology Department, Taipei Medical University-Wanfang Medical Center, Taiwan. In other words, these lenses are not designed for just any aphakic eye, but rather for eyes where posterior chamber (PC) IOLs cannot be used
– usually because of lack of capsular support, or when an anterior chamber (AC) angle fixated IOL has been determined to be not in the patient’s best interest. The lack of capsular support in aphakic eyes is often due to posterior capsular rupture and pre-existing zonular dialysis or dehiscence (ZD) – a condition characterized by weakened zonules. Pre-existing ZDs have many causes, including: history of trauma in ocular surgery (i.e. vitrectomy), pseudoexfoliation syndrome (PEX), high myopia and systemic conditions (i.e. congenital, metabolic, and endocrine disorders that affect the ciliary zonules, such as Marfan syndrome, Marchesani’s syndrome, scleroderma, homocystinuria, spherophakia, porphyria, and hyperlysinemia). While it is very important for these conditions to be treated, such pre-existing cases make treatment difficult for the surgeon. Artisan Aphakia IOL provides a solution to these extreme cases. Of course, not every lens is suited to every eye, so there are a few conditions that would exclude patients from using this lens. Patients with rubeosis iridis and aniridia, or that have inadequate iris support are not suitable for Artisan Aphakia IOL. “Because if there is no iris, there is no claw,” Dr. Wu pointed out. He also noted that patients with uvetis, or those who are prone to eye injury, from playing contact sports or self-harming (automutilation) are also not suitable. However, Dr. Wu emphasized that in eyes with shallow anterior chamber (less than 2.6 mm) and low endothelial cell count (less than 2000 per sq. mm), the procedure would work if the Artisan Aphakia IOL is implanted with retropupillary fixation (posterior segment position). Otherwise those particular patients would be unsuitable for the lens.
Side A: Anterior Chamber Application
Anterior chamber
“For those eyes with adequate anterior chamber (AC) depth and endothelial cell count (ECC), I will use the Artisan Aphakia in the anterior segment,” Dr. Wu said. While there are other choices of IOLs for aphakic patients (i.e. Kelman multiflex AC-IOL, scleral fixated PC-IOL, iris-suture IOL), issues remain. “For example,” explained Dr. Wu, “the Kelman multiflex AC-IOL has complications related to uveitis, glaucoma, hyphema, cystoid, macular edema, endothelial cell loss and corneal decompensation.” On the other hand, the scleral fixated PC-IOL is technically more difficult to implant and needs longer surgical time and anterior vitrectomy. “Therefore the risk of serious complications such as vitreous hemorrhage, suprachoroidal hemorrhage, and retinal detachment are increased. It is also difficult to precisely
last two years, “sinceIn theArtisan Aphakia IOL became available in Taiwan, it has been my treatment of choice for aphakic patients with inadequate capsular support.
”
- Dr. Chien-Liang Wu 42
and symmetrically fixate both haptics within the ciliary sulcus. And there is also a concern of biodegradation of the prolene suture 8 to 10 years after surgery,” explained Dr. Wu. Also, he noted that compared to the scleral suture, iris-suture IOL is not easy and may have severe complications including hyphema, cystoid macular edema (CME) and retinal detachment. “Compared to these IOLs, Artisan Aphakia is easy to implant. The surgical time is much less than scleral or iris fixation procedures. And it is safer than the Kelman multiflex AC-IOL. In the last two years, since Artisan Aphakia IOL became available in Taiwan, it has been my treatment of choice for aphakic patients with inadequate capsular support,” he added. In his clinical practice, Dr. Wu applies the Artisan Aphakia IOL in both anterior and posterior chamber methods. “Except for those patients with shallow AC and low ECC, I prefer anterior position (in front of the iris) for Artisan Aphakia,” he said. “You can always see what you have, and the anterior chamber applications of Artisan Aphakia has been a time-tested safe method for aphakia treatment for more than 40 years.” According to Dr. Wu, if the anterior hyaloid remains intact with no vitreous prolapse, vitrectomy may not be needed if using the anterior approach in cases of primary implantation for those with lens dislocation. “I also think that there is less iris pigment layer damage or iris chafing with anterior approach since most pigment is distributed on the rear side of the iris,” he added. Throughout his clinical practice, Dr. Wu has used AC-IOLs, scleral fixated PC-IOLs and iris-sutured PC-IOL to treat aphakic eyes. But he found that the AC application of Artisan Aphakia IOL is an easier, faster and safer procedure – and that it provides better patient outcomes and higher patient satisfaction. “In some cases there may be postoperative astigmatism due to a larger incision. But the refractive error can be corrected with LASIK or PRK if necessary,” concluded Dr. Wu.
Side B: Posterior Chamber Application
fixation is a “safeRetropupillary and effective treatment in aphakic eyes without capsular support, and the patient’s recovery is usually faster than in scleral fixation technique.
Retropupilair
Aphakic patients with complicated cataract cases are ideal candidates for Artisan Aphakia IOL. These are patients who have post-traumatic subluxation (or total dislocation of crystalline lens); ruptured cataractous lens without adequate capsular support (with or without severe laceration of the iris that required reconstruction); post-cataract surgery aphakia that resulted from intra- or postoperative complications; cases with subluxation or total dislocation of the IOL that required both anterior and posterior vitrectomy; and cases in which keratoplasty was performed in association with vitrectomy. “In all these conditions, a surgeon can choose between anterior or posterior chamber implantation. We usually prefer posterior chamber implantation because it gives a much better aesthetic result, and also because the posterior chamber is a more ‘physiologic’ site for IOL implantation,” explained Dr. Matteo Forlini, M.D., from the University of Parma in Italy. According to Dr. Forlini, retropupillary fixation is a safe and effective treatment in aphakic eyes without capsular support, and the patient’s recovery is usually faster than in scleral fixation technique. “That is because there is no need for conjunctival and scleral opening, hence less inflammation,” explained Dr. Forlini. In addition, the posterior chamber implantation (retropupillary fixation)
”
- Dr. Matteo Forlini of Artisan Aphakia IOL leads to excellent aesthetic outcomes, which also contributes to increased patient satisfaction. [Disclosure: Retropupillary fixation is an off-label application of Artisan Aphakia IOL.] Based on his clinical practice, Dr. Forlini says that the retropupillary fixation of Artisan Aphakia IOL is a faster and easier technique to perform, compared to scleral fixation technique of other PC-IOLs. “Most importantly, there is a low rate of complications reported in literature, such as: no significant increase in postoperative macular thickness, endothelial cell loss and intraocular pressure. Also, no high values of astigmatism are reported in the postoperative months (average of 1.5 to 2.0 D of postoperative astigmatism),” added Dr. Forlini. Furthermore, Dr. Forlini emphasized that retropupillary fixation of the iris-claw lens for secondary implantation is a valid alternative strategy to the classic scleral-fixed or angle-supported IOL implantation. “I’m very satisfied with the Artisan Aphakia lens, especially for retropupillary fixation (posterior chamber implantation), because the complications related to retropupillary fixation are minimal,” stated Dr. Forlini. “The advantages and benefits to both surgeons and patients are substantial,” he concluded. This content was supported by an educational grant from Ophtec BV.
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ESCRS 2017 SYMPOSIUM PREVIEW
OCT & OCTA Innovations Discover the New Gold Standard
I
n his clinical practice, Dr. Erik L. Mertens, MD, FEBO, director and ophthalmic surgeon at the Antwerp Eye Centre in Belgium, relies on his Avanti OCT system by Optovue for – of all things – IOL power calculations. Pachymetry scans measure the total corneal power (TCP) based on eight meridians on the pupil. “You get a very good idea of how the curvature is distributed between the anterior and posterior part of the cornea,” said Dr. Mertens. “Other OCT devices don’t have this calculation software; Avanti is the only one and it is much more precise than any other formula on the market.” Importantly, it [Avanti] makes a surgeon’s life much easier, noted Dr. Mertens. “We also don’t need any data from previous surgery. With other methods, you need a lot of information (e.g., refraction, K reading, etc.) You don’t need any previous data with Avanti,” he explained. In addition, the Avanti system’s AngioVue OCTA software looks at the retina – which can help reduce postoperative problems even for anterior
Presented by Optovue, the OCT & OCTA Innovations: Discover the New Gold Standard Symposium took place on October 8, from 1 to 2 p.m. at Fiera Internacional de Lisboa (Room 4.4).
segment surgeons. “You can look at the microvasculature of retina prior to anterior segment surgery and see preexisting problems that you can’t see through a microscope,” he added. Further, Prof. Dan Z. Reinstein, MD, MA (Cantab), FRCSC, DABO, FRCOphth, FEBO (UK), of the London Vision Clinic, United Kingdom, discussed the epithelium and why it is a crucial tool in screening for keratoconus. Since 1992, Prof. Reinstein has been using Artemis Insight, a very highfrequency digital ultrasound technology. Now it is also possible to measure things by OCT, emphasized Prof. Reinstein, so all of the knowledge gained by previous studies using VHF digital ultrasound can be applied to OCT measurements of the epithelium. Optovue’s Avanti OCT can measure epithelial thickness up to an expanded 9 mm zone. “Tomography devices are very good and have improved significantly over the years, but adding epithelial thickness data improves this even further,” he said. “It enables you to exclude keratoconus in cases
where there is some suspicion based on tomography alone.” During the one-hour symposium at ESCRS 2017 in Lisbon, Portugal, attendees had the opportunity to listen to the following presentations: • Total Cornea Power and AngioVue OCTA are Fundamental to My Refractive Practice with Erik Mertens, MD (Belgium) • AngioVueHD and 3D PAR: A Huge Leap Forward in Facilitating Imaging of Retinal Pathologies with Rufino Silva, MD, PhD (Portugal) • Quantification of Ocular Structure and Vasculature with AngioVue: Redefining Detection and Monitoring of Glaucoma with Kaweh Mansouri, MD (Switzerland) • The Impact of Epithelial Thickness Mapping (ETM) in Corneal Refractive Surgery with Prof. Dan Z Reinstein, MD, MA (Cantab), FRCSC, DABO, FRCOphth, FEBO (UK) • Unleashing the Power of Your OCT System - Tips from an Imaging Expert, with Adil El Maftouhi, OD (France)
You’re Invited to a Symposium
OCT & OCTA Innovations
Discover the New Gold Standard Sunday, October 8th, 2017 13:00 - 14:00 Room 4.4 FIL - Fiera Internacional de Lisboa Portugal Speakers Erik Mertens, MD Rufino Silva, MD, PhD Kaweh Mansouri, MD Prof. Dan Z. Reinstein, MD Adil El Maftouhi, OD
Space is limited. RSVP today. optovue.com/escrs2017