PIE Magazine Issue 05: The ebook version (ARVO Honolulu issue) by Media MICE

ASIA-PACIFIC’S FIRST MAGAZINE ON THE POSTERIOR SEGMENT

05 PIE-LAND ISSUE March/April 2018 www.piemagazine.org

magazine posterior segment • innovation • enlightenment

Empowering Vision and Mankind

A Journey Page

Telemedicine Project Helps Fight

Childhood Blindness, Provides Eye Care for the Poor Page 26

Is the Retina on an isolated island?

We hard land on

PIE-LAND to find out 14

Cover Story: Page

PIE-LAND: Booth #1631 at ARVO 2018

THE WORLD’S FIRST FUNKY OPHTHALMOLOGY MAGAZINE

Inside this issue...

Posterior Segment

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09 10

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Going Boldly into the Suprachoroidal Space – An ‘Outside In’ Look at Drug Delivery to the Posterior Segment

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Extending Horizons in the Management of nAMD and PCV Diagnosing Cytomegalovirus Retinitis as Part of a Multisystem Disorder – A Look at Dyskeratosis Congenita

Matt Young

CEO & Publisher

Hannah Nguyen CFO

Diabetic Retinopathy Awareness and Associations with Multiple Comorbidities: Insights from the DIAMOND Study

COVER STORY

Arriving Now on PIE-LAND: Insights into the Ties that Connect the Segments

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Innovation

page

Gloria D. Gamat

20 22

Robot-assisted Retinal Vein Cannulation for RVO

Chief Editor

Brooke Herron Associate Editor

Ruchi Mahajan Ranga Project Manager

Timmo Gunst

Publications & Digital Manager Graphic Designers

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Empowering Vision and Mankind – A Journey

page

Vitreoretinal Surgery Highlights from AVRTT@6 Workshop

Enlightenment

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Winson Chua Patalina Chua

Telemedicine Project Helps Fight Childhood Blindness, Provides Eye Care for the Poor

page

Thinking Outside of the Box to Make Ophthalmic Teaching and Learning Exciting

page

We Can Operate Too!

Writers

April Ingram Chow Ee-Tan Collins Santhanasamy Hazlin Hassan Joanna Lee Khor Hui Min Olawale Salami Cover Art

Prafulla Badgujar www.piemagazine.org Published by

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A New Vision for All

Conference Highlights

34 36

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Posterior Segment Poster Highlights from APAO 2018 Hong Kong

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Posterior Segment Poster Highlights from AIOS 2018 Coimbatore

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Hold onto your Leis… ARVO 2018 is here!

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PIE MAGAZINE LETTER TO READERS Beyond Traditional KOLs: What Bono, YouTube Celebrities and Kids Could Do For Eye Care

hen both kids and ophthalmic society leadership enjoy your ophthalmic exhibition booth, what does it mean? It means you’re appealing to the young, and young-atheart, and something magical is in the air for the future of ophthalmic communication. Ophthalmic superheroes graced our PIE Magazine booth at APAO 2018 in Hong Kong, namely PIE Person (hero of the posterior segment), and ANT Person (hero of the anterior segment). Of course, their arch nemesis, Evil Eye, an ocular villain, also was there. The children of ophthalmologists parents started showing up for pictures. And so did society leadership of the All India Ophthalmological Society (AIOS), the American Society of Retinal Specialists (ASRS), and the Asia-Pacific Academy of Ophthalmology (APAO). “I’d like to take part actively in PIE Magazine,” said Dr. S. Natarajan, incoming president of the All India Ophthalmological Society, in a Facebook message to us. He showed up soon after at our booth to take pictures in our PIE Person ophthalmic superhero mask, and light up a superhero toy. Our youthful experience has been the exception to the rule. It’s 2018, and ophthalmic communication in many respects continues as it did in 2008, and in 1998. Much of that communication is uber-technical, transmitted by people wearing suits and ties, and appealing to no one but perhaps a few dozen specialists at a time, and at most a few hundred. But can there be crossover communication appeal, engaging surgeons, patients, right down the line to…kids? We are only at the very beginning of answering that, but the short answer is yes. At the beginning of March, the number of American adults using YouTube hit 73%, surpassing Facebook at 68%, according to the Pew Research Center. Further, in the 18-24 age demographic, YouTube reached 94% of people. Given the power of YouTube videos to go viral, one begins to consider the power of young adults and even kids to influence what the world pays attention to. Cute kittens might command the attention of many of such views. If we, in the ophthalmic industry, were a little more active, we could harness the YouTube power of the young to spread the word about important eye care issues. But we’d have to do it differently to get shared and talked about on social media. Out with seriousness. In with humor, and song. In the best case scenario, Bono would sing about eye disease, thanks to encouragement from his ophthalmologist, who read this article. Bono has glaucoma. And if he sang a song on YouTube about glaucoma (for example, substituting eye care words even for his hit words in Zooropa), he’d get

millions of views and raise incredible amounts of awareness about glaucoma across the age demographic. Let’s explore. Instead of:

We would suggest:

Zooropa... a bluer kind of white

Glaucoma… the silent thief of sight

Zooropa... it could be yours tonight

Glaucoma…it could rob you tonight

We’re mild and green

Don’t lose your vision

And squeaky clean

Get an examination…

It would be the start of real crossover education about eye disease. It would bring what ophthalmologists know and care about beyond even direct communication with patients. It would bring the communication to youngsters, who in essence would become overnight KOLs, prodding their family members if they know anything about glaucoma, which might in turn be a trigger for other family members to get educated and seek treatment. All people need is an interest in eye care to get more involved in their own care, or in family members care. An interest in glaucoma could lead to a medical visit in which AMD is detected instead. There’s no reason kids have to be expert surgeons. They just have to be more engaged, curious, questioning, and prodding. Of course, if Bono is busy, I’m sure even a good B-list celebrity singing about eye care could help. In fact, a good YouTube celebrity could help, even aged 15 (i.e. a Kiddie KOL). Let’s embrace the future of youth-minded ophthalmic content, youth mediums, and influence beyond our wildest 27-gauge dreams. Meanwhile, we invite you to PIE-LAND at ARVO Booth #1631 and share your ideas for harnessing the power of youth to transmit ophthalmic information. We’ll be dressed as pilots and flight attendants, having hard-landed on PIE-LAND to explore a land of mysterious retina creatures. Read our Cover Story (Page 14) for the full story. And see you at PIE-LAND! All best,

Matt Young CEO & Publisher PIE (Posterior Segment - Innovation - Enlightenment) Magazine P.S. If you know Bono, a B-list celebrity, or a YouTube celebrity that might be interested to help raise awareness about eye disease, help connect us! Write me at matt@mediamice.com with your thoughts, or stop by Media MICE Booth #1631 at ARVO to share.

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 â&#x20AC;&#x201C; 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]

POSTERIOR SEGMENT DRUG DELIVERY SYSTEM Going Boldly into the Suprachoroidal Space

An ‘Outside In’ Look at

Drug Delivery to the Pos by April Ingram

ur understanding of the development and progression of posterior segment diseases like age-related macular degeneration (AMD), diabetic retinopathy (DR), noninfectious uveitis or central serous chorioretinopathy has never been better. This knowledge has led to the development of new drug targets and improvements to existing drugs, enhancing our ability to treat these patients and better predict outcomes. Great news! But questions still remain . . . is the effectiveness of these drugs being optimized? Are they being limited by their delivery within the eye, but not specifically to the site of disease? Are these drugs affecting non-target tissues? Drug delivery to precise structures of the eye is a puzzler for the ages. Traditional routes of delivery, namely topical eye drops and intravitreal injections, are the current gold standards used for treating most ophthalmic diseases. Topical eye drops result in low bioavailability within the anterior chamber and negligible penetration beyond, meaning they are highly limited to any role in the management of posterior segment diseases. Intravitreal injections have revolutionized the treatment of retinal disease by allowing the vitreous to serve as a natural depot, slowly releasing drug. Again, great news, however, isotropic diffusion of drug to non-target regions and tissues can lead to undesirable consequences. In addition, the eye has unique barriers: An intact blood-retinal barrier can impede the transport of drugs from the vitreous

The suprachoroidal space is an attractive target…like, enough to lure a kid into the middle of the desert with a tie on.

to the choroid and retinal pigment epithelium, which may be a beneficial target for early treatment. Considering what we know and the challenges of current drug delivery in treating patients with posterior disease, the suprachoroidal space (SCS) has been proposed as a potentially attractive site for drug delivery. Where is the SCS? The SCS is the space between the sclera and choroid that traverses the circumference of the posterior segment of the eye. Imagine drug delivery directly to the posterior segment, targeting the

choroid, retinal pigment epithelium and retina with high bioavailability, while limiting drug contact to non-target regions . . . attractive indeed! Bryce Chiang, Jae Hwan Jung and Mark R. Prausnitz from the Georgia Institute of Technology recently published a comprehensive review of drug delivery strategies within the SCS. They also explored current and potential clinical indications and the safety and efficacy of the approach. The manuscript, “The suprachoroidal space as a route of administration to the

osterior Segment “ Drug delivery to the posterior segment is often done from the inside out – that is, from an intravitreal injection outward to the retina, RPE and choroid, but also to other parts of the eye like the lens and anterior segment. Drug delivery to the suprachoroidal space localizes drug between the sclera and choroid, from which the drug travels from the outside into the choroid, RPE and retina, with much less exposure to other parts of the eye.” – Dr. Mark Prausnitz

posterior segment of the eye,” appeared online on March 8, 2018 in Advanced Drug Delivery Reviews. The authors report the anatomy and physiology of the SCS, methods of access and drug kinetics. The paper provides evidence as to how the proximity of the SCS to the choroid has the potential to optimize drug delivery for posterior segment diseases because high bioavailability within the choroid (and potentially the retina) can be achieved. This technique may allow for a lower drug dose to attain comparable efficacy to

traditional routes of administration. The compartmentalization of the SCS also limits drug exposure to non-diseased tissues, with the expectation of a more favorable side effect profile. Dr. Igor Kozak, a clinical lead at the Moorfields Eye Hospital Centre in Abu Dhabi, who has a particular research interest in retinal pharmacology and drug delivery systems, comments: “The authors present an excellent review on anatomy and physiology of suprachoroidal space of the eye as well as pharmacology and clinical application of drug delivery into this compartment.” “The report updates us on clinical trials with agents administered to suprachodoidal space and diseases to be potentially treated in this fashion,” he added. “Drug delivery to the posterior segment is often done from the inside out – that is, from an intravitreal injection outward to the retina, RPE and choroid, but also to other parts of the eye like the lens and anterior segment. Drug delivery to the suprachoroidal space localizes

drug between the sclera and choroid, from which the drug travels from the outside into the choroid, RPE and retina, with much less exposure to other parts of the eye,” explained Dr. Mark Prausnitz, study author. The paper explores accessing the SCS ab interno surgical technique, by sclerotomy with subsequent microcannulation, or by microneedle injection to the SCS. While access to the SCS by sclerotomy and catheterization has been FDA-cleared, it is a surgical intervention that is not in clinical use. Dr. Manish Nagpal, a vitreoretinal consultant at the Retina Foundation in Ahmedabad, India, agrees: “Theoretically, the suprachoroidal space seems to be ideal for injecting various drugs as the absorption would be enhanced.” He does, however, note the challenges of SCS drug delivery: “So far, the challenge has been to find a delivery which can be safely administered as an in-office procedure, by any retina specialist instead of only being given in a specialized setting.”

POSTERIOR SEGMENT DRUG DELIVERY SYSTEM

In addition to a thorough review of the existing literature, Dr. Prausnitz and his team at Clearside Biomedical have first-hand experience with drug delivery into the SCS. Dr. Prausnitz explains: “While surgical techniques have been used to access the suprachoroidal space, the use of a microneedle makes suprachoroidal injections simple and reliable in the hands of a trained ophthalmologist. With a successful phase III clinical trial recently completed and two more phase III clinical trials underway at Clearside Biomedical, there could be products available to doctors and patients in the near future for delivery of steroids and other compounds into the suprachoroidal space that optimizes drug efficacy and minimizes side effects by targeting drugs to the choroid and adjacent RPE and retina.” Dr. Kozak will be carefully watching for the upcoming results of the new surgical techniques to access the SCS, noting of the paper: “Of particular interest is microneedle injection system designed to safely deliver medicines into this virtual space. The reader is informed that several important advancements have taken place to investigate this therapeutic approach which we expect to become a popular therapeutic armamentarium for a myriad of ocular diseases.” On the other hand, Dr. Nagpal has been watching this proposed change to drug delivery evolve, noting: “Various cannulas and needles in the past have been devised but require a lot of skill and technical expertise to safely insert in the right space and hence, this area has never become widely popular.” “The concept of microneedle theoretically seems like a good solution and if it can be effectively and safely

“

The concept of microneedle theoretically seems like a good solution and if it can be effectively and safely replicated in an office procedure setting, it may change the way we deliver drugs for various pathologies.” – Dr. Manish Nagpal

replicated in an office procedure setting, it may change the way we deliver drugs for various pathologies,” he added. This paper demonstrates that the SCS offers a novel route of administration to the posterior segment of the eye and provides great promise for

improved drug targeting to sites of action in sclera, choroid and RPE. Microneedle injection into the SCS is receiving significant attention and is undergoing phase III clinical trials and optimized drug delivery strategies and formulations are the subject of ongoing research.

About the Contributing Doctors Mark Prausnitz, PhD is Regents’ Professor and J. Erskine Love, Jr. Chair of Chemical and Biomolecular Engineering at the Georgia Institute of Technology. He earned a BS degree from Stanford University and PhD degree from MIT, both in chemical engineering. Dr. Prausnitz and colleagues carry out research on biophysical methods of drug delivery using microneedles, lasers, ionic liquids and other microdevices for ocular, transdermal and intracellular delivery of drugs and vaccines. Dr. Prausnitz teaches an introductory course on engineering calculations, as well as two advanced courses on pharmaceuticals. He has published more than 250 journal articles and has co-founded five start-up companies including Clearside Biomedical and Micron Biomedical. [Email: prausnitz@gatech.edu] Igor Kozak, MD. PhD, MSc is a vitreoretinal surgeon and a retina and ocular imaging specialist who specializes in introducing the newest technologies into clinical practice. He is a graduate of P.J. Safarik University in Kosice, Slovak Republic and has completed both vitreoretinal and uveitis fellowships at the University of California, San Diego (UCSD). He also holds a master’s degree in clinical research from UCSD. He is currently a clinical lead at the Moorfields Eye Hospital Centre in Abu Dhabi, United Arab Emirates. His clinical interests include age-related macular degeneration, diabetic and hypertensive retinopathy, uveitis, and vitreoretinal surgery. In his research, Dr. Kozak focuses on retinal diagnostic imaging and image analysis, retinal pharmacology and drug delivery systems. [Email: igor.kozak@moorfields.ae] Manish Nagpal, MS, DO, FRCS (UK), is a vitreoretinal consultant at the Retina Foundation in Ahmedabad, India. He has published numerous journal articles and frequently serves as a reviewer and retina section editor for several publications. Dr. Nagpal has been recognized for his development and presentation of surgical videos and educating the ophthalmic community of advancements in information technology within the field. [Email: drmanishnagpal@yahoo.com]

POSTERIOR SEGMENT PCV MANAGEMENT

Extending Horizons in the Management of nAMD and PCV

Seeing yourself rocking: A great advantage of preserved vision in older adults

by Khor Hui Min

mong older adults, age-related macular degeneration (AMD) is one of the common causes of acute vision loss. Neovascular AMD (nAMD) is an advanced stage of the condition, which is responsible for the most acute vision loss. Meanwhile, polypoidal choroidal vasculopathy (PCV) primarily affects pigmented individuals. Currently, studies have demonstrated that the anti-VEGF therapies used for AMD may help improve vision in patients with PCV. The medical retina symposium during the 33rd Asia-Pacific Academy of Ophthalmology Congress (APAO 2018) in Hong Kong, on extending horizons in the management of nAMD and PCV was chaired by Dr. Chan Wai Man from Hong Kong University. The symposium began with a presentation on the management of PCV, with a special focus on the PLANET study, by Prof. Wong Tien Yin from the Singapore National Eye Center. According to Dr. Chan, PCV affects people of all ethnicities, but is more prevalent in the Asian community. Among patients with nAMD diagnosed

with PCV, high percentages are Japanese (23%-55%) and Taiwanese (49%). Aflibercept monotherapy results in good outcomes across multiple PCV studies. The objective of the PLANET study was to determine the efficacy and safety of aflibercept monotherapy vs. aflibercept with rescue photodynamic therapy (PDT) in subjects diagnosed with PCV, and also to determine whether aflibercept monotherapy is non-inferior to aflibercept with rescue PDT based on best corrected visual acuity (BCVA) in subjects diagnosed with PCV. It was a randomized, doublemasked, sham-controlled, multicenter Phase IIIb/IV clinical trial conducted across 62 sites. The study concluded that aflibercept monotherapy leads to favorable vision gains and high rates of polyp inactivity. Two-year data from the study demonstrated that aflibercept monotherapy is non-inferior to aflibercept + active rescue PDT. Then Dr. Masahito Ohji from Shiga University of Medical Science in Japan spoke on treatment approach in nAMD, with a special emphasis on the ALTAIR Study. He elaborated on the anti-VEGF therapy for nAMD, including fixed

injections (monthly or bimonthly), pro re nata (PRN) (as needed), and treat and extend (T&E). The ALTAIR Study is a randomized, open-label Phase IV study evaluating the efficacy and safety of repeated doses of aflibercept with variable treatment intervals in patients with nAMD, performed at 40 sites in Japan. The primary objective of the study was to assess the efficacy of aflibercept with two different T&E dosing regimens for nAMD in Japan. Meanwhile, the secondary objective was to assess the safety of aflibercept with two different T&E dosing regimens for nAMD in Japan for up to two years. Dr. Won Li Kee from Seoul St. Mary’s Hospital, the Catholic University of Korea, presented on the management of PCV – a clinician’s perspective. He found that aflibercept monotherapy results in good outcomes across multiple PCV studies, and antiVEGF monotherapy has advantages over the anti-VEGF + PDT combination in the treatment of PCV. Anti-VEGF monotherapy avoids potential side effects associated with long-term PDT treatment. Over two years in the PLANET study, patients achieved vision gains of approximately 10 letters, despite 83% not requiring PDT. Moreover, drug-induced complete polyp regression and polyp inactivation is achievable. In his summary, the chairperson of the symposium, Dr. Chan Wai Man, discussed two recent reviews on the treatment of PCV and nAMD relevant to the Asia-Pacific region. He also spoke about extending the horizons in the management of nAMD and PCV. Editor’s Note: A version of this article first appeared at the APAO 2018 Show Daily Issue 3, the official conference news of APAO 2018 (Hong Kong) published by PIE Magazine (www. piemagazine.org).

POSTERIOR SEGMENT DIAGNOSING CMV RETINITIS Diagnosing Cytomegalovirus Retinitis as Part of a Multisystem Disorder

A Look at

Dyskeratosis Congenita

by Joanna Lee

“For most diagnoses all that is needed is an ounce of knowledge, an ounce of intelligence and a pound of thoroughness.”

his Arabic proverb found in the Lancet (1951) couldn’t be truer for a team of researchers from the Jawaharlal Institute of Postgraduate Medical Education and Research in Puducherry, India, who discovered with thorough investigations how a HIVrelated eye condition presented as a part of a multisystem disorder instead. Cytomegalovirus (CMV) retinitis is an opportunistic infection most commonly found in patients with disorders which affect the immune system, namely HIV, or blood disorders like leukemia/lymphoma, or who have undergone organ transplantations. Alarm bells rang for the study’s author, Dr. Swapnil Parchand, when a 45-year-old patient presented with CMV but was confirmed to be without HIV. This prompted him to investigate the patient through a series of tests. Together with his co-author, pathologist Dr. Adarsh Barwad, Dr. Parchand unfolded their investigations in a study report. The patient was already diagnosed with viral retinitis but he wasn’t responding to the intravenous acyclovir treatment given before coming to see Dr. Parchand. He had been suffering from a decrease in left eye (LE) vision for the past 3 months. HIV was already ruled out by his referring ophthalmologist. The right eye (RE) had a best corrected visual acuity at 6/6 during the time he presented at the hospital while the LE had a cellular reaction 2+ with posterior subcapsular cataract.

For those who like cheating on tests, the correct answer involving this case study is D and C, or DC (dyskeratoris congenita).

The signs of CMV retinitis were more apparent through a LE fundoscopy which showed vitritis, optic disc pallor, retinitis patches at posterior pole, and midperiphery along the retinal vessels related with retinal hemorrhages and inflammatory vascular sheathing. A vitreous biopsy done on the LE also showed CMV retinitis. A check into the patient’s history revealed that he had lost significant weight in the past 6 months. He also had “ash-leaf spots,” or hypopigmented macules with reticular hyperpigmentation, all over his torso and upper and lower limbs – the first of the triad of symptoms for dyskeratoris congenita (DC). His nails were also suffering from dystrophy and his lip and cheek linings had the presence of oral leukoplakia. These three symptoms pointed towards DC. Subsequently, he underwent a full hemogram. His blood count, peripheral

smear, liver and renal function tests were within normal limits. Through flow cytometry and fluorescence in situ hybridization, they discovered the telomerase length in his peripheral white blood cells was below the first percentile, confirming the patient had DC. They had already ruled out other diseases like HIV, hepatitis B and hepatitis C and venereal disease. Chest imaging showed no issues with pulmonary functions. They’d also ruled out nasopharyngeal and laryngeal carcinoma. However, the doctors discovered asymmetric thickening of the pylorus area in his abdomen through contrastenhanced computer tomography, along with multiple polyps in the stomach after upper GI endoscopy with thickening antropyloric walls. Subsequent biopsy from the lesion showed adenocarcinoma at an early stage, the study reported.

DC patients have cells that have defective telomere maintenance. Telomere maintenance has its importance in indicating a person’s disposition towards aging and cancer. These short telomeres obstruct the process of optimal cell replication to the extent of compromising cell integrity. Over a period of time, this compromised replication of cells will lead to stem cell exhaustion and failure in tissues. Patients with this disorder face more risks with immunological and hematological disruptions, fibrosis of the lungs, malignancies and eventually, infections. The diagnosis usually banks upon the triad of symptoms found (skin hyperpigmentation, nail dystrophy and leukoplakia) along with bone marrow failure. Physicians must also take into account the multisystem characteristics of the disease that encompasses developmental delay, pulmonary disease, periodontal disease, epiphora, premature hair graying or loss (seen in this case study’s patient), and development of malignant lesions. The researchers recommended to observe at least two of the four major features of DC and that at least two of the multisystem features should be present in order to make a correct clinical diagnosis. Differential diagnosis of dermatologic manifestations in DC cases, which may be similar to other skin issues, should be noted due to a wide spectrum of diseases. This applies to hematological disorders in DC cases as well. It is interesting to note that the patient in the case study had normal blood counts and peripheral blood smear, but he had low CD4 percentage in his white blood cells with a compromised CD4/CD8 ratio. Nearly 70% of DC patients diagnosed as malignant die before the age of 30. Thus, it was remarkable that

“

In India, we’re seeing more vitreal retinitis in young, healthy, immune-competent patients. Some of them develop acute retinal necrosis. So, whenever we see them develop CMV retinitis, we should investigate to rule out various viral infections and possible multisystem disorders.” – Dr. Alay Banker

this patient was undiagnosed until the age of 45, when his diagnosis for CMV retinitis uncovered the core multisystem disorders. Eventually, the patient went through a laparoscopic D2 subtotal gastrectomy. They also treated his CMV retinitis with oral valganciclovir. His retinitis lesion healed, albeit with scarring in the left eye. The right eye remained unchanged. The patient had follow-ups with a gastroenterologist, hematologist and ophthalmologist, and his progress was reported to be fine after a year of follow-ups. Retina specialist Dr. Alay Banker,

director of Banker’s Retina Clinic and Laser Centre in Ahmedabad, India related to this case study with his own experience: “Interestingly, I’ve seen healthy patients who have received intravitreal steroid injections or implants develop localized immunosuppression which gives way for opportunistic infections to develop.” He also highlighted a recent retinitis related observation. “In India, we’re seeing more vitreal retinitis in young, healthy, immune-competent patients. Some of them develop acute retinal necrosis. So, whenever we see them develop CMV retinitis, we should investigate to rule out various viral infections and possible multisystem disorders,” said Dr. Banker. He also advised doctors treating CMV retinitis patients with oral antiCMV retinitis medication to supplement their treatment with intravitreal ganciclovir or cidofovir injections as intravitreal injections are direct and could supplement the oral medication’s effectiveness. Editor’s Note: Dr. Banker was generous enough to contribute on this story, but he was not a participant of the mentioned study.

Reference:

Parchand S, Barwad A. Cytomegalovirus Retinitis as a Presenting Feature of Multisystem Disorder: Dyskeratosis Congenita. Middle East Afr J Ophthalmol. 2017;24(4):219-221.

About the Contributing Doctor Dr. Alay Banker is the director of Banker’s Retina Clinic and Laser Centre in Ahmedabad, India and his practice has served the city since 2007. He started off his career as a clinical instructor and fellow at the Department of Diseases of Retina and Vitreous, Uvea and Inflammation of Eye at University of California, San Diego, USA. He was the first Indian to receive the “International Scholar Award” from American Academy of Ophthalmology in 2010 and also the youngest Indian to receive the Achievement Award by the American Academy of Ophthalmology (2006). His contributions towards his medical peers and community services has garnered also him the Senior Achievement Award from American Academy of Ophthalmology (2013) and the Dr. Piyush Patel Award for Service to Society and Mankind from Ahmedabad Medical Association (2013). He is the senior founding editor of the Retina Image Bank (ASRS 2012) and has presented at over 250 international and national conferences with over 40 papers published in peer-reviewed medical journals and five book chapters in international book publications. [Email: alay.banker@gmail.com]

POSTERIOR SEGMENT DIABETIC RETINOPATHY

Diabetic Retinopathy Awareness and

Associations with Multiple Comorbidities

Insights from the DIAMOND Study

1 out of 39 people are blind due to diabetic retinopathy, while 39 out of 39 people are blinded while putting their hands over their eyes.

by Khor Hui Min

iabetic retinopathy (DR) is the main cause of visual impairment in working-age adults and every diabetic is a potential candidate for the condition. Thus, DR is recognized as one of the most important causes for visual impairment and blindness. Globally, studies have shown that the most affected are working adults, and therefore DR also has a socio-economic impact. Data reveals that one out of 39

blind people are blind due to DR, and 1 out of 52 visually impaired people had visual impairment due to DR. As the global prevalence of diabetes increases, with India being the capital for diabetes, among the number of people with diabetes-related complications, nearly one-third of them are likely to develop DR. Blindness due to cataract is curable, but blindness because of DR is preventable. Selfreported studies in India have shown the prevalence of DR to be around 20%.

“I felt that the prevalence could be much higher given the lack of knowledge how diabetes affects the eye, and also that majority of patients visit an ophthalmologist only when the vision is affected,” said Dr. Kiran Shah, director of the Diabetes and Thyroid Care Centre in Mumbai, India. “They only see an ophthalmologist when they are already in advanced stages of DR,” he added. Dr. Kiran Shah, Dr. Alka Gandhi and Prof. Dr. Sundaram Natarajan highlighted the insights from the DIAMOND Study, a study on DR awareness and associations with multiple comorbidities, in their recent publication in the Jan-Feb 2018 issue of the Indian Journal of Endocrinology and Metabolism. This was a singlecenter, retrospective study conducted over 2 years in 6,000 patients over 40-years-old with type 2 diabetes mellitus (T2DM). The researchers analyzed awareness and prevalence of DR and association of DR with identified risk factors. The study found that almost 63% of the patients were unaware that diabetes affects the retina. Moreover, 68% of patients were unaware whether DR can be prevented or treated. Dilated fundus examination was not recommended to 73% of patients by their diabetes care provider, while the majority of patients (92%) had undergone first dilated fundus examination only when their vision was affected. When questioned why they did not seek a retinal examination, 86% reported “I can see everything” as the answer.

Data reveals that one out of 39 blind people are blind due to Diabetic Retinopathy (DR), and 1 out of 52 visually impaired people had visual impairment due to DR.

Overall, 52.02% of smokers were reported to suffer from DR. Smokers are more likely to have relatively large changes in the venular caliber, arterial stiffness and the associated free radicals can cause damage to the vascular endothelium. Also, smoking causes the release of catecholamines, increases heart rate and blood pressure. These adverse hemodynamic are changes associated with progression of atherosclerosis. “The harmful effect of smoking does not depend on whether patients smoke cigarettes, beedis, or hookah, but is more dependent on the amount smoked. There are studies which have shown smoking may accelerate the development of, or worsen DR,” said Dr. Shah. “In our study, the prevalence of DR was significantly higher amongst the male smokers as compared to nonsmokers,” he shared. There is a strong relationship between microvascular and macrovasular complications and the relationship is in continuum and not distinct. In the study, a strong association was observed between hypertension and DR, with 42.6% of patients having coexistence of hypertension and DR. Also, a high proportion of patients (49.11%) had coexistence of cardiac morbidity and DR. There is a strong relationship between DR and cardiovascular diseases (CVD)

and presence of DR is associated with new CVD events independent of glycemic levels and CVD risk factors. DR status may be used as a guide for treatment decision making in diabetics needing revascularization, such as percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG). Meanwhile, patients having diabetic kidney disease (DKD) also reported DR. Almost all diabetics with DKD have DR, but all diabetics with DR may not have DKD.

In addition, 43.85% of patients with microalbuminuria had two times more risk of developing proliferative DR. Diabetics with microalbuminuria were around two times as likely to have DR as those without microalbuminuria, and this risk is almost six times in the presence of macroalbuminuria. The high prevalence and significantly high unawareness for DR in T2DM patients must be addressed. The researchers were unanimous that all diabetics must be screened or undergo dilated fundus examination for DR. Education and creating awareness for DR should not only be for the patients but also involve the treating primary care physicians, diabetologists, endocrinologists and every doctor involved in the treatment of diabetes. This is essential to prevent visual impairment or blindness associated with DR. Furthermore, the modifiable risk factors associated with DR should be looked for and treated intensively to prevent development and progression of DR.

Reference:

Kiran S, Alka G, Natarajan S. Diabetic Retinopathy Awareness and Associations with Multiple Comorbidities: Insights from DIAMOND Study. Indian J Endocrinol Metab. 2018; 22(1):30-35.

About the Contributing Doctors Dr. Kiran Shah is a diabetologist at the Diabetes & Thyroid Care Centre, Aditya Jyot Eye Hospital Pvt Ltd, Conwest Jain Hospital, Masina Hospital, Nagpada Police Hospital, and Ranawat Health Care. He is also the Director of Diabetes & Thyroid Care Centre. Moreover, he is also a postgraduate lecturer for diabetology courses conducted through the College of Physicians & Surgeons of Mumbai. [Email: drkiranshh@gmail.com]

Prof. Dr. S. Natarajan is a multi-award-winning ophthalmologist who has performed over 27,000 exclusive vitreo-retinal surgeries in the past 33 years, and trained 64 vitreo-retinal surgeons across the globe. He is visiting professor in the Marmoindes University (Argentina), University of Lugano (Switzerland), Balaji Medical College (Chennai, India), and Saveetha Medical University (Chennai, India). [Email: prof.drsn@adityajyoteyehospital.org]

COVER STORY

on Insights into the Ties that

Pie-Land

Connect the Segments

by Brooke Herron and Gloria D. Gamat

If you look outside your window you will see Posterior Island and Mount Retinal Hemorrhage.

his is your captain speaking. Kindly look out your passenger-side window, and let me be the first to welcome you to PIE-LAND . . . a remote retinal island, discovered originally by the staff of PIE Magazine. In about 20 minutes, we’ll be doing a hard landing on PIE-LAND with surgical precision. Today’s weather includes a sprinkling of the anterior segment, and at the current time it’s unclear on how interconnected it remains to the posterior segment. Passengers not on connecting PIE-AIR flights, if this is your final destination, be advised: watch – but do not touch – the

mysterious retina creatures on PIE-LAND at ARVO Booth #1631. Before disembarking, we asked ophthalmologists to consider if the posterior segment is an island to itself . . . or if it interacts with the anterior segment, the brain, (and perhaps other parts of the body) too? As we descend, and on behalf of eyeballs everywhere, we thank the doctors who answered these questions and look forward to seeing their input in the flight report below.

It’s an ophthalmic tale as old as time: The posterior is the posterior and the anterior is the anterior, and never the twain shall meet – except when they do. On occasion, anterior issues overflow into the posterior and vice versa. So, what’s an ophthalmologist trained in a specific subspecialty to do? Are the segments totally separate (like the retinas on remote PIE-LAND), or are they interconnected? To help explain the connection between the segments, vitreoretinal ophthalmologist and surgeon Dr. Andrew Chang, provided the following analogy: “The eye is a house and there are different rooms in the house which serve different purposes. Each room shares the same materials in construction – therefore, disease processes that affect the material will affect multiple rooms. Surgery or renovating one room may result in changes in an adjacent room. Each room is interconnected with electrical, plumbing and data cabling.” With that analogy it appears that the two segments are both interconnected and separate. Beyond being two parts of the same organ, how are they connected? And in the same vein, is it just physiology that separates them or is it something else? Let’s begin with the physiology. The combination of the segments allows for the detection of light, but the visual pathway is not limited to just the eye – it’s only one part. “The eye/globe

is an end-organ that detects light. The electrical impulses are modulated and interpreted with complex post-processing by the brain. This is perceived as vision,” explained Dr. Chang. Further, there are similar anatomic “materials” in the front and back of the eye. “Embryologic development of the eye results in pigmented layers in the anterior and posterior segments, like the uveal tract which is affected by the same disease processes,” he said. In addition, Dr. Chang notes that the same disease processes such as inflammation, trauma, neoplastic, inherited and metabolic disorders affect different parts of the eye. “These may produce different manifestations depending on the part of the eye affected and they may impact each other.” He cites several examples of this: trauma in the anterior segment causes bleeding and damage that may affect the posterior segment; glaucoma may cause damage to the fluid drainage channels which could then affect the optic nerve; and uveitis produces different manifestations depending on which part of the uveal tract is involved. In addition, the surgeries themselves can create problems in the opposite segment. Surgery originating in the anterior can cause posterior issues like dislocated lens, endophthalmitis and macular swelling. Meanwhile, posterior surgeries can cause anterior problems like cataract and glaucoma.

Dr. Andrew Chang, MBBS (Hons), PhD, FRANZCO, FRACS is a vitreoretinal ophthalmologist and surgeon. He is the medical director of the Sydney Retina Clinic, head of the retinal unit and consultant vitreoretinal surgeon at Sydney Eye Hospital (Australia), and clinical associate professor at University of Sydney.

“

Anatomy between the segments is different – and this gives rise to different issues, as pathologic diseases manifest uniquely between the front and back. Symptoms relating to problems in the segments differ. Examination findings are different. Different diagnostic tools are used to examine the anatomic structures. Surgery is based on anatomy and therefore approaches must be different.” – Dr. Andrew Chang

However, though some disorders and surgical techniques create a bridge connecting the segments, they still remain in decidedly different “rooms” in the “house.” Dr. Chang explains some the differences. “Anatomy between the segments is different – and this gives rise to different issues, as pathologic diseases manifest uniquely between the front and back. Symptoms relating to problems in the segments differ. Examination findings are different. Different diagnostic tools are used to examine the anatomic structures. Surgery is based on anatomy and therefore approaches must be different.” He notes one caveat to all these differences: “Medical treatments such as anti-VEGF injections or steroids address similar pathologic process in different parts of the eye.” Are these differences big enough to keep the posterior segment on an island all its own? Or are we getting closer to building a bridge to connect the segments?

COVER STORY

Dr. Manish Nagpal, MBBS, MS (Ophthalmology), FRCS( Edinburgh, UK), is a vitreoretinal consultant at the Retina Foundation in Ahmedabad, Gujarat, India. He has been recognized for his development and presentation of surgical videos and educating the ophthalmic community of advancements in information technology within the field.

Connecting the segments through sub-specialties Perhaps one way to bridge the gap is to connect the sub-specialties. Dr. Manish Nagpal acknowledges that while the sub-specialties deal with specifics, there can be an overlap of sorts regardless if it’s a retinal, corneal, cataract or neurological issue. “When we treat patients for various retinal pathologies, over time, some of these patients develop glaucoma, cataracts or corneal problems as a sequalae of various intravitreal injections or surgical procedures,” he said. “Now, the same eye needs the expertise of two or three sub-specialties for treatment. If a child has retinopathy of prematurity (ROP), more often it is treated by a retinal surgeon rather that a pediatric ophthalmologist – even though it may have been diagnosed by the latter.” He adds that there are also neurological conditions that are diagnosed by retina specialists. For example: “On examination it’s noted that there’s a disk oedema or retrobulbar neuritis – and sometimes a tumor is detected when we send the patient for an MRI.” Dr. Nagpal says that the specialties are constantly overlapping – and that’s best for the patient, otherwise, the patient may not receive the best possible treatment.

This talk of sub-specialization brings us to an important point – the training and practice of ophthalmology was traditionally based in subspecialization, which according to Dr. Augustinus Laude, may be defined by anatomy, like anterior and vitreoretina. He says there is also a related issue regarding the acceptance amongst the professionals and licensing privileges (and medical practice insurance coverage) of doing certain surgical procedures (i.e. pars-plana vitrectomy and laser refractive surgery). However, as today’s technology creates innovative breakthroughs, it is possible that this “school of thought” – or training and regulation processes – can change as well. According to Dr. Laude, he sees the impact of emergent technology disrupting this model. “For example, the introduction of MIGS surgery, specifically for models

such as the iSTENT (Glaukos), which is designed to be done during cataract surgery without the need for postoperative bleb management, may encourage non-glaucoma specialists to include them in the armamentarium for management of patients with cataract and glaucoma or ocular hypertension,” he said. “In addition, advances in femtosecond laser assisted cataract surgery may reduce the need to refer the cases on to surgeons who are fellowship-trained in managing complex cataracts.”

Is computer-assisted diagnosis the wave of the future? Dr. Laude notes that advances in computer algorithms to OCT image analysis (with automated segmentation) greatly help with interpretation and diagnosis. “We anticipate that further advances of OCT-angiography may make this non-invasive imaging tool more accessible for ophthalmologists who are not fellowship-trained in medical retina or vitreoretina to diagnose and manage patients with maculopathies.” And while fundus imaging is an ideal way to screen eyes (it’s simple, non-invasive and cost-effective), it’s also time-consuming and challenging to manually evaluate the images.

Dr. Augustinus Laude, MBChB, MMed (Ophth), MRCSEd (Ophth) is an adjunct associate professor and a senior consultant in the National Healthcare Group Eye Institute at Tan Tock Seng Hospital (Singapore) with clinical and research interests in cataracts, macula diseases and low vision.

However, new computerassisted technology has recently been researched and proposed. These advances will not only aid in diagnosis, but their benefits will be felt beyond the ophthalmic field. Dr. Laude explains: “Artificial intelligence (AI) and computer-aided diagnosis (CAD) is being actively explored for fundus image processing to be used by nonophthalmologists in screening for eye diseases early for timely intervention and management.” This means that general practitioners could potentially diagnose an ophthalmic condition – or an ophthalmologist specializing in the anterior could diagnose a condition in the posterior. This is key as diseases like age-related macular degeneration (AMD), diabetic retinopathy (DR), and glaucoma may lead to irreversible vision loss if left untreated. Researchers expect these new tools to especially provide assistance to doctors in developing countries and rural areas, where patients may not have access to specialized care. Several studies have analyzed the results of AI and CAD in patient diagnosis with favorable results. A recent study conducted by Dr. Laude and colleagues proposed an original approach to automated eye screening. The authors state: “It is an innovative approach, and the first work to the best of our knowledge proposed to assist the ophthalmologists in making an accurate diagnosis of the various eye conditions by providing an adjunct tool.” They proposed an objective and novel algorithm using the pyramid histogram of visual words (PHOW) and Fisher vectors for the classification of fundus images into their respective eye conditions (normal, AMD, DR and glaucoma). The proposed algorithm extracts features which are represented as words. These features are built and encoded into a Fisher vector for

classification using random forest classifier. This proposed algorithm is validated with both blindfold and ten-fold cross-validation techniques. An accuracy of 90.06% is achieved with the blindfold method, and highest accuracy of 96.79% is obtained with ten-fold cross-validation.1 These results led the authors to conclude: “The highest classification performance of our system shows the potential of deploying it in polyclinics to assist healthcare professionals in their initial diagnosis of the eye. Our developed system can reduce the workload of ophthalmologists significantly.” “Our proposed CAD system can be placed in third world countries and remote villages where the healthcare services are limited. Additionally, the proposed CAD eye system can be used to conduct a mass eye screening session for the elderly as an early detection of any eye abnormality,” stated the authors. “The performance

of the system can be further improved by taking more diverse images in each class. Also, our proposed technique can be used to detect other eye diseases like diabetes maculopathy, floaters, retinal detachment and macular hole.” Should these developments be approved for clinical use, they could certainly revolutionize the way patients are diagnosed and treated. In addition, their use would allow a general doctor or ophthalmologist to screen patients and then refer as needed to a practitioner in the necessary subspecialty – potentially saving sight for those in the beginning stages of disease. From this, we can extrapolate, that technological advances like these will almost certainly help to connect the segments, the sub-specialties, and even ophthalmologists to primary care physicians.

Reference:

Koh JEW, Ng EYK, Bhandary SV, et al. Automated retinal health diagnosis using pyramid histogram of visual words and Fisher vector techniques. Comput Biol Med. 2018;92:204-209.

Ahem. This is your captain again. We have landed on PIE-LAND. Our radar continues to show a smattering of blips on the screen that both connect and separate the posterior from the anterior and brain. Our current technology indicates that upgrades will be coming soon, which will allow your flight crew to better serve you. Please use caution when opening the overhead bins, as ideas may have shifted during the flight. We hope you have enjoyed this PIEAIR Flight, and again, let us be the first to welcome you to PIE-LAND at ARVO Booth #1631.

Captain PIE, of PIE Air

INNOVATION ROBOTICS IN RVC

Robot-assisted Retinal Vein Cannulation

for by Collins Santhanasamy

etinal vein occlusion (RVO) is one of the most common causes of retinal vascular disease, with an estimated worldwide prevalence of 16 million patients globally (0.5%). Occlusion of the retinal vein leads to a decrease in retinal circulation outflow which may result in ischemia, macular edema, retinal damage and ultimately blindness. Although lasers have successfully been used since the 1970s to treat these sequelae of vein occlusions, anti-VEGF agents are increasingly being used as first-line treatment for vision loss for this disorder. Central and branch retinal vein occlusions have

RVO

different pathophysiologic mechanisms which must be addressed separately. Vitreoretinal surgeon, Prof. Peter Stalmans, MD, PhD, from the Department of Ophthalmology, UZ Leuven, Belgium, presented on the topic of â&#x20AC;&#x153;Robot-Assisted Retinal Vein Cannulation for Retinal Vein Occlusionâ&#x20AC;? during the APVRS 2017 meeting held in Kuala Lumpur, Malaysia. Retinal vein cannulation (RVC) is a difficult procedure performed for drug delivery into small retinal veins. The currently available glass cannulas used in this procedure are hard to visualize and fragile, making the procedure a challenging one, even for the most experienced of surgeons. Until now, robotics have never been used in RVC.

Application of Robotics in RVC Prof. Stalmans and the Department of Mechanical Engineering at KU Leuven began to explore possible options for the application of robotics in RVC as early as 2010. Several robotic prototypes were developed and tested. A major achievement of this process was the development of an ultrathin aluminum coated glass microneedle with a 30-micron outer diameter for the delivery of a thrombolytic agent (ocriplasmin) into the retinal vein. Pre-clinical, in vivo results demonstrated the technical capabilities of performing a prolonged retinal vein cannulation using robot-assisted RVC with a 73.3% complete success rate,

and no technical failures with the device when performed on 9 sets of pig’s eyes.* In 5 of the eyes, a second cannulation at the optic disc border was performed which resulted in an average cannulation time of 361.8 (± 138.5) seconds. Dr. Stalmans performed the first ever robot-assisted RVC in a human patient with central retinal vein occlusion (CRVO) in January 2017. With the aid of a robotic co-pilot, up to 5 mg of ocriplasmin (Jetrea, ThromboGenics, NJ, USA) was infused over a maximum of 10 minutes into the occluded vein using a needle measuring 0.03 mm in diameter. This was part of the Phase 1 trials which had a total of 4 patients. Results of the phase 1 trials investigating the feasibility and safety of a robot-assisted RVC in these 4 patients with CRVO were recently published which demonstrated the technical success in the cannulation of the retinal vein and delivery of ocriplasmin with an average infusion time of 355 seconds per case. CRVO can either take on a mild, nonischemic form or a severe, ischemic form with a much worse visual prognosis. The best predictor of final visual acuity is the vision at presentation with 80% of patients presenting with worse than 20/200 vision unable to achieve improvement. The etiology of this condition is thought to be thrombosis of the central retinal vein posterior to the lamina cribrosa sclerae. Risk factors include uncontrolled diabetes, hypertension and open angle glaucoma. Occasionally, patients with clotting disorders, dysproteinemias and vasculitis can develop CRVOs. Following the inciting event, an average of 16% of all patients develop neovascularization of the iris and/or angle which can cause difficult to manage neovascular glaucoma.

Retinal vein cannulation (RVC) is a difficult procedure performed for drug delivery into small retinal veins. The currently available glass cannulas used in this procedure are hard to visualize and fragile, making the procedure a challenging one, even for the most experienced of surgeons. I got this…

MYNUTIA, a project of the Department of Mechanical Engineering at the KU Leuven created in close collaboration with the KU Leuven Technology Transfer Office, is aiming at commercializing this promising technology by stretching the limits of eye surgery with state-of-the-art robotic technology. With the aid of its surgical robots, eye surgeons can improve the quality of existing therapies and perform previously impossible treatments that have the potential to give millions of visually impaired and blind people a chance to regain their vision.

A Unique Stabilization System In contrast to traditional surgical robots, no joystick is required to operate the robot. This surgical procedure designed by Leuven engineers and clinicians allows the surgeon to work in comanipulation with the robot by holding the instrument as a normal vitreoretinal surgeon would during routine surgery. For maximum safety and intuitiveness, the surgeon retains direct control of the instrument and its motion, guiding it whilst the robot focuses exactly on

what matters most: increasing the surgical precision over ten times by eliminating vibrations and stabilizing the movements. This precision enhancement is obtained by offering stabilization on three different levels: the surgeon’s hand, the patient’s eye and the surgical instrument. Once the needle is successfully positioned in the retinal vein, the robot is locked and both the eye and the needle are automatically held in place. Delivery of desired drug into the vein is then achieved. For the Phase 1b trials in 2018, improvements in visualization with a Rescan 700 microscope (Carl ZEISS Meditec, Jena, Germany) and enhancement of the robotic device which now has improved ergonomics and stability will be tested alongside intraoperative iOCT and angiography.

References:

APVRS 2017 Meeting Presentation by Prof. Peter Stalmans, Department of Ophthalmology, UZ Leuven, Belgium *Willekens K, Gijbels A, Schoevaerdts L, et al. Robot-assisted retinal vein cannulation in an in vivo porcine retinal vein occlusion model. Acta Ophthalmol. 2017;95(3):270-275.

INNOVATION OPHTHALMIC COMPANY

Empowering Vision and Mankind

A Journey

The road less travelled: Where Appasamy headed in 1978

by Ruchi Mahajan Ranga

“W

e dedicate and resolve ourselves to continue our work, which will engulf the common man with easier and affordable access to the best possible vision care services.” That is basically Appasamy’s mission, but there is more to this company than meets the eye. How did it grow from three employees in the late 1970s to 2700+ employees today? What is their secret to success?

Appasamy Associates and Group of Companies (Chennai, Tamil Nadu, India) is a leading name in manufacturing and distribution of wide assortment of ophthalmic equipment, microscopes, lasers, pharmaceuticals, microsurgical instruments, and IOLs. Since its inception in 1978, Appasamy continues to work toward their aim of providing modern equipment and technology that is easily accessible to ophthalmic surgeons and vision care professionals.

In the year of its inception, Appasamy introduced India’s first low-cost cryosurgical instrument for ophthalmology, which was less than 1/10th of the price of its internationally imported counterpart. The company also launched the world’s first non-electric vitrectomy unit in ophthalmology, which has now become a preferred choice for many eminent surgeons across India, rather than the imported units. The company ventured into manufacturing and sale of slit lamps in 1989 and now offers photography and videography models to assist physicians. The company has also been manufacturing and selling single piece IOLs since 1995. Appasamy’s IOL manufacturing unit is not only an ISO 9002-certified facility, but also has been certified by TUV, Germany, since 1998. The company’s Vice Chairman, Mr. R.N. Kasthuri shares: “We started off with just three employees and today we have grown to 2700+ employees with offices in more than 40 cities across India.” With its strong presence across the country, the company’s success lies in its ability to manufacture and sell based on the needs of the patients. Regarding the company’s ability to keep costs low, Mr. Kashuri explains: “We do not have a marketing department. Our company follows a supermarket approach where we make products that have to sell themselves. We stand by our products and offer the promise of reliability and that is why our customer base continues to spread.” He further revealed that Appasamy doesn’t charge the customers for the services but only

for the parts of the products, which ultimately helps to keep the costs of the products very low compared to competitors in India and abroad. The company’s core production staff, which forms a strong foundation to carry out operations effectively, has been with Appasamy for more than 35 years. With clearly defined goals and power to execute operations, the staff at Appasamy acts independently in different spheres. In addition to instrumentation, Appasamy Ocular Devices (AOD), a pharmaceutical division of the company has also recently launched a drug to treat myopia. “In view of the alarming problem of myopia in young children these days, we have introduced a drug called Myopin that helps to treat and control progression of myopia. AOD was the first among Indian pharmaceutical companies to launch this ‘need of the hour’ drug for Indian children on 14th November 2017, to mark Children’s Day ”, shared Sivagnanam Subbiah, general manager for Clinical Research & Promotions at Appasamy. “In the highly gadget-oriented environment these days, most of the children develop myopia due to exposure to screens of televisions or mobile phones, while some inherit it from their parents. The most affected age group is 6 to 13 years, for which this drug would be highly beneficial,” added Mr. Sivagnanam. As myopia in children continues to multiply year after year, Myopin was launched in a very cost-effective manner so that it would be available to patients belonging to all categories of society and ultimately reduce further progression of myopia. Blindness from cataract is another huge problem in the Indian population – and India holds first place in the world regarding cataract surgeries performed every year. With the presence of responsible corporate identities dedicated to social welfare

like Appasamy, 70% of total cataract surgeries in India are performed free-ofcharge. Talking about the company’s goals in the short- and long-term, Mr. Kasthuri mentions: “As we have achieved a noticeable position with respect to our goals in India, we are already on the move to extend our services internationally to parts of world where they are needed the most and people cannot afford to pay heavy pricing.” With this in mind, Appasamy continues to extend its network to ophthalmologists in Africa. When asked about why they chose Africa as their first international market, Mr. Kasthuri replies: “The African market is not a place that many companies like to serve, so we have chosen it to benefit from our services. Our main aim is not to make money, but to help people benefit from our cost-effective products.” Shedding light on the company’s strength and strategy, Mr. Kasthuri shared that they always reinvest their profits in order to upgrade their manufacturing facilities. The products also get upgraded and benefits are passed to customers at a very nominal pricing. Appasamy is proud of its milestones, achievements, and unique mission – which is very well achieved thus far. Editor’s Note: Both Mr. R.N. Kasthuri and Mr. Sivagnanam Subbiah contributed equally to this article.

A multi-awarded company in India, here are some of the awards Appasamy has received throughout the years: • Star Performer Award for Outstanding Contribution to Engineering Exports in the Product Group: EEPC India National Awards for Export Excellence 2008-2009 • Star Performer in 2009-2010: EEPC India National Awards for Export Excellence • Star Performer in 2010-2011: EEPC India National Awards for Export Excellence • Star Performer in 2011-2012: 44th EEPC India National Awards for Export Excellence • Star Performer in 2012-2013: EEPC India National Awards for Export Excellence • Special Trophy for Excellence in Exports of High Technology Products in 2013-2014: EEPC India National Awards for Export Excellence • Star Performer in 2014-2015: EEPC India Southern Regional Awards for Export Excellence • Special Award in 2015 by EEPC India Southern Regional Awards for Export Excellence • Star Performer in 2016 by EEPC India Southern Regional Awards for Export Excellence

About the Contributor Mr. R. N. Kasthuri is the Vice Chairman of Appasamy Associates and Group of Companies and has been with the company since its inception. [Email: rnkasthuri@appasamy.com]

INNOVATION AVRTT@6 COVERAGE

Vitreoretinal Surgery Highlights

from AVRTT@6 Workshop by Olawale Salami

Grapefruit peeling: less complex than ILM peeling. Grapefruit: also tastier than the retina.

Surgical Management of Myopic Maculopathy: To Peel or Not to Peel the ILM? Based on a presentation by Dr. Andrew Chang, Vitreoretinal Ophthalmologist and Surgeon, Medical Director, Sydney Retina Clinic, Consultant Vitreoretinal Surgeon and Head of Unit Sydney Eye Hospital, and Clinical Associate Professor, University of Sydney, Australia

urgical management of myopic maculopathy remains one of the most unpredictable situations faced by vitreoretinal surgeons. In a lecture delivered at the recently held AVRTT@6 workshop in Ahmedabad, India, Dr. Andrew Chang led discussions and provided key insights into current approaches toward addressing the complications of surgery for myopic maculopathy. According to Dr. Chang, the unpredictability of surgical management of myopic maculopathy arises due to several underlying mechanisms. Notably, there is marked inward vitreous traction and retinal arterial stiffening, resulting in failure of retinal stretching and non-compliance of the eye lens. Recent studies have discussed the classification of macular structure and the timing of surgical intervention. Further, Dr. Chang noted that in the early stages of disease characterized by foveoschisis, patients may be asymptomatic

and currently there is no consensus on whether early surgical intervention might prove beneficial. In addition, he highlighted several unanswered questions concerning the surgical approach. These questions surround the safety of ILM peeling, outcomes of foveal sparing techniques and the effectiveness of triamcinolone. Furthermore, more clinical data is needed on the outcomes of the drainage of sub-retinal fluid via peripheral retinotomy or through the hole itself in cases of retinal detachment. Dr. Chang discussed the surgical management of 2 cases of myopic maculopathy. The first case was a 35-yearold female with previous retinal detachment repaired with scleral buckling who presented with progressive worsening of vision and foveal detachment. Vitrectomy was performed and visual landmarks highlighted with triamcinolone. No internal limiting membrane (ILM) peeling was performed to avoid the risk of forming a macular hole. At postoperative day 10, patient was reviewed and the foveal detachment had settled, but patient later presented with an enlarging scotoma. A diagnosis of retinal detachment was made and the large volume of fluid was drained via a peripheral retinotomy. The second case presented by Dr. Chang was that of a 43-year-old woman who presented with poor vision, a posterior staphyloma and foveal detachment. At surgery the fovea was difficult to visualize at the base of the staphyloma and triamcinolone was used (specifically Kenacort). At postoperative day 14, the patient presented with an enlarging scotoma and a diagnosis of macular hole retinal detachment was made. Drainage was performed though the macular hole. A few years later the patient presented again with schisis in the other eye associated with vitreal traction and was managed conservatively. Patient later presented with sudden loss of vision and a macular hole was identified. Intraoperatively, triamcinolone was used to highlight the visual landmarks, and standard ILM peeling and air-fluid exchange were performed. Schisis was resolved fully at postoperative review. During the discussion session that followed, it was concluded that ILM peeling is useful in removing vitreal traction. Dr. Chang concluded that ILM peeling itself might increase the risk of macular hole retinal detachment. â&#x20AC;&#x153;As a safer option, foveal sparing ILM peeling, which avoids macular hole formation should be considered.â&#x20AC;?

The Versatile ILM and Macular Pathology Based on a presentation by Dr. Shobhit Chawla, Medical Director and Chief Vitreoretinal Consultant, Prakash Netra Kendr, Gomtinagar, Lucknow, India

urgical removal of the ILM represents one of the most important advances in vitrectomy in the past 15 years. In a lecture delivered at the recently held AVRTT@6 workshop in Ahmedabad, India, Dr. Shobhit Chawla shed light on recent advances in the understanding of the ILM structure, functionality and its role in macular pathology. The ILM is a 1.2mm thick Periodic acid Schiff-positive structure. It is the boundary that establishes the contact and communication point of two compartments: the retina and vitreous. The sheer strength generated by the movement of the liquified vitreous induces specific inflammatory reactions on the ILM, while expression of contractile proteins leads to cellular transformation into fibroblasts, which induces scar tissue formation. Multiple pathologies can exist proximal and distal to the ILM, such as the posterior hyaloid phase, hyaline traction, partial thickness macular hole, and therefore, peeling the ILM resolves these multiple pathologies. ILM removal is performed to release the pathological influence of the vitreous on the retina, and is useful in restoring the normal anatomical shape of the macula and improving visual acuity. This technique has been utilized in a variety of indications such as diabetic maculopathy, retinal vein occlusion and retinal dysplasia. However, ILM peeling can cause morphological changes at the macula like dissociated optic nerve fiber (DONF). Although no functional consequences have been attributed to this anatomical change, some studies have demonstrated that electrophysiological changes can occur after ILM peeling, and microperimetry may be useful in delineating functional outcomes of DONF. During his presentation, Dr. Chawla noted that a fundamental question in the field, is whether to peel the ILM or not. Currently, there are no answers to this important question. Though many surgeons opt to peel the ILM, peeling may not be necessary in absence of significant ILM damage. Furthermore, caution is needed in the presence of circulatory and metabolic comorbidities. Current data shows that epiretinal membrane (ERM) recurrence following combined ERM and ILM removal occurs in <9% of cases, and varies between 7.5-56%. Visual results have also been variable, and there is currently no consensus whether ILM alone, or the ILM and ERM, should be removed. Dr. Chawla explained that, given the variability

of ERMs in clinical experience, consideration of ILM removal should be based on ILM appearance post-ERM removal at the time of surgery. Large areas of ILM are removed during ERM peeling, as evidenced by sequential staining and small punctate hemorrhages. Then Dr. Chawla provided more insights into surgical techniques of ILM peeling. He stressed the importance of removing all residual particles, to reduce incidence of postoperative fibrosis. In addition, Dr. Chawla advised the audience that the use of an inverted ILM flap technique for large, full thickness macular holes and myopic macular holes may be more effective than complete ILM peeling in cases of myopic macular holes with retinal detachment.

Myopic Foveoschisis: Looking Between the Layers Based on a presentation by Dr. Hemanth Murthy, Consultant and Vice-president, Retina Institute of Karnataka, Bangalore, Karnataka, India

yopic foveoschisis (MF), also known as myopic tractional foveoschisis, is increasingly being recognized as one of the major causes of visual loss in highly myopic eyes. Dr. Hemanth Murthy shared his experience in the management of MF at the recently held AVRTT@6 workshop in Ahmedabad, India. MF presents as pathological myopia in 8-24% of cases. Mechanically, MF is associated with tangential traction from the pre-macular membrane, and inverse traction from the posterior staphyloma. According to Dr. Murthy, the etiology of MF is not known but it may be related to the relative thickness of the inner compared to outer retinal layers over the area of the staphyloma, the non-distensible nature of the ILM, and incomplete posterior vitreous detachment (PVD). The natural course is variable and patients may remain asymptomatic for long periods. Early symptoms could include blurring of vision, and progressively develop to foveal detachment and macular hole. In the presence of a lamellar hole, progression to retinal detachment is rapid. In discussing the surgical management of MF, Dr. Murthy utilized clinical cases and highlighted that the surgical approach involves vitrectomy and staining of the vitreous using triamcinolone combined with or without ILM peeling. Dr. Murthy concluded that in treating MF, ILM peeling ensures that cortical remnants are removed, but is slightly traumatic to the inner retina. Nonetheless, the results are excellent for the majority of patients. â&#x20AC;&#x153;Foveal sparing ILM peeling could be utilized if the fovea appears thin on OCT,â&#x20AC;? he added.

INNOVATION AVRTT@6 COVERAGE Vitrectomy for Endophthalmitis: Time is of the Essence Based on a presentation by Dr. Andrew Chang, Vitreoretinal Ophthalmologist and Surgeon, Medical Director, Sydney Retina Clinic, Consultant Vitreoretinal Surgeon and Head of Unit Sydney Eye Hospital, and Clinical Associate Professor, University of Sydney, Australia

Endophthalmitis: just as cuddly as this dog.

ndophthalmitis is still a rare but potentially eye-threatening complication of intraocular surgery. In a lecture delivered at the recently held AVRTT@6 workshop in Ahmedabad, India, Dr. Andrew Chang provided an overview of the current trends in the management of postoperative endophthalmitis. While summarizing the landmark Endophthalmitis Vitrectomy Study (EVS) published in 1995, Dr. Chang stated the key historical importance of the EVS recommendations was the management of acute postoperative endophthalmitis. Notably, the study was the first to confirm the visual benefit of vitrectomy in patients presenting with acute postoperative endophthalmitis and visual acuity of light perception only. This was due to significantly improved outcomes of a 3X higher chance of achieving 20/40 vision or better and a reduced possibility of severe vision loss. However, if vision loss is at hand movement or better, then a tap or injection was the preferred approach. The study also showed that there was better prognosis in patients with better visual acuity scores and culture negative at presentation. However, Dr. Chang questioned the relevance of said study findings in current practice, given the availability of better vitrectomy technologies, newer antibiotics and different procedures which were unavailable in the mid-1990s when the EVS was conducted. According to Dr. Chang, recent years have witnessed an exponential rise in the number of intravitreal injections (IVIs) in the management of cataracts and subsequently, an increased risk of endophthalmitis. However, studies have shown that the spectrum of organisms causing post

IVI endophthalmitis differs from those implicated in following cataract surgery. Therefore, it is important to delineate the differences in post-IVI and post-cataract surgery endophthalmitis. Dr. Chang and colleagues studied a consecutive series of 101 patients presenting with acute endophthalmitis. Out of those patients, 53 were post-IVI and 48 were postcataract surgery. They found that post-IVI endophthalmitis was associated with poorer visual outcomes, and this was related with an increased chance of streptococcal infection. Furthermore, streptococcal infections were associated with increased odds of enucleation. There are several advantages of early vitrectomy, Dr. Chang noted, such as better diffusion of antibiotics, earlier visualization of the retina and debridement of bacteria, inflammatory debris and toxins. However, there are challenges including iatrogenic retina damage and anesthetic risks. To assess the efficacy and safety of early vitrectomy in acuteonset endophthalmitis, Dr. Chang and colleagues at the Sydney Eye hospital conducted the Early Vitrectomy Study. This was a retrospective study of 64 consecutive patients from 2009-2013, who developed endophthalmitis following a range of procedures. Patients were followed and the primary outcome was visual acuity (VA) at 12 months. In these patients, immediate vitreous tap and injection of antibiotics were performed under local anesthesia in the emergency units. Following this, patients underwent 23-G vitrectomy within 72 hours, with anterior chamber washout, corneal debridement, core vitrectomy and intravitreal vancomycin. The mean age of patients was 77.5 years and mean time from onset of inciting procedure was 5.7 days. In majority of patients, the inciting procedure was phacoemulsification and IVI, while the most predominant bacteria species implicated were streptococci and S. epidermidis. Overall, the study findings were impressive. Visual outcomes were improved in 89% of patients and 42% had final VA better than logMAR 0.477 (Snellen 6/18). VA was better in post-cataract surgery as compared to post-IVI. Retinal detachment occurred intraoperatively in 9.4% of eyes, and postoperatively in 6.2%, and epiretinal membrane formation occurred in 9.4%. Based on their findings, Dr. Chang concluded that micro-incisional vitrectomy is associated with better visual outcomes and effective in improving vision in acute infective endophthalmitis (culture negative) and post-cataract surgery endophthalmitis. In addition, visual prognosis is limited to macular pathology. Editorâ&#x20AC;&#x2122;s Note: AVRTT@6, the 6th Advanced Vitreo-Retinal Techniques & Technology event took place on March 17 -18, 2018, at Narayani Heights, Ahmedabad, India. AVRTT@6, is a live surgery workshop organized by the Retina Foundation & Eye Research Center, headed by Dr. Manish Nagpal.

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ENLIGHTENMENT COMMUNITY SERVICE Telemedicine Project Helps Fight Childhood Blindness, Provides Eye Care for the Poor

This little baby went to market, this little baby stayed home, this little baby had roast beef, this little baby had none, this little baby could see, see, see, all the way home!

by Hazlin Hassan

etinopathy of prematurity (ROP) is a potentially blinding disease that affects premature infants. It occurs when normal blood vessels fail to complete their growth cycle to the edges of the retina. In its advanced stages, the untreated disease can result in permanent and complete blindness. An ongoing telemedicine project to screen for ROP among premature babies in Gujarat, India, has helped to treat more than 500 eyes, potentially saving the eyesight of infants at risk. The Gujarat Retinopathy of Prematurity (GUJROP) Project provides free treatment to poorer patients. This project was made possible through a partnership between the non-profit Health and Care Foundation, vitreoretinal surgeon Dr. Alay Banker (who heads its retina division), and the state government. Over the last five years, they worked together to screen and treat over 13,000 premature babies, weighing 2 kg or less. The project was initially started with technical collaboration with renowned eye hospital Narayan Nethralaya in Bangalore, India. “ROP is emerging as a leading cause of blindness and is seen in larger and heavier babies in India,” said Dr. Banker, who leads GUJROP. The highest number of pre-term births in the world is in India, according to figures from the World Health Organization. The disease is particularly common among pre-term babies who have been treated with oxygen. Too much of the gas causes blood vessels in the retina to close, affecting their development. Any infant with a birth weight of 2 kg

or under is at risk of a loss of vision irrespective of class and socio-economic background of the parents, especially if they are not diagnosed within 30 days. Dr. Banker noted that there is a huge logistical mismatch between cases to be screened and available ophthalmologists in India. His project aims to provide treatment to pre-term babies within their own city, town or village via telemedicine. The Polio Foundation has installed high-tech equipment in a van to make diagnosis easily available in rural areas. A team comprising a doctor and a technician scans the babies’ eyes and uses a dedicated server to send the scan to the doctor, who then recommends the appropriate treatment. “To date, we have been able to screen 16,271 babies and saved 565 eyes from blindness, which itself is an achievement in this field,” said Dr. Banker. The ultimate aim is to rid the state of Gujarat of what is, essentially, a curable disease. These results show that GUJROP telemedicine Public-Private Partnership

initiative offers a cost-effective, reliable and accurate screening methodology for identifying infants with ROP without sacrificing quality of care. “It also did not miss any diseases that required follow-up care nor did any patient have any adverse outcomes,” he said. The project was also helpful in increasing awareness of ROP among patients and pediatricians, and could be very effective in screening for ROP in resource-strapped areas. A partner of the project, the nonprofit Health and Care Foundation, in Ahmedabad, India, has been providing free medical care to underprivileged patients for more than 28 years through prevention, disease control, surgeries and better understanding of their health issues. The organization first started by providing corrective surgeries for children afflicted with polio, with the aim of helping to eradicate polio in the country in the near future. Slowly but steadily, it began spreading its wings to other streams to help more people. To date, it has units for pediatric orthopedics, spinal surgeries, diabetic retinopathy, retinal surgery, pediatric and adult cataract, squints, corneal grafting, glaucoma surgery, mammography and cervical cancer unit, rehabilitation of children with cerebral palsy, pain management, dialysis and diabetic foot conditions. They also provide artificial limbs for needy patients.

About the Contributing Doctor A vitreoretinal surgeon, Dr. Alay Banker is the director of his own Retina Clinic and Laser Center in Ahmedabad, India. After having obtained his medical degree at Gujarat University, Dr. Banker proceeded to receive fellowships at the Medical Research Foundation in Madras, India and the Shiley Eye Center at the University of California, San Diego, in surgical ophthalmology. Dr. Banker holds the honorary position as the Head of the Department of Vitreo¬retinal Diseases at the Health and Care Foundation Hospital in Ahmedabad. His accolades include receiving the Senior Honor Award from the American Society of Retinal Specialists, and the Senior Achievement Award from the American Academy of Ophthalmology. For his service to his community, he received the Dr. Piyush Patel Award for Service to Society and Mankind from the Ahmedabad Medical Association and the Nilkanthrai Chatrapathi Award for his contributions in fighting childhood blindness. [Email: alay.banker@gmail.com]

ENLIGHTENMENT OPHTHALMIC EDUCATION of amblyopia treatment or discovery of amblyopia therapy. He used a bee under a magnifying lens to represent B-scan to get the audience’s attention.

Thinking Outside of the Box to Make Ophthalmic Teaching and Learning Exciting by Khor Hui Min

r. Pushkar Dhir ventured into ophthalmology because he developed a passion for it. He recalled beginning his ophthalmology residency with morning tutorials, journals, seminars . . . and days which would end with the hope of seeing something different the next day. One day when he was sitting in the lecture hall, he began to observe the students and lecturer and found that most of the students looked bored and sleepy. While some juniors were trying to understand what was being taught, others were fiddling with their cellphones. The next day was the same, and the day after . . . it was a monotonous routine. He said that it was like a leader coming on stage every day and giving a dreary speech to a passive audience with no elements of interactivity. Most of the sleepy students were just waiting for the “Thank You” slide to come on, signifying the end of the class. He realized that these lectures were a waste of time and energy. Lectures cannot only be a one-way communication – the lecturer must

carry the crowd with him or her until the end and deliver a fruitful message. Dr. Dhir recalled that in his school days, his teacher used to say that the average attention span of a human brain is only six minutes. And though he never checked the validity of that statement, it stuck in his memory forever. He firmly believes that the lecturer cannot think of themselves only – they need to think of the audience and how to captivate their attention and maintain it. That was when he started his concept of “Out of Box – Out of Class.” He ensured his presentations were relatable to real life scenarios with fun elements. For example, he used a pirate wearing black cover as a sign

Once, he was asked to make slides on the pupil and he thought: Why would this interest anybody? But then, he read an interesting fact: “Whenever we see someone we like, our pupils grow larger.” It’s almost as if our eyes are trying to see as much of this person as possible. Shakespeare once said: “For she had eyes and chose me.’’ He made these the starting lines of his presentation. Dr. Dhir always makes sure not to compromise on clinical aspects of various topics, but rather gives the audience something interesting that touches their everyday life, reeling in their attention and not letting it escape into boredom. Videos are referred to as “Game of Thrones.” Competitions are converted into IPL fights in India, which correlates with famous Cricket tournaments. Through this method of teaching, Dr. Dhir’s continuing passion for ophthalmology is evident – and just like he used to look forward to something new and different each day, through his dedication and creativity, he’s now creating that same excitement for his students.

About the Contributing Doctor Dr. Pushkar Dhir is a long-term surgical fellow in Vitreo-Retina Services, Sri Sankardeva Nethralaya, Assam, India. He is also a fellow of the International Council of Ophthalmology, London. His most recent publication is “Glueless and Sutureless Pterygium graft In ‘Vision By Venu.’” Dr. Pushkar’s current research includes prevalence and treatment outcomes in children suffering from retinoblastoma in the North Eastern Indian population, the role of virtual reality headset in assistance of amblyopia treatment (V-HAT Study), and the role of Ozurdex in infectious and non-infectious uveitis. [Email: drdhir2014@gmail.com]

ENLIGHTENMENT WOMEN IN OPHTHALMOLOGY by Brooke Herron

We Can Operate Too! Discussing barriers to female leadership in ophthalmology

ender equality is an issue worldwide – and for female ophthalmologists in Asia-Pacific, there is a striking difference between the number of men in key leadership roles versus women. This fact has been recognized by organizations like Women in Ophthalmology (WIO), which is helping to empower women and enhance leadership development in the field. But the question remains: Why aren’t women in these key leadership roles? Is this a question of equality . . . or is it due to some other barrier? To explore these issues, PIE Magazine CEO Matt Young spoke with several female ophthalmologists to discuss challenges women face in the field.

What role does culture play? We know Asia is a large, culturally diverse continent. So how does that diversity impact gender roles in the workplace? As it turns out, for Asian women, it’s a mixed bag. For example, in India, Dr. Lipika Roy estimates that today, 60 to 75 percent of key ophthalmologists are women. And in Hong Kong, Dr. Joy Leung says that being a woman can be an advantage. “In India, women are getting good opportunities,” said Dr. Roy. “They have good positions and they are managing well. But if you go to other places in Asia or the Middle East, it depends on the culture.” Dr. Ava Hossain reports that there are about 160 women training to be ophthalmologists – so, it’s clear things are changing. In South Korea, when Dr. Seung-Young Yu was studying only 10 percent of students were female. However today, that ratio has evened out. And Dr. Leung believes that it’s just a matter of time: “I believe that it [gender equality] wasn’t very different in the west 100 years ago.”

Interview with Dr. Ava Hossain on PIE Talks.

Barriers to female leadership According to Dr. Catherine Green, it’s very clear that women are underrepresented in leadership roles in ophthalmology. “In my own organization, about 20 to 25 percent of ophthalmologists are women, and 35 percent of trainees are female. Less than 10 percent in leadership roles are female.” She attributes this to what she calls the “leaky pipeline,” where there are obvious and hidden barriers. For example, not asking a woman to participate because one assumes she is busy with family would be an obvious barrier, while a hidden barrier might be the medical training system itself, which was designed for and by men. Dr. Carmen Chan notes that about half of the ophthalmic trainees in Hong Kong are women – but the problem is rising through the ranks. “Dr. Green asked me how many head of departments are female at this moment in Hong Kong . . . and there are none. I think it’s what she mentioned about the leaky pipeline: There are a lot of female ophthalmologists who start training, but somehow they do not rise to the top.” So, are women staying out of leadership roles on purpose? According to the women we spoke with, that could certainly be the case.

“Honestly, I think that a lot of us aren’t putting ourselves forward for promotion because – even in this day and age – if you’re married with children, then as a woman your primary responsibility is with the family. Everyone expects that the woman will look after the kids, so there are some family expectations,” said Dr. Chan. “I have two children, they are 8 and 9, and I enjoy spending time with them. But there are only 24 hours in a day . . . so do I want to be head of a department? Not really – I enjoy spending time with my family,” added Dr. Chan. PIE Advisory Board Member Dr. Gemmy Cheung (Singapore) agrees – rather than there being a glass ceiling, women just don’t want to take on time-consuming leadership roles. “It’s probably more related to how much women are willing to invest in their career, often it may not be a real glass ceiling, but for some women they may reach a point where they say enough, and it’s their choice.” “I think as a female ophthalmologist, the one thing – and a very practical issue – is pregnancy,” added Dr. Leung. “To strike a balance between family and work . . . how much time do you have for kids, how much do you put for your career. It’s something female doctors have to face.”

“

To strike a balance between family and work . . . how much time do you have for kids, how much do you put for your career. It’s something female doctors have to face.” – Dr. Joy Leung

Of course, struggling with time and prioritization is not a gender specific challenge – but it can be more difficult for women, where the responsibility of looking after children falls heavily on women. “There’s an emotional struggle and a sense of guilt as to furthering your career, or to call it and say no, this is family time,” said Dr. Cheung. “Overall, I think that ophthalmology is a friendly field for women.” Editor’s Note: Search YouTube for “PIE Talks Episode 01: The Female Experience in Asia-Pacific Ophthalmology” and check other videos in PIE Magazine’s YouTube Channel to find the full videos of the individual interviews with these fabulous women of ophthalmology.

Interview with Dr. Carmen Chan on PIE Talks.

ENLIGHTENMENT BLINDNESS PREVENTION

A New Vision for All by Chow Ee-Tan

n estimated 253 million people in the world live with vision impairment â&#x20AC;&#x201C; and of those, 36 million are blind and 217 million have moderate to severe vision impairment. These staggering statistics from WHO Vision Impairment and Blindness Fact Sheet (dated October 2017) also show that over 80% of all vision impairment can be prevented or cured. Uncorrected refractive errors and unoperated cataracts are the top two causes of vision impairment. Twenty million people are blinded by cataract, which remains the leading cause of blindness in low- and middle-income countries. This is because many visually impaired patients cannot afford treatment, have no access to good eye care, do not know that their blindness is curable or that a one-off surgery can restore vision.

If a person with visual impairment loses the ability to earn a living (which happens often), they can become a burden on other family members. In addition, blind people often feel neglected and this often leads to depression and other mental illnesses. In recognition of the prevalence and burden of vision impairment, a non-profit organization was formed to make eye care accessible to all, regardless of patientsâ&#x20AC;&#x2122; ability to pay. Based in Singapore, A New Vision (ANV) has been actively funding and coordinating free clinics, providing free cataract surgeries to the masses. These clinics, predominantly in Indonesia, have been running on a regular basis and restore sight to thousands of people annually. ANVâ&#x20AC;&#x2122;s aim is to eliminate cataract induced, curable blindness throughout the world. Advancements in medical technology have enabled cataract patients to see again following a

5-10-minute, low-cost surgery. With proper postoperative care, patients can regain their sight within 48 hours or less. Co-founder Effi Jono witnessed the awe-inspiring event of restoring vision to 695 people (some had lived with blindness for 30 years) and realized the massive impact these surgeries have. The organization had its humble beginnings in 2010, with four individuals pooling funds raised from family and friends for its first free cataract clinic in Indonesia. Ms. Jono, who is originally from Indonesia and spent most of her working life in the corporate world, met Singaporean Tan Ching Khoon who shared her desire to help the less fortunate. They hoped to start a humanitarian project with wellknown humanitarian eye surgeon Dr. Sanduk Ruit, whose Tilganga Institute of Ophthalmology in Nepal is a place where the poor are treated equally and can afford superior eye care.

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It was the first time I saw so many blind people at one spot. Some had been blind for decades and they could see the very next day after the surgery. It was unfathomable that they had been living in misery all these years when a simple procedure could have cured them.” – Ms. Effi Jono

With the help and connection of her uncle Dr. Indra Wahidin, a prominent social activist in Indonesia (North Sumatra, specifically), Ms. Jono decided to approach Dr. Ruit to provide medical help to the visually impaired in Indonesia. “I travelled to Kathmandu to meet Dr. Ruit and within five minutes of our meeting, he said, `if you think you can bring us to Indonesia, we are ready’,” recalled Ms. Jono. “Unbeknownst to me, the international ophthalmology community there was well aware of the high prevalence of blindness in Indonesia but faced difficulty and resistance from Indonesian counterparts to assist.” In the first week of December 2010, Dr. Ruit and his team arrived in Indonesia and performed 600 surgeries in a few days. “It was the first time I saw so many blind people at one spot. Some had been blind for decades and they could see the very next day after the surgery. It was unfathomable that they had been living in misery all these years when a simple procedure could have cured them,” shared Ms. Jono. Spurred by what they witnessed, Ms. Jono, Dr. Wahidin and Tan Ching Khoon decided they must not let this fire die, and together with Dr. Ruit, they formed A New Vision (ANV) to continue the work of treating the visually impaired.

Testimonies of Hope ANV’s newsletters highlight success stories of individuals whose eyesight has been restored from surgeries at their cataract clinics over the years. The newsletters are a heartwarming read and are published once or twice annually. Past issues can be found on ANV’s website (www.anewvision.org) and serve as a form of communication for the organization’s supporters and donors, with the purpose of spreading awareness about what they do and their needs. The first few years of ANV newsletters were compiled in a Word document by Ms. Jono herself. Later, she received editing and graphic design help from some committed volunteers. In 2014, the newsletter was named “New Sight,” and now contains more colors and pages to accompany the touching testimonies and other useful information on eyesight and ophthalmology.

Excerpts from ANV newsletters A Homeless Lady Gets Hope in Sight (2016/2017) This inspiring woman, Tan Swie Lan who is in her 70s, heard about our cataract surgical event in Central Java over the radio. Homeless and taking shelter at her neighbor’s house, Mrs. Tan has no other family members. With her vision limited to just shadows (hand movement), Mrs. Tan’s resolve to see again was so great that she took a bus to our screening place all alone and arrived stumbling at the front gate. Guide dogs, white canes and other devices for the vision impaired that we in the developed world take for granted are simply unattainable for the very poor in countries like Indonesia. Their lives are far more drastically impacted by their vision loss due to the lack of visual aids combined with a rudimentary lifestyle. Although she has no material possessions to speak of, Mrs. Tan is a woman of immense dignity. At lunch, as we did for all of our patients, we brought her a lunchbox of rice. Ten minutes later she said, reaching into her pocket to retrieve a few old crumpled notes, “Someone gave me a packet of rice. I haven’t paid for the rice yet, how much do I owe?” Everyone at the event was charmed by this inspiring and very kind lady. She made friends at the outreach and although she arrived alone and blind, she went home with both new sight and new friends – many of whom live in the same village as her.

Lelihai and her Mother (June 2016) Meet 32 year-old Lelihai, who, as a child, was blinded in her right eye by a rock from boys playing slingshot. Imagine the devastation when she found her only functioning eye became blind from cataracts. Her husband divorced her. She had to give her 6-year-old daughter to her sister because she could no longer look after her. She subsequently moved back to live with her mother in a remote village where the two earned a living selling wood collected from a nearby forest. Their average daily income was just US 38 cents. Working together, the two would collect wood. Dewi, Lelihai’s 62-year old mother, would find and pick up the wood. She would then hand it to the younger Lelihai to carry. With their futures uncertain except for the likelihood of poverty, anxiety was high. But both women’s lives have been transformed by recent surgery curing the cataract in Lelihai’s left eye, their job prospects and earning potential vastly improved.

ENLIGHTENMENT BLINDNESS PREVENTION

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“We did not have any organizational name when we did our first event, and all of the funds required were contributions from family and friends. Fortunately, as we grew, we managed to attract many good volunteers. They have been very helpful in helping us with many logistical tasks – from booking flights and payment processing to website maintenance and newsletters.” ANV works with local communities and relies on local community figures to bring patients to their events. The responses from patients have always been very good. Their partners include local community groups, local government and international blindness foundations like the Fred Hollows Foundation and Tilganga Institute of Ophthalmology, corporate donors, individual donors and volunteers. “We focus on helping to alleviate blindness, specifically cataracts as 50% of blindness in developing countries is caused by cataract. Here, cataract are formed 10-15 years earlier due to higher exposure to UV rays and are often found in those with outdoor occupations such as farmers, fishermen and plantation workers,” said Ms. Jono. They also provide basic education on eye health to local communities and support Indonesian surgeons and eye nurses for training at Tilganga Institute of Ophthalmology. According to ANV’s website, through their events in various communities in Indonesia, ANV has checked close to 57,000 people for eye diseases and performed close to 21,500 successful sight restoration surgeries. In addition, 9,178 community representatives have been trained in basic eye health education. Ms. Jono noted that ANV still faces many challenges today, including protests from certain people and groups: “Some ophthalmologists believe

We focus on helping to alleviate blindness, specifically cataracts as 50% of blindness in developing countries is caused by cataract. Here, cataract are formed 10-15 years earlier due to higher exposure to UV rays and are often found in those with outdoor occupations such as farmers, fishermen and plantation workers.” – Ms. Effi Jono

these patients are their inventories, and that by giving these free surgeries, we are taking their potential income away. Other ophthalmologists prefer that we pay them at a rate they set to do the surgeries at their convenience.” There have been other problems too, like donors who promised donation or sponsorship and parties who were supposed to play their part, then did not honor their commitment and could no longer be contacted after the event. Running ANV can be a roller coaster ride. However for Ms. Jono, it’s all worthwhile when she sees patients who have regained their sight.“Many of these people already suffer so much in

life, and on top of that, they are blind. When it only takes minutes of treatment to return their sight, not doing anything to help them is a crime,” she explained. ANV is striving to take bigger and bolder steps. In 2017, it began performing cataract surgical outreach in countries outside Indonesia, namely Cambodia and Nepal. ANV is now a member of The International Agency for the Prevention of Blindness, with an objective to eliminate avoidable blindness by the year 2020. “Our goal is to replicate the sustainable Community Eye Hospital, where Dr. Ruit was successful in reducing the rate of blindness in Nepal, particularly in communities where there is evidence of higher need,” said Ms. Jono. She hopes that ANV can be more sustainable – that they can have a steady income stream to carry on the work and inspire more people, groups and organizations to collaborate with them. “We also hope that government authorities realize that although blindness is not a deadly disease, it significantly reduces one’s quality of life and causes burden and hardship to the family. We hope the government will take action to place blindness eradication high on public health agenda,” she concluded.

About the Contributor Ms. Effi Jono is trained in finance and spent most of her life working in the corporate world. Originally from Indonesia, she now lives in Singapore, and spent 10 years in Australia before moving to Singapore. She is a Certified Practicing Accountant by trade and held executive director (finance and tax) positions with multinationals in Australia, Indonesia and Singapore, including Lend Lease Group and Schlumberger. With 25 years of experience and demonstrated leadership role in a wide breadth of operational areas, Ms. Jono has worked with multinational companies across the globe. She is a knowledgeable, communicative and pragmatic finance partner for businesses at all levels and experience in leading the integration of acquired businesses, building the desired corporate culture and business transformation. Ms. Jono co-founded A New Vision in 2010. She takes charge in innovating and creating a game-changing practice and standard in blindness prevention in Indonesia despite having no prior experience in a not-for-profit organization or health/eye care. Besides eradicating avoidable blindness, she is passionate about animal rights and tries to exercise daily. [Email: effijono@gmail.com]

CONFERENCE HIGHLIGHTS APAO 2018 POSTERS

Posterior Segment Poster Highlights from

APAO 2018 Hong Kong by Collins Santhanasamy

rom retinal fiber layer defect to retinal degeneration, we canâ&#x20AC;&#x2122;t get enough of the posters presented at APAO 2018 Hong Kong . . .

Comparison of Retinal Nerve Fiber Layer Defect Detection between Color, Red-Free and High-Dynamic-Range Disc Photography

n clinical settings, the presence of a retinal nerve fiber layer defect (RNFLD) provides early objective evidence of damage caused by glaucoma. Because a reproducible visual field defect appears only when a significant number of ganglion cell axons (20%-40%) are lost, the nerve fiber layer (NFL) evaluation is an important investigation when suspected glaucoma patients do not exhibit visual field loss. Dr. Ubonwan Rasaruck and colleagues from the department of ophthalmology in Chulalongkorn University and King Chulalongkorn

Memorial Hospital in Bangkok, Thailand, conducted a study where color, red-free and High-DynamicRange (HDR) disc photographs (DP) of 24 glaucoma patients and 24 normal controls were independently assessed by 3 glaucoma specialists, 3 general ophthalmologists with more than 5 years of experience and 3 general ophthalmologists with 1-5 years of experience. The evaluators were asked to detect and identify the area of RNFLD in the photographs. The authors concluded that although HDR-DP is limited in its specificity, it also significantly improves the sensitivity of RNFLD detection in the whole group including the media opacity group which is the limitation of color disc photography (C-DP) and is thus a suitable screening tool for RNFLD detection by general ophthalmologists and trainees.

Average imaging systems donâ&#x20AC;&#x2122;t compare to HDR-DP (not pictured).

Outcomes of Foveal-Sparing compared to Fovealinvolving Photodynamic Therapy for Myopic Choroidal Neovascularization

horoidal neovascularization (CNV) is the formation of new blood vessels in the choroidal layer of the eye and is a common vision-threatening complication of both myopia and pathological myopia. Photodynamic therapy (PDT) may still possibly have a role in the management of patients with myopic CNV where anti-vascular endothelial growth factor (anti-VEGF) agents are contraindicated due to systemic risks or in certain patients who are unwilling to accept the systemic and ocular risks associated with such treatment. Dr. Colin S. Tan from the National Healthcare Group Eye Institute of Tan Tock Seng Hospital and Dr. Tock Han Lim from the Fundus Image Reading Center at the NHG Eye Institute in Singapore, conducted a study where an interventional case series of 24 consecutive patients with myopic CNV were treated with PDT over a 2-year period. The final outcome measure was in the form of LogMAR visual acuity (VA) which was 0.26 in the fovealsparing PDT group as compared to 1.00 in the foveal-involved PDT group. The conclusion from this study suggests that patients suffering from myopic CNV who undergo fovealsparing PDT could expect significantly better long-term visual outcomes as compared to those who choose to undergo foveal-involved PDT, indicating that foveal-sparing PDT may be of value in the treatment of myopic CNV in antiVEGF contraindicated patients.

Unilateral Retinitis Pigmentosa

o-authors Dr. Pritam Bawankar, Dr. Ronel Soibam, Dr. Divakant Misra and Dr. Nilutparna Deori Das from India, presented a poster at APAO 2018 Hong Kong which reported the discovery of 3 cases of unilateral retinitis pigmentosa (RP) cases at an outpatient clinic in a tertiary eye center in North-East India. RP refers to a group of inherited diseases causing retinal degeneration. Patients suffering from RP experience a gradual and painless deterioration in their vision and a worsening peripheral vision that leads to ‘tunnel vision’ due to the degeneration of photoreceptor cells in the retina. A unilateral presentation of RP is uncommon with fewer than 100 cases reported in current literature. Posterior segment evaluation of all 3 cases from this retrospective study revealed unilateral findings of optic disc pallor, arteriolar narrowing and variable amounts of bone spicule-shaped pigment deposits in the mid-peripheral retina with sparing of the posterior pole. Full field, 120 point screening test with a Humphrey perimeter showed normal findings in one eye with residual small central islands of vision in all 3 affected eyes. Full field electroretinography showed unilateral extinguished responses with normal amplitudes in the corresponding eye. Diagnosis was confirmed with the fulfillment of the François and Verriest criteria.

Association of Serum Uric Acid Level with Age Related Macular Degeneration

r. Fazil Khurrum and collaborators conducted a hospitalbased case control study in India with the aim of investigating the association of serum uric acid levels and body mass index (BMI) as a risk factor for age-related macular degeneration (AMD) which is currently the leading cause of blindness and visual impairment in developed countries. A total of a hundred patients were divided into 2 groups with 50 consecutive cases diagnosed with AMD and 50 acting as the control group with no retinal pathology. Patients above the age of 40 with neovascular and non-neovascular AMD were included in this study. Results from this study showed that the mean serum uric acid levels were higher in patients with neovascular AMD (505 +/- 13.57 umol/l) than in non-neovascular AMD (322 +/- 26.26 umol/l) as compared to the control group (318.42 +/- 76.23 umol/l). Interestingly enough, every unit increased in BMI lead to the expected increase of 4.282 times more chance of AMD which was statistically significant at 95% confidence level and p value of <0.001. The authors concluded that from the results obtained, a statistically significant correlation exists between serum uric acid level and severity of AMD. They also highlighted that the increased risk with increasing BMI could be due to excessive calorie intake which increases the risk of oxidative damage leading to the development of AMD.

INDUSTRY UPDATE Quantel Medical Receives FDA Approval for Next-Generation Compact Touch Ophthalmic Ultrasound Platform

uantel Medical has received approval from the U.S. Food and Drug Administration (FDA) for the Next-Generation Compact Touch Ophthalmic Ultrasound Platform, known for its high quality imaging, intuitive software, compact design and versatility. This new generation of Compact Touch boasts a 15 MHz B probe which increases the quality of B-scan imaging, while its interactivity is enhanced with DICOM compatibility, WiFi and Bluetooth connectivity and HDMI video output. The new platform uses a touchscreen interface and is fan-less, and is described as user-friendly, with software enhancements to improve workflow.

In a press release, Dr. Bievelez from the Centre Ophtalmologique Louis Paufique in Lyon, France, said: “The new generation 15 MHz B probe of the Compact Touch offers a resolution increased by 30%, which enables me to better differentiate thin vitreous membranes and retinal detachments. It also allows me to visualize tumors inferior to 2mm. In addition, the system automatically measures the axial length from the B-mode image, which is advantageous when I am evaluating patients who have long myopic eyes, such as patients with staphylomas.” Quantel Medical’s CEO Jean–Marc Gendre says physicians will consider

this state-of-the-art technology very practical, as the capabilities come in a sleek, portable, well-designed and highly interactive package. “We are excited to share with ophthalmic specialists and their patients the clinical advantages of the new generation of Compact Touch, which enhanced image quality will aid diagnosis.” Quantel Medical is a global ophthalmic medical device company dedicated to developing leading technologies to improve the diagnosis and treatment of ocular diseases. Since the first generation of Compact Touch was launched in 2008, more than 3,300 units have been sold worldwide.

CONFERENCE HIGHLIGHTS AIOS 2018 POSTERS

Posterior Segment Poster Highlights from by Olawale Salami

AIOS 2018 Coimbatore

IE Magazine has arrived in India, and we were at the recently held All India Ophthalmology Society Congress (AIOS 2018) in Coimbatore, Tamil Nadu, India to check out India’s biggest and premier ophthalmology meeting. Meanwhile, here are some of the poster presentations that caught our attention...

“Retinal detachment” is a hard phrase to act out during a game a charades. Unless you have a couple grapefruits handy, and an ophthalmologist in the crowd…

A Novel Approach to Surgical Visualization in Patients with Retinal Detachment

r. V. Sameera and colleagues from the M. M. Joshi Eye Institute and Research Center (Hubballi, Karnataka, India) shared findings of a study which compared the safety and efficacy of the 25-Gauge Chandelier endo-illumination system (CES) with indirect ophthalmoscopy for scleral buckling (SB) surgery in patients with primary rhegmatogenous retinal detachment (RRD).

In this prospective interventional case series, 28 eyes of 28 patients with recent primary RRD were divided in to 2 equal groups: 1 and 2. Group 1 patients were operated by SB using 25-G Chandelier illumination and non-contact viewing system, with the Chandelier at 180 degrees from the primary break. Group 2 patients were operated with conventional procedure, in which successful break localization was followed by cryopexy, standard scleral buckling and sub-retinal fluid drainage. The preoperative demographics, success rate of retinal reattachment at 3 months, intraoperative findings, and postoperative complications were evaluated.

In group 1 patients, 4 eyes experienced a new break intraoperatively while 10 eyes on postoperative day 1 showed well attached retinas. Vitreous prolapse from the 25-G port and port suturing for 2 cases were noted. In group 2 patients, no intraoperative breaks were noted. Eight (8) eyes had sub-retinal fluid on postoperative day 1. Dr. Sameera and co-authors found no differences in postoperative BCVA and anatomical success in both groups at 3 months. The investigators concluded that the Chandelier endo-illumination system allows excellent visualization and treatment of retinal breaks and safety during subretinal fluid drainage. “It can be considered an effective alternative to vitreoretinal surgery in simple retinal detachment cases, aids in teaching purposes and facilitates improved ergonomics for the surgeon.”

A New Technique Improves ILM Flap Retention in Patients with Large Macular Holes

he surgical outcomes of large chronic macular holes are poor, with closure rates of as low as 40%. Therefore, there is a need to develop improved techniques which ensure better patient outcomes. Dr. P. Bawankar and colleagues from the department of vitreo-retinal surgery, Sri Sankaradeva Nethralaya (Guwahati, Assam, India) shared interesting insights into a new internal limiting membrane (ILM) flap technique that improved ILM flap retention on the macular surface.

The authors conducted a hospital-based retrospective interventional case series involving 11 eyes in 11 patients with chronic idiopathic macular holes larger than 700 microns. Patients with proliferative diabetic retinopathy, retinal detachment and age-related macular degeneration were excluded. Eyes underwent 3-port pars planar vitrectomy with a modified ILM flap technique in which, following ILM folding onside the macular hole, 0.2 ml of viscoelastic cap is injected into the flap, forming a “viscoelastic cap” which mediates flap retention inside the macular hole during fluid-gas exchange. The authors measured the visual acuity (VA) and optical coherence tomography (OCT) images preoperatively, and at 1 week, 3 weeks, and at 6 and 12 months postoperatively. The main outcome measures were visual outcome and macular hole closure rate. The age range of patients was 61-70 years, with 7 males and 4 females. Mean linear diameter of macular hole was 811.4 µm. The pre- and postoperative mean VA was 1.2 logMAR and 0.56 logMAR, respectively. Macular hole closure was confirmed in 100% of cases. Based on their findings, Dr. Bawankar confirmed that this modified ILM flap technique improves retention of the ILM flap within the macular hole and improves reliability and reproducibility of the operation. “This procedure is also suitable for redo cases where there is no ILM bordering the macular hole.”

presentations ranging from asymptomatic to central vision loss and diplopia. Vision loss is secondary to retinal traction and cystoid macular edema (CME), full thickness retinal folds, foveal ectopia and pseudo-hole formation. Dr. Puja Maitra and colleagues discussed findings from their study which aimed to evaluate visual outcomes of double membrane peeling in patients diagnosed with ERM, and to identify correlates of postoperative visual improvement. In this prospective observational study, the authors included 51 eyes with OCT confirmed ERMs, pseudophakic of clear lens and no other macular pathologies. Baseline visual acuity (VA) was <6/9. They performed double membrane peeling with the aid of trypan blue and confirmed with the aid of dyes brilliant blue-G and sulfur hexafluoride-6. Patients were evaluated at postoperative weeks 2, 4, 8 and 12 with BCVA, subjective metamorphopsia analysis and OCT. The authors found that 84% of patients recorded BCVA gains and 35% attained useful near vision. Preoperative corticospinal tract (CST) and pattern of ERM attachment had no effect on surgical outcomes. The authors concluded that with the double membrane peeling technique, 2/3 of patients attained maximum visual improvement by 8 weeks.

Visual Improvement following Double Membrane Peeling for Epi-retinal Membrane

pi-retinal membrane (ERM), also known as pre-macular gliosis, describes a cellular proliferation on the inner retinal surface with a wide spectrum of

What are the Retinal Changes Seen in Dengue Fever? A Case Report cular involvement in dengue fever is a relatively rare occurrence with reported incidence varying from 7.940.3%. Clinically, dengue maculopathy manifests as macular hemorrhage, and retinal edema, along with other associated findings such as anterior sheathing, cotton wool spots, perifoveal telangiectasias

and micro aneurysms. Recently, acute macular neuroretinopathy (AMN) has been associated with dengue maculopathy. AMN lesions are characterized by hypo-reflective parafoveal wedge shaped areas on near infra-red imaging due to underlying deep capillary plexus ischemia, which shows as hyper reflectivity of the outer retinal layers on OCT. Dr. Kanika Aggarwal and colleagues from the Advanced Eye Centre at Postgraduate Institute of Medical Education and Research (PGIMER) (Chandigarh, India) reported the OCT angiographic features of dengue maculopathy and AMN. This was a 39-year old female who presented with bilateral diminished vision of 7-day duration, following a febrile illness of 15 days, for which she was IgM positive for dengue. Best corrected visual acuity (BCVA) was 20/200 in the right eye and 20/80 in the left eye. On examination, she had grayishwhite lesions with granular appearance in the parafoveal region on the right and hard exudates on the left eye. Macular OCT showed hyper-reflectivity in the inner nuclear layer, outer plexiform layer and disruption of the outer retina of the right eye. OCT angiography (OCTA) showed disruption of both the superficial capillary plexus (SCP) and deep capillary plexus (DCP) with flow deficit in the foveal region, suggestive of AMN. The patient was treated with oral prednisolone, 1mg/day, tapered over a 2-month period. Final BCVA at month 2 follow-up improved to 20/40 in the right eye and 20/60 in the left. Dr. Aggarwal and co-authors concluded that this case highlights the involvement of retinal capillaries at various levels among patients with dengue maculopathy. “OCTA appears to have great value in demonstrating the spectrum of retinal in patients with dengue maculopathy.”

CONFERENCE HIGHLIGHTS ARVO 2018 PREVIEW

ARVO 2018 is here!

by Brooke Herron

ision researchers and ophthalmologists worldwide will say “aloha” to Hawaii during the Association for Research in Vision and Ophthalmology (ARVO) 2018 Annual Meeting. Held in sunny Honolulu from April 29 to May 3, an expected 11,000 attendees from more than 75 countries will descend on the Hawaii Convention Center in Honolulu for five days of breakthrough vision research lectures and presentations. This year’s meeting features more than 6,000 poster and paper presentations of cutting-edge eye and

vision research. These presentations offer an early glimpse to the latest advances in potential treatments for eye disease and blindness — often years ahead of their introduction to clinical practice. Topics among the ARVO 2018 research presentations include: high tech tools for improving eye care; novel treatments for allergies and other eye conditions; new approach to corneal graft to restore vision; surgical procedures to restore vision in Ebola survivors; exploration into early diagnosis of and treating eye cancer; and imaging tools for the eye.

Award Lectures In addition to presentations, attendees will have the opportunity to attend prestigious award lectures featuring the latest innovations in eye and vision research. This year’s Beckman-Argyros Award in Vision Research lecture was awarded to Prof. James G. Fujimoto, PhD, the Elihu Thomson Professor of Electrical Engineering at the Massachusetts Institute of Technology. Currently Prof. Fujimoto – who is considered the pioneer of OCT imaging in ophthalmology – is developing

advanced optical imaging for cancer detection, including endoscopic OCT and surgical guidance. His lecture covers the history, evolution and future prospects of OCT. The 2018 Champalimaud Vision Award, which is presented to research groups actively involved in basic or clinical research that have contributed to important progress in understanding and preserving vision, was awarded to a trio of award laureates: Dr. Babar Qureshi with CBM; Dr. Sunday Isiyaku with Sightsavers; and Amanda Jordan with Sightsavers. Together, CBM and Sightsavers are recognized as pioneers in fighting blindness in dozens of countries worldwide and have created a model to combat vision disorders based on three pillars: prevention, healing and support. Through this work, many people with severe disabilities are living productive and independent lives and are contributing to society with dignity. This year’s Proctor Award Lecture discusses observations in the retina clinic with insights into pathophysiology and was awarded to Dr. Artur Cideciyan, PhD and Dr. Samuel Jacobson, MD, PhD, FARVO. During this lecture, the presenters will cover how clinical diagnoses remain the starting point for detection of monogenic outer retinal degenerations, but also, how advances in non-invasive tools have added opportunities to further understand pathophysiology. In the Friedenwald Award Lecture, Dr. Reza Dana, MD, MSc, MPH, FARVO, provides an overview of ocular immune regulation, and relates fundamental qualities of immune cell phenotype and function to the art of M.C. Escher and the music of J.S. Bach. During the Weisenfeld Award Lecture, Dr. Mary Elizabeth Hartnett, MD, FACS, FARVO, addresses the changing and diverse pathology of

retinopathy of prematurity (ROP), including: the roles of oxygen and VEGF signaling in both pathologic and physiologic angiogenesis and how this has translated to current trials using anti-VEGF agents, the need for optimal models to assess pathophysiology, and protective mechanisms to prevent ROP. Dr. Felipe Medeiros, MD, presents the Cogan Lecture regarding micro-imaging to macro-functioning in glaucoma, addressing some of the challenges in determining how these new technologies can result in meaningful improvements in patient outcomes.

Social Program & Things to do in Hawaii Of course, the ARVO 2018 Annual Meeting is not all about its scientific programs. Attendees will find numerous opportunities to network and socialize during events like the ARVO Foundation and Dowling Society Gala, the Sunday Social, the Student/Trainee Social, the Annual Women in Eye and Vision Research (WEAVR) Luncheon, the

ARVO Classical Concert, ARVO Karaoke and the Vancouver Welcomes ARVO 2019 Kick-Off Reception. Although ARVO 2018 has a jampacked scientific and social program, attendees would be remiss if they didn’t take a bit of time to explore the island. From historical sites like Pearl Harbor, to outdoor activities like golf, hiking, sailing, snorkeling, surfing, scuba diving, whale watching and dolphin excursions, there is something for everyone. Additionally, those seeking an authentic Hawaiian experience can attend a live hula performance, or take in lessons on native Hawaiian culture, including hula lessons, ukulele lessons, and Lei-Making lessons at the Royal Hawaiian Center in Waikiki. Beyond ARVO 2018’s stunning setting in Hawaii, this year’s event is set to be one for the record books with trail-blazing research, presentations and lectures. With so many engaging events occurring, ARVO has made it easier for attendees to sort their schedule – check on their online planning tool, or their mobile app to ensure you don’t miss a beat! For additional information, visit www.arvo.org/annual-meeting.

If you’re expecting hula dancers, don’t come to PIE-LAND (Media MICE Booth #1631 at ARVO). There’s nothing but a freaky retina creature there chasing downed cabin crew.

SOME SAY WE’RE THE ELEPHANT IN THE ROOM

For the record, we’re the MICE.

Visit Us at A RV O at Booth # 1631

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