PIE Magazine Issue 07X (The AAO 2018 issue)

ASIA-PACIFIC’S FIRST MAGAZINE ON THE POSTERIOR SEGMENT

07X

The eXpanded Mozart Issue September/October 2018

magazine

www. piemagazine.org

posterior segment • innovation • enlightenment

Cover Story

If Mozart had lived

and evolved into an opht halmologist, what revolut ionary tools would he use today? Page 20 THE WORLD’S FIRST FUNKY OPHTHALMOLOGY MAGAZINE

Inside this issue...

Posterior-Anterior Segment

06

page

Addressing Critical Needs of Patients with Bilateral Macular Scars with the SIVA Lens

08 10

page

Let’s give them something to talk about. . .

Ocular Blood Flow

page

Combined Phaco-Vitrectomy Systems, Revolutionizing the Surgical Landscape

Posterior Segment

14 15

16 18

page

Alcon’s NGENUITY Revolutionizes Surgery with Greater Depth and Visualization

page

Taking on Dry AMD with Aflibercept

page

Post-injection Retinal Detachment: Expect the Unexpected

page

Transforming Information into Insight with Integrated Diagnostic Imaging

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COVER STORY

Out of the Opera Theater and into the Operating Theater . . .

If Mozart had lived and evolved into an ophthalmologist, what revolutionary tools would he use?

page

Matt Young

CEO & Publisher

Hannah Nguyen

Production & Circulation Manager

Gloria D. Gamat Chief Editor

Brooke Herron Associate Editor

Ruchi Mahajan Ranga Project Manager

Alex Young

Publications & Digital Manager

Innovation

26 28

30 32

page

Predicting the Future for AMD Patients

page

Bringing Ophthalmic Innovation to Southeast Asia

page

So, you want to be an inventor?

page

Yamane Double Needle Technique Sets The Standard

Graphic Designers

Winson Chua Patalina Chua Writers

April Ingram Collins Santhanasamy Hazlin Hassan Joanna Lee John Butcher Khor Hui Min Olawale Salami Cover Art

Prafulla Badgujar www.piemagazine.org Published by

Media MICE Pte. Ltd.

6001 Beach Road, #19-06 Golden Mile Tower, Singapore 199589 Tel: +65 8186 7677 Fax: +65 6298 6316 Email: enquiry@mediamice.com www.mediaMICE.com

Enlightenment

34

Reaching the Unreached: The Arunodaya Story

page

Conference Highlights

37 39 41

42-45 46

page

ASEAN Ophthalmologists Collaborate to Improve Healthcare Services in the Region

page

page

Color Vision Deficiency (CVD) 101

page

page

Key Factors to Successful Ophthalmic Entrepreneurship Highlighted at OPHTHALL 2018

We are looking for eye docs who can contribute articles to PIE magazine.

Interested? Let's talk! Send us an email at enquiry@mediamice.com.

Best of PIE Post

The Countdown to APAO 2019 Begins

To place an advertisement, advertorial, symposium highlight, video, email blast, or other promotion in PIE magazine contact CEO Matt Young at matt@mediamice.com.

PIE MAGAZINE LETTER TO READERS

CREATIVITY>KNOWLEDGE Dear Readers,

I

f you saw someone in a Banana Suit, you might think that’s wild.

Now, forget about any Banana Suit, Watermelon Suit, or whatever.

MOZART IS HERE at AAO!!!

Friends, this is a phenomenon – a fun, funky, feast of medical communication – that’s happening only in ophthalmology.

Not dermatology, not cardiology, and not at any other medical conference in the world. I hope you’re wearing a REACTION watch by Kenneth Cole, because it’s time to react! Take notice! Get inspired! Get involved!

Boooom… whatever you are doing in ophthalmology, the media in which you do it has changed. Because we say so. A little arbitrary, I know. A little sad if you’re a stick in the mud, if you’re an ultra-buttoned up corporate type, or if you have no sense of humor or fun.

But if you do, oh baby, step up and enjoy something akin to David Hasselhoff on the Berlin Wall.

The times, they aren’t a changin’. They’ve changed already!

Don’t believe me? Consider the money that has supported PIE from show to show globally. How much do you think it would take to publish 5 publications in Hong Kong this past February, 4 of them overnight, in a city more expensive than New York, with a staff of 15 people?

How much would it take to roll that same process out again at the ESCRS/EURETINA meeting in Vienna a month ago?

To take our magazine to Hawaii at ARVO and here to Chicago?

To India?

So that’s America, Europe and two different parts of Asia.

We don’t have investors. And they don’t make string long enough for some kind of shoestring budget at this point.

All right, tough crowd. Room full of millionaires, I get it.

But then, why would we be embraced by our region’s most important society, the Asia-Pacific Academy of Ophthalmology (APAO) as this year’s official media partner if our approach was wrong? Why would we be the official media partner also of the Asia-Pacific Vireo-retina Society (APVRS), and be going deeper country by country within Asia-Pacific with new society partnerships? And why is a French ophthalmic society approaching us? I mean, no Eiffel Tower theme yet.

We also have a few aces up our sleeves in case you aren’t paying attention. What am I saying, OF COURSE YOU ARE! So yeah, you remember our antics from last year’s AAO in New Orleans: The Fruit Suits. The Banana Suits, Watermelon Suits, Orange Suits and perhaps the StrawberryFlower suits.

No? No landline phone either, eh? Well, leave your cave and ask a friend.

We have decided to take our themes a step further, so every issue we have a new Cover Story theme, new matching costumes and a new themed exhibition booth.

We therefore start with creativity to then pose ophthalmic questions, like this issue’s central theme/question: If Mozart instead were a surgeon today, what revolutionary tools and therapies would he use?

Notice the difference?

We at PIE are using creativity, whose byproduct is attention, to pose important ophthalmic questions.

In other ophthalmic media, any creativity is secondary to the dissemination of field knowledge.

So at PIE, creativity>knowledge while at other media, knowledge>creativity.

Now, we might be saying that a little strongly. PIE is full of ophthalmic knowledge and we revere it. But we’re talking about media here, which requires the creation of something, unlike say, short selling. It’s therefore natural to ally with creativity.

Other ophthalmology media, meanwhile, is naturally weak. Often they are the media mouthpieces of societies, for example, where the society>the media. In other cases, our competition is a spoke in a wheel of other media. There, the matrix>the media. Nothing there will be rocking the boat.

Well, we ain’t no society and we ain’t no matrix.

We swallowed the red pill in Asia, and now we’re making red pills worldwide. They’re all free by the way, as PIE always is.

Want one?

Matt Young CEO & Publisher PIE (Posterior Segment - Innovation - Enlightenment) Magazine

03

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PIE MAGAZINE ADVISORY BOARD MEMBERS Dr. Gemmy Cheung, MBBS(Lond), FRCOphth(UK) Dr. Cheung currently serves as deputy head and senior consultant of the medial retina service for Singapore National Eye Centre (SNEC), as well as senior clinician investigator for the Singapore Eye Research Institute (SERI). Her research interests include the study of risk factors and clinical features of macular diseases that may be unique in Asian populations.

Dr. Cheung has published more than 150 articles, mostly regarding age-related macular degeneration, including polypoidal choroidal vasculopathy, and conducted several clinical trials in anti-vascular endothelial growth factor therapies. Dr. Cheung has also been actively involved in training and education, and has served as an instructor on Asia-Pacific Academy of Ophthalmology (APAO) and American Academy of Ophthalmology (AAO) courses and many other educational programmes. In addition, she is also a volunteer faculty member for the ORBIS Flying Eye Hospital Programme.

Dr. Cheung has received a number of prestigious awards, including the Macula Society Young Investigator Award (2017), APAO achievement award (2017), APAO Nakajima Award (2014), APAO Outstanding Service in Prevention of Blindness Award (2013), the Bayer Global Ophthalmology Research Award (2012), the Roper-Hall Medal (2005) and the Elizabeth Hunt Medal (Royal College of Ophthalmologists, UK). [Email: gemmy.cheung.c.m@singhealth.com.sg]

Prof. Mark Gillies, M.D., Ph.D. Dr. Gillies presently holds a number of positions including: director of research and director of the Macula Research Group for the Save Sight Institute; foundation fellow for the Sydney Medical School; professor in the Department of Clinical Ophthalmology at the University of Sydney; head of the Medical Retina Unit at the Sydney Eye Hospital; deputy chair for the Ophthalmic Research Institute of Australia; and director of Eye Associates in Sydney.

Dr. Gillies has served as a principal investigator or associate investigator in more than 70 clinical trials, and his research regarding macular degeneration and drug safety and efficacy has been published in 188 journals. He has also received a number of grants to study treatments for age-related macular degeneration, retinal disease and Muller cell dysfunction – among other treatments and studies. Dr. Gillies has also appeared in national media on numerous occasions, including the evening news of all major networks, on ABC radio as a local expert, as well as in print media.

His dedication and research has resulted in multiple awards. Most recently, he received Gerard Crock trophies for the best papers at the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Annual Scientific Meeting (2013 and 2015), an achievement award from the Asia-Pacific Academy of Ophthalmology (APAO) in 2014, and an achievement award from the American Academy of Ophthalmology (AAO) in 2015. [Email: mark.gillies@sydney.edu.au]

Dr. Vishali Gupta, M.D. Dr. Gupta currently serves as a professor of ophthalmology at Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh in India. Throughout her career, she has completed original work in the fields of intraocular tuberculosis, optical coherence tomography, diabetic retinopathy, and fungal endophthalmitis. In addition, she is actively studying vitreoretina and uveitis diseases.

She has been published in 65 per-reviewed journals, and has authored 17 book chapters and four complete books. Dr. Gupta also holds a US patent for the development of multiplex PCR for uveitis. In addition, she is a sought after speaker, and has made more than 350 presentations in various national and international meetings.

Dr. Gupta has received several awards for her work, including the first JN Pahwa award from the Vitreo Retinal Society of India, the first NA Rao Award from the Uveitis Society of India, and the first NA Rao award from All India Ophthalmological Society (AIOS). [Email: vishalisara@yahoo.co.in]

05

POSTERIOR-ANTERIOR SEGMENT IOL FOR LOW VISION

Addressing Critical Needs of P with Bilateral Macul

by Olawale Salami

V

ision improvement in patients with bilateral macular scars remains a major challenge faced by retinal surgeons.

“For patients with bilateral macular scars, either from age-related macular degeneration (AMD) or from any other disease, there are limited options.

Usually, these patients are sent to a low vision clinic, where they are provided with low vision devices, which in many cases, do not meet the patients’ needs,” said Dr. Abhishek Kothari, director and chief vitreoretinal surgeon at the Pink City Eye and Retina Institute, a super-specialty center dedicated to the treatment, research and prevention of eye diseases in Jaipur, India.

According to Dr. Kothari, currently, there are limited surgical options for patients with bilateral macular scarring.

One option is the implantable miniature telescope (IMT) developed by Dr. Isaac Lipchitz from Israel (IMT; VisionCare Ophthalmic Technologies, CA, USA).

However, this implantable telescope is very difficult to insert and requires a large 7-8 mm incision for insertion.

The other option is the Scharioth macular lens (SML; Medicontur, Zsámbék, Hungary). The SML is a sulcus lens, flat design, with zero power optics except for a central 1.5mm diameter circle which has +10D power.

In the spectacle plane, the SML acts

like a +6 magnifying glass, which is optimal for patients with small macular lesions. “However, in patients with large macular lesions, the SML does not provide significant improvements in vision,” noted Dr. Kothari.

“The SML is very expensive, not readily available for patients in India, and has limitations in the range of power available. Therefore, we have developed the Sulcus Implantable Vision Aid (SIVA) lens for these patients.

It has significant improvements over the existing SML, including increased power from +10D to +12D and +14D. These three varieties offer more options for patients,” he explained.

Like a crystal ball, the SIVA lens allows patients to see clearly . . . although perhaps not into the future.

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Patients lar Scars with the SIVA Lens In addition, Dr. Kothari says that compared to the SML, where insertion requires good pseudophakia with no iridocapsular adhesions, the SIVA lens can be inserted in patients with capsular adhesions where the sulcus space is small, by utilizing 2 small pockets. This device is easy to implant in the sulcus by both anterior segment and retinal surgeons.

Furthermore, Dr. Kothari explains that the SIVA lens has wider indications as compared to the SML, which is indicated primarily for patients with bilateral macular scars. “For example, when the SIVA lens is inserted bilaterally in younger individuals with nystagmus,

their reading ability increases, and they can continue school and perform learning activities. This is a major advantage of this lens,” he shared.

In addition to individuals with bilateral low vision secondary to nystagmus, Dr. Kothari also said this new lens has added benefit for patients with AMD and macular scars, as well as patients with geographic atrophy involving the fovea, for which there is no treatment.

“A key advantage of the SIVA lens is the availability of wider range of powers: 10D, 12D and 14D. In addition, due to the vault design, as opposed to the flat design of the existing lens, the SIVA lens can be used in both pseudophakic and younger, phakic patients,” Dr. Kothari further explained. “The SIVA lens can give hope to patients who have bilateral low vision due to a variety of pathologies,

who are unable to use or unsuited to routine optic devices.”

“Notably, elderly patients with tremors or other motor disabilities, find existing low vision devices difficult to use, but with the SIVA lens, they can see improvements in near vision without using cumbersome low vision devices,” he concluded.

Editor’s Note: The SIVA lens was developed by Dr. Abhishek Kothari in partnership with several ophthalmic companies in India (currently Biotech Visioncare and Appasamy Associates).

The reason for giving the design to multiple companies, according to Dr. Kothari, is that they do not want to patent or have financial interest in the lens. The intention was to lower the cost of the IOL. Once more affordable, more patients can benefit from the lens.

The SIVA lens can give hope to patients who have bilateral low vision due to a variety of pathologies, who are unable to use or unsuited to routine optic devices.

About the Contributing Doctor Dr. Abhishek R. Kothari, MS, FMRF, FICO, FRCS, completed his undergraduate medical education from Coimbatore Medical College and ophthalmology residency from S.M.S. Medical College, Jaipur. He completed a fellowship in vitreoretinal surgery at Sankara Nethralaya, Chennai and worked at the world renowned Aravind Eye Care System in India. He has presented several research papers and has won prestigious awards at national and international fora (including The All India Ophthalmologic Society Academic Research Committee Award 2007, S Natarajan All India Ophthalmologic Society award for best paper in Retina in 2009, the International College of Ophthalmology Merit Award 2009, the Best paper in the All India Ophthalmologic Society Retina 2010, The Natarajapillai Award 2010, Asia Pacific Vitreoretinal Society Merit award 2010, the Rajasthan Ophthalmic Premier League Award 2012 and many others). He has also delivered numerous presentations in various national and international conferences. Dr. Kothari has published several papers and is the chief editor of a textbook on vitreoretinal surgery (Principles and Practice of Vitreoretinal Surgery, Jaypee Brothers, New Delhi), besides having authored several chapters in other textbooks. He is actively working on automated image recognition in OCT images using artificial intelligence/deep learning techniques, and has interests in the economization of high quality healthcare. He has trained several Indian and overseas vitreoretinal fellows. [Email: dr.a.kothari@gmail.com]

07

POSTERIOR-ANTERIOR SEGMENT OCULAR BLOOD FLOW

Let’s give them something to talk about. . .

Ocular Blood Flow: A Potential New Frontier in Glaucoma Prevention and Treatment

G

laucoma: The second most common cause of blindness AND the most common cause of preventable visual disability worldwide.

To date, reducing intraocular pressure (IOP) remains the mainstay for treating this progressive, neurodegenerative disease – however, this treatment is often only partly effective.

This could be because some patients – like those with normaltension glaucoma (NTG) – never experience elevated IOP. In fact, research shows that 20 to 30 percent of patients never have IOP of more than 20mmHg, but still show glaucomatous damage.1 Norman M. Aquino, M. D., clinical associate professor and chief of the Glaucoma Service of the University of the Philippines-Philippine General Hospital, Manila, Philippines, says that glaucomatous optic neuropathy is brought about by a variety of complex and interrelated biomechanical and biochemical factors. “These initiate a cascade of events that will eventually lead to retinal ganglion cell death,” he added.

Studies have found that some glaucoma patients may present with signs of ocular and vascular abnormalities. Moreover, patients with glaucoma have a higher incidence of vascular-related clinical symptoms such as low systolic blood pressure, migraines, peripheral vasospasm and obstructive sleep apnea syndrome.2 These suggest that factors other than IOP may be involved in the disease pathogenesis.

“The effects of IOP and vascular dysregulation are recognized as major risk factors in the pathogenesis of glaucoma,” said A/Prof. Aquino. “Their effects on ocular structures like the lamina cribrosa, ocular microcirculation and perfusion, and apoptosis are known and well documented.”

So, is IOP – while agreeably the most important risk factor for glaucoma – just one culprit of this progressive pathology?

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The current understanding of OBF in glaucoma In 2010, Martinez and Sanchez hypothesized that changes in ocular blood flow (OBF) are associated with the progression of glaucomatous damage.3 The authors believed it was conceivable that an increase in OBF may protect against glaucomatous visual field (VF) deterioration, and in the almost decade since, additional research has corroborated this theory.

Assessing VF progression remains one of the most important but challenging aspects of glaucoma management – therefore, a better understanding of pathology’s clinical risk factors may encourage the development of new strategies to improve care.

A review article published in the Asia-Pacific Journal of Ophthalmology (2016) stated that many studies have found that glaucoma is associated with decreased OBF. Research also shows that OBF reduction in the optic nerve head (ONH) is associated with glaucoma progression, and glaucoma patients with asymmetric visual field loss have lower blood velocity in the central retinal artery of the more affected eye.4 There is also a correlation between mean flow velocity and mean arterial blood pressure in the central retinal artery, and it’s stronger in subjects with primary open-angle glaucoma (POAG) than in healthy control subjects.

Eyes with advanced NTG also have significantly lower blood flow velocity and a higher resistive index in the central retinal artery and the short posterior ciliary arteries than eyes with milder visual field defects, even when IOP is similar. These findings led the authors to conclude that vascular factors may play an important role in patients with POAG and NTG.4 In addition, the Leuven Eye Study – which is noted to be the largest clinical trial on OBF in glaucoma – found that glaucoma groups had lower retrobulbar velocities, higher retinal venous saturation and choroidal thickness asymmetries when compared to healthy groups.2 This is supported by color doppler imaging, which has shown that

retrobulbar blood velocity is significantly reduced in eyes with high IOP.4 Population-based epidemiological and clinical studies have found that low ocular perfusion pressure (OPP) is closely related to the prevalence and progression of POAG.4 Therefore, determining the causative role of low OBF in the pathophysiology of glaucoma is an important goal of current research because it may lead to the discovery of new glaucoma treatments based on OBF.

Neuroprotection: Improving blood flow and preserving the visual field with medication

Different drugs have been used for the treatment of glaucoma and have been effective in lowering IOP. Among these, topical carbonic anhydrase inhibitors (CAIs) have been routinely used as concomitant medications.

Dorzolamide was the first topical CAI with a significant IOP-lowering activity to become available on the market.3 Medications from Santen Pharmaceutical Co. Ltd. (Tokyo, Japan) including dorzolamide and tafluprost (a prostaglandin analog) have been noted to aid in visual field preservation and have been studied for their neuroprotective benefits for patients with glaucoma. Now, they’re also being studied for their effects on OBF. According to a paper published in the Journal of Ophthalmic Visual Research (2016), “neuroprotection in the field of glaucoma is defined as any treatment, independent of IOP reduction, which prevents retinal ganglion cell (RGC) death.”

Neuroprotection aims to protect undamaged, and to rescue already damaged neurons, from the glaucoma insult(s) to retinal ganglion cells. It has the potential to prevent retinal ganglion cell death independently of the factors that damage the optic nerve. The authors list glaucoma medications with blood regulatory effects and nitric oxide synthase inhibitors among compounds with possible neuroprotective activity in preclinical studies.5

In 2010, Martinez and Sanchez studied rates of VF progression in eyes treated with dorzolamide–timolol compared with eyes treated with brinzolamide–timolol. They concluded that “the fact that both combinations (dorzolamide–timolol and brinzolamide– timolol) had a similar IOP-lowering effect, although different vascular effects, provides further evidence to support a local vasoactive effect as opposed to an ocular tension mechanism.” Treatment also had a strong influence on progression: The dorzolamide–timolol combination reduced the relative risk for progression by 48 percent compared with brinzolamide–timolol.3 This led the authors to suggest that that dorzolamide significantly increases hemodynamic parameters in retrobulbar vessels – and thus, is perhaps evidence that reduced OBF is associated with VF loss.

And according to A/Prof. Aquino, dorzolamide has been shown to influence ocular hemodynamics by dilating ocular blood vessels and thereby improving blood flow. “This will be beneficial in addressing the vascular aspect of the pathogenesis of glaucoma,” he said.

A study published in the British Journal of Ophthalmology by Stewart et al., suggests that dorzolamide, as a single agent and in fixed combination with timolol, has been shown to increase red blood cell velocity with pulsatile OBF, color Doppler and laser Doppler techniques in normal individuals as well as NTG and POAG patients. This positive effect on ocular hemodynamics has been greater than observed with other drugs – even with similar or lesser intraocular pressure lowering.6 Topical CAIs increase the velocity of OBF in the retinal circulation, central retinal, and short posterior ciliary arteries, but not in the ophthalmic artery.4 Tafluprost has also shown to have the effect of increasing OBF. This was shown in a 2017 study by Iida, et al., which evaluated retinal blood flow velocity change in the parafoveal capillary after topical tafluprost treatment in eyes with POAG. The authors found that mean IOP was significantly decreased (1 week,

−19.1%; 4 weeks, −17.7%; and 12 weeks, −23.5%; all P<0.001) and mean pBFV was significantly increased from the baseline at all follow-up periods after initiating treatment (1 week, 14.9%, P=0.007; 4 weeks, 21.3%, P<0.001; and 12 weeks, 14.3%, P=0.002). These results reveal that tafluprost may not only lower IOP but may also improve retinal circulation in POAG eyes.7

The experts chime in

Dr. Poemen Chan, Assistant Professor from the Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong (CUHK), Hong Kong, notes that some people continue to experience [glaucoma] disease progression despite meeting an acceptable intraocular pressure target: “We usually talk about reduction of IOP by 20 to 30 percent, but even with that, some people’s progression is out of control.” He says this has led experts to consider vascular components.

“We know that compromising vascular health is an issue [a risk factor] in the progression,” he explained. “When the blood supply to the optic nerve is compromised, we have degeneration.”

“If we have a situation where glaucoma continues to progress despite adequate pressure control, then we need to think about neuroprotection – and blood supply is part of neuroprotection,” said Dr. Chan. “The aim is to slow down the progression of glaucoma. Either it’s a ‘push factor’ – the IOP – or it’s the “supply factor” – the OBF.” “First of all, we know OBF plays a role. However, we don’t have a definite guideline of how much we should improve and when we should do it,” continued Dr. Chan. “There are several large population-based studies that specifically identify a decrease in ocular perfusion pressure, similar to ocular blood flow, as a risk factor for glaucoma. They manage to find ways to reduce retinal or choroidal or retrobulbar blood flow – but how should we quantify it? That’s the problem.”

Although ocular circulation at the retina and optic disc is known to be associated with the pathology of glaucoma, direct measurement of

blood flow velocity has been difficult to obtain.4 This is because blood flow in glaucoma however does not depend upon one type of circulation but rather involves multiple circulations including retina, choroid and optic nerve head.

So far there is not a single device or a technique, which can measure all three circulations. Therefore, multiple techniques have to be employed to study these circulations.7 “Medical treatment that will be able to adequately address both IOP and vascular dysregulation would be ideal,” said A/Prof. Aquino. “By controlling these two risk factors, the cascade of events leading to retinal ganglion cell death can be modified and will result in better control of the glaucomatous disease process. This will be translated to improved treatment outcomes.”

“The role of OBF is certainly worth looking into, especially in a significant portion of patients whom we have lowered the pressure enough, but glaucoma is still progressing,” said Dr. Chan. “All these need further investigation. And I suppose that’s the major challenge.”

References:

Mahar PS. Ocular Blood Flow and its Determination and Relevance in Glaucoma.

Pak J Ophthalmol. 2006, Vol. 22 No. 3.

2 Abegao, L, et al. Ocular blood flow in glaucoma – the Leuven Eye Study. Acta Ophthalmol. 2016: 94: 592–598 3 Martinez A, Sanchez-Salorio M. Predictors for visual field progression and the effects of treatment with dorzolamide 2% or brinzolamide 1% each added to timolol 0.5% in primary open-angle glaucoma. Acta Ophthalmol. 2010: 88: 541–552.

4 Nakazawa, T. Ocular Blood Flow and Influencing Factors for Glaucoma. Asia Pac J Ophthalmol. 2016;5: 38–44.

5 Doozandeh A, Yazdani S. Neuroprotection in Glaucoma. J Ophthalmic Vis Res. 2016 Apr-Jun; 11(2): 209–220.

6 Stewart W, Feldman R, Mychaskiw MA. Ocular blood flow in glaucoma: the need for further clinical evidence and patient outcomes research. Br J Ophthalmol 2007;91:1263–1264.

7 Iida Y, et al. Retinal Blood Flow Velocity Change in Parafoveal Capillary after Topical Tafluprost Treatment in Eyes with Primary Open-angle Glaucoma. Scientific Reports.

2017. 7: 5019.

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POSTERIOR-ANTERIOR SEGMENT PHACO-VITRECTOMY SYSTEMS Like these aces, combined Phaco-Vitrectomy systems also make a great pair.

Combined Phaco-Vitrectomy Systems

Revolutionizing the Surgical Landscape

by Olawale Salami

T

he integration of combined cataract and vitrectomy surgery into modern ophthalmic surgery systems has remarkable benefits for many patients, especially those with simultaneous anterior and posterior segment pathologies.

These all-in-one surgical platforms are providing surgeons with ultimate control – which is of paramount importance to every surgical procedure.

And features, like hypersonic technology, are proving to be a game changer in vitrectomy.

The Vitesse hypersonic vitrectomy system, exclusive to Stellaris Elite (Bausch+Lomb, Rochester, NY, USA), represents a revolutionary approach to vitreous removal. Using hypersonic technology, it liquefies vitreous for a new level of surgical control and precision. As opposed to standard cutters, hypersonic technology creates first a vitreous liquefaction highlylocalized at the front of the port, then liquefied vitreous is aspirated. Its openport design is 100 percent open 100 percent of the time for consistent flow,

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and its unique single-lumen design provides unobstructed aspiration.

“The Stellaris Elite is an excellent platform for vitrectomy and I find its integrated Vitesse hypersonic vitrectomy capability quite compelling,” said Dr. Carl C. Awh, the president of Tennessee Retina in Nashville, Tennessee, USA. Dr. Awh, who has used the Stellaris since it became commercially available, noted that the bi-blade vitrectomy cutter is outstanding and compared to other 27-G probes he has used, the Stellaris Elite bi-blade 27-G cutter is superior.

“It has a higher flow rate and more effectively removes vitreous,” he shared.

“The Stellaris Elite has enabled us to function very efficiently and effectively in a very busy vitreoretinal practice, and we can address all of the surgical challenges that retinal surgeons are familiar with. We don’t do cataract surgery in our practice but if we did, that would be a major advantage with the Stellaris Elite platform because it’s an outstanding phacoemulsification unit as well,” added Dr. Awh.

In his clinical practice, Dr. Awh has performed numerous retinal surgical procedures utilizing the Stellaris Elite and highlighted a recent case in which the Stellaris Elite proved particularly beneficial. “This was a very challenging case. The patient had total retinal detachment and a dislocated crystalline lens. Using the Stellaris Elite’s bi-blade cutter, I was able to completely remove all the dislocated lens material and then repaired the retinal detachment,” he shared.

Furthermore, Oertli Instrumente AG (Berneck, Switzerland) has developed the next generation of surgical platforms. One of them is the OS 4, with the primary aim of increasing the direct control of the surgeon’s actions and decreasing surgery time. The OS 4 is a powerfully efficient all-in-one platform for cataract, glaucoma and vitreoretinal surgery. As a versatile and user-specific OR device, the OS 4 works as the extended hand of the surgeon and carries out his orders and intuitions perfectly.

Talking about his reason for adopting the Oertli OS 4 platform in his practice, Dr. Manzar Saeed, MBBS, FRCSEd, FRCOphth, consultant ophthalmic surgeon at the Queen Elizabeth Hospital NHS Foundation Trust, King’s Lynn Norfolk, UK, stated

OS4 All-in one platform

OS4 Front Infusion

OS4 Pedal

that having tried other machines, OS 4 turned out to be the most feasible choice. “It has out-performed competitors in technical performance.

The business model was suited to my hospital’s financial preferences as well.

It’s simplicity of design and engagement with the manufacturing design team instilled extra confidence in me as a surgeon,” explained Dr. Saeed.

At first encounter, highlighted Dr. Saeed, the ease of use of the OS 4 platform was just remarkable. “My first-hand experience with the OS 4 led me to believe that it is not merely an upgrade from OS 3 (previous machine generation from Oertli) but an altogether new machine. OS 4 set-up and troubleshooting (never required so far), is also easy to learn from a nurse assistant’s point of view,” he shared.

Dr. Saeed also highlighted some outstanding features of the OS 4 platform. “Its 23-gauge gives me the best of both worlds: uncompromised speed, sutureless ports, viscous fluid injection as well as extraction without the need to enlarge ports. Also, OS 4 sclerotomy ports are stable and do not have leakage problems. Its pedal can be customized to have total and constant control over vacuum and cut rate,” he explained.

The platform’s versatility across a range of indications is truly remarkable, noted Dr. Saeed. “With the all-in-one OS 4 platform I can perform whole range of cases from simple to highly complex, as well as from soft to very hard cataracts. In complex cases such as diabetic vitrectomy whereby vitreous base shaving is common, control is of paramount importance,” said Dr. Saeed.

Dr. Saeed recalled a clinical case in which the performance of the Oertli all-in-one OS 4 platform was exceptional. “I had this trauma case where the lens had dislocated from the vitreous. This was complicated by dense vitreous hemorrhage. During vitrectomy, a retinal detachment with over 180-degree giant retinal tear was encountered. The OS 4 high performance bi-directional Continuous Flow Cutter performed extremely well in

Stellaris Elite Bi-Blade

Stellaris Elite

Stellaris Elite Graphic User Interface

removing the hard lens nucleus safely and efficiently,” he shared.

“Also, I was able to tailor the vitrectomy with different pumps [thanks to Peristaltic, SPEEPMode and Venturi options]. My default option is usually the unique SPEEPMode,” added Dr. Saeed.

In this case, the lens nucleus was removed with a Venturi pump while maintaining maximum suction and minimizing retinal damage by the

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POSTERIOR-ANTERIOR SEGMENT PHACO-VITRECTOMY SYSTEMS free-floating lens fragments. Peristaltic pump was employed during vitrectomy of anterior vitreous and base shaving, coupled with ultra-high speed 10,000 cut rate, allowing smooth operation without causing iatrogenic tears on a mobile retina.

“The dual linear foot pedal is a great design which I have customized to allow independent control of vacuum and cut rate – parameters which I can constantly change during vitrectomy,” he further explained.

And then there’s the simplicity of the Oertli OS 4 as a teaching tool: “The OS 4 is great for teaching due to its customizable foot pedal. I have found it incredibly useful to teach trainee surgeons, both for cataract and pars plana vitrectomy. I would recommend the Oertli all-in-one OS 4 platform unreservedly to other retinal surgeons,” concluded Dr. Saeed.

About the Contributing Doctors Dr. Carl C. Awh (pronounced “Oh”) completed a fellowship in vitreoretinal surgery at the Duke University Eye Center. He is an active investigator in industry and NIH-sponsored multi-center clinical trials, holds 10 U.S. patents for surgical devices, and has designed dozens of vitreoretinal surgical instruments. Dr. Awh is a consultant to numerous ophthalmic companies and is a frequent lecturer at international retina conferences. He has been named one of the “Best Doctors in America” and is the recipient of Honor Awards and Senior Honor Awards from both the American Society of Retina Specialists (ASRS) and the American Academy of Ophthalmology (AAO). He was named a charter inductee of the “Retina Hall of Fame” in 2017. Dr. Awh serves as Program Chair and Executive Committee Member for the American Society of Retina Specialists (ASRS). He is the happily married father of three children and enjoys golf, running, and travel. [Email: carlawh@gmail.com] Dr. Manzar Saeed is a consultant ophthalmic surgeon at The Queen Elizabeth Hospital King’s Lynn (NHS Foundation Trust), Norfolk, England. He completed his FRCS Ophthalmology, Royal College of Surgeons of Edinburgh in October 1995, and in July 2016, received his FRCOphth (Fellowship by Election). He has performed numerous complex cataracts, totaling over 15,000 to date. He has extensive experience in vitreoretinal surgery for all conditions including retinal detachment, macular hole, epiretinal membrane, complex diabetic disease, vitreous hemorrhage and treatment for floaters. He is currently responsible for teaching and training of VR Fellows. [Email: manzar.saeed@me.com]

INDUSTRY UPDATE

Heidelberg Engineering Announces Changes to Leadership Team

H

eidelberg Engineering GmbH (Heidelberg, Germany), a hightech imaging solutions company which designs, manufactures, and distributes diagnostic instruments for eye care professionals, recently announced changes to its leadership team.

New appointments to the leadership team include Ali Tafreshi, the new head of Product Management and Clinical Affairs, who previously served in sales, marketing and research in both the U.S. and German organizations for the past six years; and Krysten Williams, who helped establish the U.K. subsidiary seven years ago and will now move to the headquarters to support Marketing and Education.

They join Dr. Tilman Otto (Research and Development), Claus Gärtner (Finance, IT and Operations), Kfir Azoulay (Business Development

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and Healthcare IT), Erich Bangert (Sales and Customer Service) and Andrea Ritter (Human Resources) to form the new leadership team.

Christoph Schoess, who along with Dr. Gerhard Zinser founded the company nearly 30 years ago, will continue to jointly lead the company with Arianna Schoess as Managing Directors.

“In this leadership team we have so many talented people who have worked with the founders of the company for many years and others who have joined the company because of our ethos of uncompromising integrity,” explained Arianna. “This is the next generation that will carry on the tradition of exploring avenues that combine the company’s core technologies to create innovative, clinically relevant imaging solutions that empower clinicians to improve patient care.”

Arianna says as the company’s leadership passes to the next generation, it’s important to foster a positive collaborative environment to build a sustainable future for the company.

“Our family business has been built on the mutual trust and respect of a unique partnership between my father and Gerhard, the founders of the company. Their genuine humility has tempered success with self-examination and continuous improvement,” said Arianna. “This is the legacy that has been left in my care and I want to preserve it. If we uphold these principles, I know that we can continue to be successful.”

For more information about Heidelberg Engineering, visit www. heidelbergengineering.com.

POSTERIOR SEGMENT VITREORETINAL SURGERY

Alcon’s NGENUITY Revolutionizes Surgery with Greater Depth and Visualization

T

hanks to Alcon, the global leader in eye care, ophthalmic surgeons now have a new tool that will revolutionize the way they operate: Introducing the NGENUITY 3D Visualization System with DATAFUSION. The NGENUITY system’s high definition screen provides retinal surgeons unprecedented 3-D visualization of the back of the eye, with greater depth and detail during surgery than with traditional microscopes. Plus, with the DATAFUSION software, NGENUITY is now combined with the CONSTELLATION Vision System – the leading technology platform for vitreoretinal surgery. All of these revolutionary systems are linked together, which allows surgeons to track real-time data feedback on one screen during procedures.

In addition, when compared with traditional analog microscopes, NGENUITY delivers up to 19 percent increased magnification, up to 2.7 times extended depth of field, and up to 19 percent increased depth resolution.

These increases are much-needed by surgeons to see finer details during intricate surgeries.

“The high magnification is a real boon and a great advantage because you can look at the peripheral retina and look for tiny breaks which are often missed in the preoperative

examination,” said Dr. Atul Kumar, a CONSTELLATION and NGENUITY user.

The extended depth of field also helps surgeons like Dr. Kumar know how far away the membrane is from the retina.

In the past, Dr. Kumar says it was difficult to operate using traditional visualization – without 3-D visualization he couldn’t get the magnification he wanted: “I couldn’t see those semivisible membranes or nearly invisible membranes on the retinal surface as well as I see them now,” he explained.

And for many surgeons, when you can see better, you can treat better.

“I can treat a pathology much better intraoperatively, and the results seem to be much better using NGENUITY,” Dr. Kumar added. In addition, the high magnification is useful for many surgeries, including diabetic vitreous surgery. This is a benefit to Dr. Kumar as advanced diabetic eye diseases are common in India due to the high number of diabetic patients.

Dr. Kumar also says that the system has a short learning curve: “I picked it up very quickly… it took two weeks, and then I wanted to purchase the machine. We got the first unit in India,” shared Dr. Kumar.

The system is also beneficial for his students and residents as they can see exactly what he is doing on

Typical student reaction when seeing NGENUITY for the first time.

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the big screen. “Before the advent of NGENUITY, we used to just look at the tiny screen on the wall. That was a big handicap. Now we have a huge screen and they get to see what I’m doing. It is a very useful educational device. The younger generation will really benefit from NGENUITY,” said Dr. Kumar.

One of the other surprising benefits of NGENUITY for surgeons is that it’s a pleasure to use – many surgeons feel almost like they are watching a movie from the comfort of their own home.

“It is making me enjoy my surgery, otherwise it can become drab and boring … you don’t move forward,” he added. “I love watching the screen now. I can’t go back to looking through the microscope. I feel that without the screen, I will be handicapped.”

The DATAFUSION software seamlessly integrates the CONSTELLATION Vision System and the NGENUITY 3D Visualization System, allowing surgeons to track key data parameters on one screen in real-time, such as intraocular pressure, flow rates, infusion pressure and laser power. Dr. Atul Kumar is one of the many surgeons in India excitedly looking forward to the DATAFUSION software upgrade in their existing systems.

“I can alter my parameters accordingly based on the surgery and what is happening. It is going to be more helpful for the surgeon,” said Dr Kumar. He says surgeons will not want to go back to analog after trying NGENUITY: “Even if I leave this hospital and go into private practice I will still need NGENUITY. Now, I don’t want to operate without it,” he said.

Dr. Atul Kumar is chief and professor of ophthalmology at the Dr. Rajendra Prasad Center for Ophthalmic Sciences (RPC-AIIMS), the National Apex Ophthalmic Centre at All India Institute of Medical Sciences, Delhi. He also heads the Vitreo-Retinal, Uvea and ROP services at RPC-AIIMS.

POSTERIOR SEGMENT RETINAL DETACHMENT Post-injection Retinal Detachment

Expect the

Unexpected Floaters are a warning sign of retinal detachment.

by Olawale Salami

I

ntravitreal injection is a relatively safe procedure. However, given that most patients require repeated injections, serious complications such as retinal tears, retinal detachment, breakthrough hemorrhage and endophthalmitis can occur, according to Dr. Referano Agustiawan of the Jakarta Eye Center (JEC) in Jakarta, Indonesia.

Dr. Agustiawan reports that the average number of intravitreal injections in JEC is 1200 eyes per year (bevacizumab 30%, ranibizumab 33%, aflibercept 32%, steroid agent 4%, antibiotic 1%). He says that although data from JEC shows that the overall incidence of retinal detachment after intravitreal injection of antiVEGF agent is low (0 - 0.67%), it is one complication that must not be underestimated.

According to Dr. Agustiawan, patients’ risk factors include age (more common in patients over 40 years), high myopia and advanced eye disease.

In addition, he identified surgical technique as a key determinant of the rate of post-injection retinal detachment,

and poorly trained or inexperienced doctors pose a higher risk.

Early identification of retinal breaks is the key to successful management.

Dr. Agustiawan notes that it is important to explain to post-injection patients that they must return to the clinic as soon as they notice any floaters or blurring of vision because these may indicate early retinal break. “When patients present with alarming symptoms of retinal break

formation (i.e. floaters and flashes) they must be examined immediately for possible retinal detachment,” he explained.

“Retinal detachment presenting after retinal injection may be causally linked to the injection. However, one must be aware that retinal injection can be related to other causes in the postinjection period, which are not injection related. Therefore, careful peripheral retina examination in macular disease patients is mandatory before injection, and importantly, after repeated injections,” Dr. Agustiawan further emphasized.

Then how can we prevent or lower the risk of post-injection retinal detachment? Dr. Agustiawan explained that the precise site of injection (3.5to 4 mm posterior to the limbus) is important. He says that one should not hesitate to use calipers for injections, even if you have a lot of experience.

“In addition, it is important to see the peripheral retina clearly before injection,” he said. Furthermore, he says to use smaller gauge needles, and tunneled insertion of the needle to avoid vitreous reflux.

Editor’s Note: Dr. Agustiawan discussed the topic of post-injection retinal detachment as case presentation at the recent ASEAN Ophthalmology Society (AOS) Forum Meeting held in Bangkok, Thailand, on 2-4 August 2018.

About the Contributing Doctor Dr. Referano Agustiawan is a full-time ophthalmologist at the Jakarta Eye Center (JEC). His field of specialization is in vitreoretinal diseases. Dr. Agustiawan completed his basic medical education at the Medical Faculty Brawijaya University in Malang, Indonesia, in 2000. He then did post-graduate studies in ophthalmology from University of Indonesia, Jakarta, Indonesia. From 2004 to 2005, he was continuously involved in the ophthalmology care of patients in community eye health center in Lombok, West Nusa Tenggara, Indonesia, and performed various ocular surgeries, and high volume cataract surgeries. He did his fellowship in vitreoretinal surgery at the Aditya Jyot Eye Hospital, Mumbai, India, in 2008. His clinical work includes both medical and surgical retinal diseases, with a large content of age-related macular degeneration, diabetic eye disease (including complex macular edema and advanced proliferative diabetic retinopathy), retinal vascular disorders, retinal detachment including complex proliferative vitreoretinopathy and giant tears, and macular surgery including macular holes and epiretinal membranes. His practice also includes general ophthalmologic problems, cataract, retinopathy of prematurity (ROP) and ocular trauma. Dr. Agustiawan is involved in teaching and training of ophthalmology nurse and fellows in vitreoretinal specialty in Jakarta Eye Center. His area of interest for research is in cataract, vitreoretinal surgery, and clinical retina. [Email: referanoagustiawan@yahoo.com]

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POSTERIOR SEGMENT AGE-RELATED MACULAR DEGENERATION

Taking on Dry AMD with

Aflibercept

by Joanna Lee and Gloria D. Gamat

C

an we stop the onslaught of nonexudative (or dry) age-related macular degeneration (AMD)? A determined team of researchers from the Gifu Pharmaceutical University’s Department of Biofunctional Evaluation, Gifu, Japan, is on to the task. The group recently published a study1 in the Journal of Pharmacological Sciences on how the use of aflibercept could have a positive effect in the treatment of non-exudative AMD in a paper entitled “Intravitreal aflibercept protects photoreceptors of mice against excessive light exposure.”

Their investigation stemmed from a 2015 study by some of the group’s team members that showed an anti-placental growth factor (PlGF) antibody protected the retina in a lightinduced retinal damage model, which is commonly used as a model for dry age-related macular degeneration (or non-exudative AMD).2 To continue the first episode of their investigations in 2015, the team now looked at how aflibercept could inhibit both vascular endothelial growth factors (VEGF) and PlGF. Currently, aflibercept is used to treat exudative (or wet; neovascular) AMD, as well as retinal vein occlusion (RVO) and diabetic macular edema (DME).

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The team first set out to investigate if aflibercept could protect the function and structure of photoreceptors against light exposure in mice, as well as on PlGF-treated human retinal pigment epithelial cells (hRPE).

Using an animal study, carried out in line with ARVO Statement for the Use of Animals in Ophthalmic and Vision Research, the researchers conditioned non-anesthesized mice by exposing them to 24 hours of darkness in a room.

Next, they were exposed to three hours of 8000 lx of white fluorescent light and subsequently placed back into darkness for another 24 hours before being returned to the regular daily light cycle.

The mice were injected in the left eye intravitreally with aflibercept, or VEGF, or an anti-VEGF antibody before the light exposure.

After 5 days of light exposure, a recording of the electroretinograms (ERGs) and its analysis were carried out. Subsequently, after anesthesizing and dilating the pupils of the mice, the left eyes of the mice underwent a flash ERG and readings were recorded. Their left eyes were then removed from them

and placed into a solution containing 4% paraformaldehyde (PFA). They also measured the thickness of the outer nuclear layer (ONL) which was 240µm intervals from the optic disc to the periphery.

The next part of the test involved injecting hRPE cells which were previously incubated for 14 days and later stained for zonula occludens-1 (ZO1). This is in order to examine the tight junctions of the hRPE cells.

After being prepared, the eyes were then enucleated to evaluate the tight junction of the RPE cells in vivo. The team looked at the images photographed for three quadrants of the eye and manually traced the cell to cell junctions, pitting the thickness of the ONL against the distance from the optic nerve head.

What they found was an intravitreal injection of 20µg/eye of aflibercept before the light exposure significantly reduced the degree of the ONL’s thinning. However, the intravitreal injection of both the VEGF and the anti-VEGF antibody did not affect the thickness of the ONL.

When examining the tight junction protein of the RPE cells, they also discovered that the PlGF exposure caused a disruption of ZO1. However, aflibercept curbed the disruption of the RPE tight junctions caused by the PlGF. Furthermore, they also found that VEGF receptor signalling may be tied to the disruption of the RPE. More studies will be done to investigate the links between these two, as reports indicate that perhaps a balance of VEGF within the retinal neurons and RPE is essential.

Overall, the team’s previous and present studies seem to suggest that aflibercept, which traps PlGF and has been used widely for the treatment of wet AMD, could also be considered for the treatment of dry AMD. “Excellent clinical outcomes of anti-angiogenic agents in the treatment of retinovascular disease have been reproducibly demonstrated both in various clinical trials and clinical practice,” added Dr. Igor Kozak, clinical lead at Moorfields Eye Hospital Centre in Abu Dhabi, United Arab Emirates.

Vascular endothelial growth factor (VEGF)-A, VEGF-B, and PlGF are known to be elevated in these diseases, and their suppression leads to obvious, but perhaps not sustainable, clinical response.

Dr. Kozak says that while the ophthalmic community has been educated about molecules of VEGF

“

Excellent clinical outcomes of antiangiogenic agents in the treatment of retinovascular disease have been reproducibly demonstrated both in various clinical trials and clinical practice.

”

“

Apart from its primary role as antiangiogenic agent, aflibercept may have a secondary role as a potential neuroprotective agent. As such, this concept would be appealing not only to retinal exudative diseases but also to non-exudative diseases such as dry age-related macular degeneration.

”

– Dr. Igor Kozak family for years, PlGF came to doctors’ attention predominantly with the introduction of aflibercept to clinical use. The knowledge about the role of PlGF in retinal vasculopathies and especially diabetic retinopathy and diabetic macular edema has been exponentially growing.3-5 “The concept of blocking PlGF to preserve retinal microanatomy and electroretinography response is novel,” said Dr. Kozak. As demonstrated in the study of Kuse et al1, this was all achieved using aflibercept along with

tightening cellular junctions of hRPE cells disrupted by PlGF. “Apart from its primary role as antiangiogenic agent, aflibercept may have a secondary role as a potential neuroprotective agent. As such, this concept would be appealing not only to retinal exudative diseases but also to non-exudative diseases such as dry age-related macular degeneration,” concluded Dr. Kozak.

Editor’s Note: Dr. Kozak was generous enough to contribute on this story, but he was not a part of the mentioned study.

References:

Kuse Y, Takahashi K, Inoue Y, et al. Intravitreal aflibercept protects photoreceptors of mice against excessive light exposure. J Pharmacol Sci. 2018; S1347-8613(18)30130-0 [Epub ahead of print] 2 Izawa H, Inoue Y, Ohno Y, et al. Protective effects of antiplacental growth factor antibody against light-induced retinal damage in mice. Invest Ophthalmol Vis Sci. 2015;56(11):6914e6924.

3 Mesquita J, Castro-de-Sousa JP, Vaz-Pereira S, et al. Vascular endothelial growth factors and placentagrowth factor in retinal vasculopathies: Current research and future perspectives.

Cytokine Growth Factor Rev. 2018;39:102-115.

4 Al Kahtani E, Xu Z, Al Rashead S, et al. Vitreous levels of placental growth factor correlate with activity of proliferative diabetic retinopathy and are not influenced by bevacizumab treatment.

Eye (Lond). 2017;31(4):529-536.

5 Van Bergen T, Hu TT, Etienne I, et al. Neutralization of placental growth factor as a novel treatment option in diabetic retinopathy. Exp Eye Res 2017;165:136-150.

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About the Contributing Doctor Igor Kozak, MD, PhD, 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]

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Transforming Information into Insight with

Integrated Diagnostic Imaging

T

ime is of the essence – especially when managing progressive disease and prescribing treatment for sight threatening conditions that require swift and accurate intervention.

In a busy practice, where multiple diagnostic innovations are at play, a myriad of important but overwhelming testing data are being generated for each case. The arduous process of finding correlations among all the results is challenging for physicians who prefer to spend less time interpreting and more time leading their patients to better outcomes.

For Dr. Peter A. Karth, M.D., a Retina and Vitreous Physician & Surgeon, board certified ophthalmologist and fellowship trained retina specialist in Oregon (USA), reviewing and analyzing this everincreasing amount of data has become increasingly complex and unbearably time-consuming. “I need to be able to use this mountain of diagnostic data to support complex, and often expensive, treatment decisions,” he says. This task takes time – and as patient loads increase, it must be done quickly.

“How can we leverage our diagnostic tools to provide more efficient care to our patients? For me, the answer is simple: improved data integration, visualization, and analysis,” says Dr. Karth.

Thankfully for Dr. Karth – and ophthalmologists worldwide – an answer has arrived. From Carl Zeiss Meditec Inc. (Jena, Germany), the Integrated Diagnostic Imaging (IDI) platform not only means better care for patients, but more efficiency for doctors as well. This powerful software-driven system allows doctors to visualize and analyze data from different modalities all on one screen.

IDI Glaucoma case

Recently unveiled at the European Society of Cataract and Refractive Surgeons (ESCRS) 2018 meeting in Vienna, Austria, the ZEISS Integrated Diagnostic Imaging easily and seamlessly pieces together images from multiple modalities over time. By gathering, integrating and combining data from different diagnostic devices and developing simple individualized assessments, this platform helps doctors make optimal treatment decisions, quickly and efficiently.

IDI BRVO case

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IDI is expanding physicians’ level of care by providing a clinical cockpit for understanding. With multi-modal and treatment effect overlays, pointto-point registration and expanded temporal comparison ability, IDI is changing the landscape of diagnosis and treatment… for the better.

This multi-modality in diagnostics and imaging is increasingly becoming the standard of care in eye clinics. Not only does this technology save precious time, the ability to assess and compare

IDI 2Up screens

IDI is expanding physicians’ level of care by providing a clinical cockpit for understanding.

With multi-modal and treatment effect overlays, point-to-point registration and expanded temporal comparison ability, IDI is changing the landscape of diagnosis and treatment… for the better. data from multiple modalities also gives doctors more confidence in proposing customized treatment regimens for each patient’s needs.

This could have an impact on diagnosis and treatment of complicated retinal conditions. According to Dr. Karth, this integration is crucial in detecting, diagnosing and treating retinal disease. “One of the biggest challenges in retina practices today is viewing and integrating multimodal imaging to efficiently and fully assess macular disease in busy clinics,” says Dr. Karth.

For retinal applications, the IDI works with ZEISS’s gold-standard instruments such as CIRRUS™ HDOCT, ultra-widefield retinal camera CLARUS® 500, complimented with therapy with the new VISULAS green therapeutic laser.1 It allows physicians to see all relevant imaging on one screen, navigate patient data up to

three visits at a time, track treatment efficiency with history charts and clinical events, and review and analyze multiple exams simultaneously.

In addition, data from OCT Angiography can be registered from CIRRUS AngioPlex, and AngioPlex Metrix quantification tools support complex disease investigation. In addition, True Color HD ultra-widefield fundus images can be integrated and registered with OCT Angiography for targeted pathway visualization . . . allowing doctors to fully assess retinal diseases from the macula to the periphery in seconds.

“Retinal workplace2 gives clinicians fully integrated multi-modality assessment capabilities from the macula to the periphery with a single click in a few seconds all-in-one view,” adds Dr. Karth.

The ability to integrate data from multiple modalities is not just beneficial

for detecting and treating retinal diseases, it’s also valuable for managing glaucoma, a complex progressive disease that requires continuous followup assessment.

In glaucoma, with the IDI, results from visual field testing and OCT can be combined and associated to enable clinicians to identify changes in progression that could impact disease management. It simplifies the complex with a unique combination of data from the Humphrey Field Analyzer and CIRRUS OCT. By viewing this integrated information, doctors can detect signs and symptoms of glaucoma early, identify changes and create an individualized treatment plan.

These digital solutions can help doctors who are faced with an overwhelming amount of data from different sources – making eye care even more complex. Not only is analyzing this data time-consuming, it can also be inefficient: If the data is not correctly identified in the clinical findings, doctors could miss something that is vital to their treatment and prognosis. ZEISS and IDI are working to change that by transforming data into turning points of care.

“I consider the ZEISS Integrated Diagnostic Imaging platform to be a key part of patient management, giving me the data integration that I need to make the best decisions for my patients,” adds Dr. Karth.

For more information about IDI and to watch related videos, visit: https://www.zeiss.com/meditec/int/c/ zeiss-integrated-diagnostic-imaging. html.

This content was supported by an educational grant from Carl Zeiss Meditec. The products mentioned in this article may not be available in all regions for all indications.

VISULAS green therapeutic laser is 510(k) pending.

2 RETINA Workplace 2.5 is 510(k) pending.

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COVER STORY

Out of the

Opera Theater Operating The

and into the

What note would Mozart hit as an ophthalmologist?

by Brooke Herron

A

s one of the most famous classical composers, Wolfgang Amadeus Mozart often evokes complexities from previous periods, having created a combination of old, current and new uses for musical devices culminating in a masterpiece.

As a composer, Mozart was extremely versatile, working in every major genre – and he is credited as advancing the technical sophistication and emotional reach in each form. He spent the last decade of his life living and composing in Vienna, the location of 2018’s European Society of Cataract and Refractive Surgeons (ESCRS) and the European Society of Retina Specialists (EURETINA) congresses . . . and that

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got us thinking: If Mozart were an ophthalmologist today, instead of a composer then, what would he do?

Based on his musical style, we could say that his surgical technique would use a mix of traditional and modern therapies, with new insights.

His versatility would (naturally) extend into ophthalmology, so he would be well-versed in every major subspecialty.

In addition, his innovations and methods would undoubtedly advance the therapies, techniques and the tools of the trade. Indeed, Mozart would be looking into the future. Here we imagine which instruments (or therapies) Mozart would use as an ophthalmologist to create the perfect symphony of treatment.

Lasers and Anti-VEGF for the treatment of Diabetic Retinopathy (in C Minor) Like Mozart blending the older Baroque and newer Classical style, today, many ophthalmic conditions are treated with a combination of traditional and modern therapies. To Mozart, laser photocoagulation – which has been the mainstay of diabetic retinopathy treatment since the mid-20th century – would be a traditional, or Baroque, therapy. Its use was diminished by the more recent advent of anti-vascular endothelial growth factor (anti-VEGF); however many revolutionary advances in laser technology have been developed since.1

eater . . .

However, like Mozart, she is looking ahead: “Newer pharmacologic agents with even longer duration of action will be useful.”

Both Drs. Banker and Cheung see more innovation on the horizon.

He says new lasers – like subthreshold or micropulse lasers – will aid in the future treatment of DR and its related complications. These insights are echoed by Dr. Cheung, who has also heard that new lasers, like micropulse lasers, have been reported by investigators to produce good results for treating conditions like DME.

A Revolution of Lasers and Implants (an Encore)

Dr. Alay S. Banker, the director of Banker’s Retina Clinic and Laser Centre in Ahmedabad, India, finds harmony by using traditional laser pan retinal photocoagulation (PRP) for proliferative diabetic retinopathy (PDR) and modern anti-VEGF therapies for diabetic macular edema (DME). Dr. Gemmy Cheung, MBBS(Lond), FRCOphth(UK), deputy head and senior consultant of the medical retina service for Singapore National Eye Centre (SNEC) and senior clinical investigator for the Singapore Eye Research Institute (SERI), also uses modern anti-VEGF treatments to treat DME. “With anti-VEGF therapy, we use new pharmacologic agents, of which there are currently several in clinical use, as opposed to using laser (traditional method),” said Dr. Cheung.

A 2015 paper published by Samuel Yun and colleagues reported on newer lasers and treatments for DR and its related conditions.1 Whereas conventional laser therapy utilizes continuous wave of energy delivery, micropulse mode divides a single energy delivery of laser burn with cycles of 100 μs on time and 50 μs off down time until the full duration of laser spot (100–300 ms) is delivered.

The authors concluded that pilot studies have suggested the benefit of these subthreshold diode lasers [along with navigational lasers (NAVILAS)] for treating DME, while randomized trials combining these lasers with anti-VEGF therapy are yet to come.1 In addition to advances in laser technology, Dr. Banker says newer drug therapies for intravitreal use apart from anti-VEGFs will aid in the future

“Dr. Mozart”, he is a doctor now, you won’t want to hear his screechy violin…

treatment of DR. Indeed, new (Mozartapproved) treatment paradigms are in the works. A 2017 study published in Open Ophthalmology Journal reported that combined intravitreal dexamethasone (DEX) implant and micro-pulse laser for anti-VEGF resistant DME is both safe and effective.2 A meta-analysis published in 2018 evaluated the effectiveness and safety of DEX implant and intravitreal anti-VEGF treatment for DME. The authors found that compared with anti-VEGF, the DEX implant improved anatomical outcomes significantly – however, this did not translate to improved visual acuity, which may be due to the progression of cataract. They concluded that the DEX implant may be recommended as a first choice for select cases, such as for pseudophakic eyes, anti-VEGF-resistant eyes, or patients reluctant to receive intravitreal injections frequently.3

“

With anti-VEGF therapy, we use new pharmacologic agents, of which there are currently several in clinical use, as opposed to using laser (traditional method).

– Dr. Gemmy Cheung

”

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COVER STORY

“Dr. Mozart” still plays the piano today, but not well, as he is so focused on medical innovation.

“

Artificial intelligence and machine learning are being used to develop algorithms for mass screening and early detection of diabetic retinopathy.

”

– Dr. Alay S. Banker

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Artificial Intelligence and Machine Learning for Retinal Disease (an Opera)

PHACO, lasers and IOLS (a Piano Concerto of Cataract with Astigmatism)

Perhaps – out of all the new innovations – Mozart would have been most interested in the revolutionary implications of artificial intelligence (AI) and machine learning (ML). At the 2018 EURETINA congress, several sessions are dedicated to AI, regarding screening, diagnosis and treatment pathways for different posterior segment conditions.

Dr. Banker says: “Artificial intelligence and machine learning are being used to develop algorithms for mass screening and early detection of diabetic retinopathy.” A 2018 study called “Artificial intelligence in retina,” notes that fully-automated AI-based systems have recently been approved for screening of DR. The authors noted that the potential for this technology includes screening, diagnostic grading as well as guidance of therapy with automated detection of disease activity, recurrences, quantification of therapeutic effects and identification of relevant targets for novel therapeutic approaches. In addition, they concluded that “prediction and prognostic conclusions further expand the potential benefit of AI in retina which will enable personalized health care as well as large scale management and will empower the ophthalmologist to provide high quality diagnosis/therapy and successfully deal with the complexity of 21st century ophthalmology.”4 Dr. Harvey Uy, M.D., is the medical director at the Peregrine Eye and Laser Institute in Makati City, Philippines. He says that AI is an area of great research. Particularly regarding polypoidal choroidal vasculopathy (PCV), he says: “Artificial intelligence will compile genetic, demographic, phenotypic, angiographic, and previous response to treatment information and develop treatment algorithms for each patient.”

Dr. Uy also finds a mix of conventional and contemporary treatments benefit his patients with cataract (+ astigmatism). He says his first line of treatment is 75% conventional and 25% contemporary, being PHACO and laser-assisted (respectively). Like Mozart, Dr. Uy is also looking toward the future, noting that upcoming adjustable intraocular lenses (IOL) will allow surgeons to correct refractive errors that occur immediately, or even years after surgery.

One such adjustable lens was recently approved (November 2017) by the US Food and Drug Administration (FDA). The Light Adjustable Lens and Light Delivery Device from RxSight Inc. (formerly Calhoun Vision) is the first medical device system that can make small adjustments to the artificial lens’ power after cataract surgery.

According to the company, the IOL is made of a unique material that reacts to UV light, which is delivered by the Light Delivery Device, 17-21 days after surgery. Patients receive three or four light treatments over a period of 1-2 weeks, each lasting about 40-150 seconds, depending upon the amount of adjustment needed. The device is intended for patients who have astigmatism (in the cornea) before surgery and who do not have macular diseases.5 “There are also femtosecond lasers that can change the IOL refractive index to correct refractive errors,” added Dr. Uy. “It is a bright future for cataract surgeons and patients as refractive errors after cataract surgery will likely someday be a thing of the past.”

“

There are also femtosecond lasers that can change the IOL refractive index to correct refractive errors...

It is a bright future for cataract surgeons and patients as refractive errors after cataract surgery will likely someday be a thing of the past.

– Dr. Harvey Uy

”

Topical Therapies (a Chorus for Uveitis and Dry Eye Disease)

The Next Great Act in Treatment (yet Unwritten)

Two common ocular inflammatory diseases are uveitis, which is associated with inflammation of the inner eye, and dry eye disease, which affects the ocular surface. While the complexities of each condition vary, they are in the same genre – therefore traditional topical treatments are generally prescribed. According to Dr. Banker, steroids are often used topically and systemically for uveitis, while Dr. Uy prefers customized lubricants, ciclosporin drops, and limited steroid use to treat dry eye.

Like Mozart would, ophthalmologists today are seeking additional routes to ease discomfort from these inflammatory annoyances.

Dr. Banker suggests that newer nonsteroidal therapies and sustained drug delivery systems will aid in the future treatment of uveitis. This includes drugs like Humira, Sirolimus, as well as steroid implants and suprachoroidal drug delivery systems.

Those suffering from dry eye disease may also find relief soon, according to Dr. Uy. He currently uses the TearLab system and has recently employed keratography to treat dry eye. “Our Topcon slit lamp can also help us easily visualize the health of the Meibomian glands,” he added.

“In addition, we look forward to the introduction of the Allergan TrueTear system, which is a non-invasive device that stimulates immediate tear production.”

As an ophthalmologist, Mozart would have advanced the technical sophistication of existing procedures – he would have been interested in applying new therapies, tools and techniques to existing treatments to enhance their efficacy. This forwardthinking is shared by ophthalmologists worldwide as they seek out better diagnosis, treatments and tools to increase prevention and reduce treatment burden.

Dr. Uy is one such forward-thinker.

He says that extended treatment regimens will reduce the patient treatment burden for those suffering from PCV. This includes intravitreal injections every three to four months, and refillable anti-VEGF implants.

Currently, Dr. Uy utilizes a combination

Yep, “Dr. Mozart” knows medicine, and especially the revolutionary tools and therapies of ophthalmology today.

of anti-VEGF and photodynamic therapy (PDT) for treating PCV. And while Dr. Banker currently uses intravitreal injections to treat agerelated macular degeneration (AMD), he sees quite a bit of innovation coming for those suffering from the condition.

He says newer drugs, newer drug delivery systems, sustained-release devices, gene therapies, drugs targeting pathways other than VEGF, newer lasers will aid in the future treatment of AMD. It’s clearly an exciting time to be in ophthalmology as new devices, treatments and other innovations continue to emerge to advance the field. And at congresses worldwide, ophthalmologists in every major subspecialty convene and share ideas.

Between the mixing of old and new, rapidly advancing innovation and the exchange of knowledge, we believe Mozart would have felt right at home as a 21st century ophthalmologist.

As the great composer said: “We live in this world in order to always learn industriously and to enlighten each other by means of discussion and to strive vigorously to promote the progress of science and the fine arts.”

– Wolfgang Amadeus Mozart

References:

Yun SH, Adelman RA. Recent Developments in Laser Treatment of Diabetic Retinopathy.

Middle East Afr J Ophthalmol. 2015 Apr-Jun; 22(2): 157–163.

2 Elhamid AHA. Combined Intravitreal Dexamethasone Implant And Micropulse Yellow Laser For Treatment Of Anti-VEGF Resistant Diabetic Macular Edema. Open Ophthalmol J. 2017 Jul 21;11:164-172.

3 He Y, Ren XJ, Hu BJ, Lam WC, Li XR. A meta-analysis of the effect of a dexamethasone intravitreal implant versus intravitreal anti-vascular endothelial growth factor treatment for diabetic macular edema.

BMC Ophthalmol. 2018 May 21;18(1):121 4 Schmidt-Erfurth U, Sadeghipour A, Gerendas BS, Waldstein SM, Bogunović H. Artificial intelligence in retina. Prog Retin Eye Res. 2018 Aug 1. pii: S13509462(18)30011-9.

5 FDA approves first implanted lens that can be adjusted after cataract surgery to improve vision without eyeglasses in some patients. November 22, 2017. Available at: https://www.fda.gov/newsevents/newsroom/ pressannouncements/ucm586405.htm 1

23

PIE MAGAZINE

PIE rate AdVenTures of the

Posterior Segment

g with HOYA Medical India PIE Magazine CEO Matt Youn launch of the HOYA gym on Director Mukesh Sinha at the i.

Delh op, rooft any the comp

PIE Magazine recently went on a 2-week tour of India to launch its 06 “PIErates of the Posterior Segment” magazine issue at Ophthall in Chennai, at the BOA in Mumbai, and hit some spots in between in Delhi.

Of course, PIE did it all in PIErate style! Check out all our back issues at piemagazine.org if you dare!

PIE Magazine cuts the ribbon to open the new HOYA gym, which promotes exercise and ophthalmic work-life balance.

Working out with HOYA.

at Ophthall “Busy doing nothing” with delegates.

in Chennai

Our PIE Magazine distribution effort at Ophtha ll in Chennai.

It’s all fun and games until

k.

some doctor walks the plan

(Left to Right): Quartermaste r, First Mate, Captain, Gunner, Surgeon. The Powder Monkey, Sailing Master, Botswain and Cook are not shown. plundering, PIE Magazine CEO When he was not pillaging and nai.

Chen hall, Opht at e Matt Young spok

Over my dead body…

With south Indian Celebrity Sonia Agarwa

l at Ophthall.

Eyewear is fashion in

24

nnai.

India at Ophthall, Che

It’s great to see a PIErate (right) getting along with PeyeRates (left).

INNOVATION AMD MONITORING

Predicting the Future for

AMD Patients iHealthscreen’s Prediction Model for Risk of Progression to Late AMD

by April Ingram

M

onitoring and management of age-related macular degeneration (AMD) can be taxing on patients and their caregivers, as well as the eye care team. This burden might be eased if it were possible to tell which patients need more careful monitoring, which patients may progress, or which could wait a little longer between visits.

Now, the solution may not be that far away thanks to the innovators at

These tools are not effective predicting late AMD.

26

iHealthScreen, who have recently developed a product for automatic screening and prediction of AMD. Dr. Alauddin Bhuiyan, Ph.D., founder and CEO of iHealthScreen Inc., (USA), has been leading teams focused on artificial intelligence-based retinal and systemic disease screening.

Recently, Dr. Bhuiyan and his company developed an image-based prediction tool which can identify individuals at risk of developing late AMD. “This is

the first tool that can predict late AMD, non-invasively,” shared Dr. Bhuiyan.

This early-detection device is powered by artificial intelligence (AI) and machine learning (ML) and is intended to be used by healthcare providers through a telemedicine platform.

This is a game-changer in AMD management. As the leading cause of vision loss in those over the age of 50 in the developed world, the number of people with AMD is expected to increase 1.5-fold over the next 10 years due to an aging population, hypertension and other causes. Dry AMD accounts for 80 to 90 percent of all AMD diagnoses, and there is currently no treatment available for its advanced form, geographic atrophy.

Once detected, it is often too late to mediate the issue as too much vision has already been lost. And though treatment with anti-vascular endothelial growth factor (anti-VEGF) has revolutionized the management of neovascular (or wet) AMD, and is effective in maintaining or improving

Figure 1. The AMD screening system. [Photo credit: Dr. Bhuiyan]

vision, it is not curative.

In addition, the costs of AMD are significant. While the direct cost of AMD is $225 billion per year, and is expected to increase due to the snowballing number of AMD cases, the indirect costs are even greater: injury, depression, and social dependency resulting from blindness. The key to lowering costs and better treatment is effective screening, early detection and early intervention.

Dr. Bhuiyan says his group at iHealthScreen has developed this software tool for family physicians and optometry clinics to use during yearly patient checkups to detect and prevent this vision threatening disease.

“The tool will be used to determine (or screen) whether an individual with intermediate AMD should be referred to an ophthalmologist for further review.

Utilizing the software’s prediction capabilities, the ophthalmologist will then decide whether or not to administer AREDS (age-related eye disease study) supplements or further treatment to prevent the development of late AMD.” “The AMD screening tool can accurately identify early or intermediate stages of AMD at greater than 98 percent precision. The prediction tool

can identify an individual who will likley progress from intermediate to late AMD with 83 percent accuracy or above. This is the first image-based, non-invasive model which can predict an individual’s incident of late AMD,” he added.

So, how does it work? The device uses a fundus camera to capture a patient’s high-resolution retinal images.

Those are then uploaded and analyzed by an intelligent AMD screening system deployed on cloud servers.

Through fundus image analysis, the user receives a detailed disease level

indication analysis delivered to their choice of device almost instantaneously.

This telemedicine-based AMD disease screening system (Figure 1) has a web interface and a mobile app so that a user can get screening reports automatically, through the advanced automated eye-disease screening system. The system will be available for doctors, healthcare workers and patients to upload and access their medical data in a secure, HIPAA (Health Insurance Portability and Accountability Act) compliant system.

References: 1

2

Alauddin Bhuiyan, Arun Govindaiah, and R. Theodore Smith. A Prediction Model for Risk of Progression to Late Age-related Macular Degeneration (AMD). Investigative Ophthalmology and Visual Science, ARVO abstract, 2018.

Alauddin Bhuiyan’s recent interview at ARVO’18 conference. Available at: https://macularnews. org/2018/06/07/arvo-2018-alauddin-bhuiyan-phd/

About the Contributor Dr. Alauddin Bhuiyan, Ph.D., is the founder and CEO of iHealthScreen Inc., (USA) and is currently serving as a principal investigator of a National Institute of Health (NIH) grant. Dr. Bhuiyan received his Ph.D. from the University of Melbourne, which is one of the top universities in the world (no. 1 in Australia). He served a research scientist at the Centre for Eye Research Australia and Commonwealth Scientific and Industrial Research Organization (CSIRO), the top research institutes in Australia.

He was awarded prestigious Endeavour Fellowship (Australia Award) in 2014 and a Visiting Scholar at Harvard University. His team won Western Australia ICT Award (WAITA’14) and finalist of ICT Award’14 in research and development category. He received numerous grants, fellowships and scholarships from NIH, NHMRC and State and Federal Governments in Australia and the USA. He is a senior member of IEEE Computer Society. [Email: bhuiyan@iHealthScreen.org]

27

INNOVATION EXPLORING PATENTS

So, you want to be an

inventor?

by Brooke Herron

I

mprovement and innovation are constant in the medical field. This is especially evident in ophthalmology, where new technology (including surgical devices and imaging systems) is regularly emerging. And as experts in the field, ophthalmologists are well suited to address current needs and create new instrumentation.

Dr. Samir Sayegh, the medical director of The EYE Center (Chicagoarea, USA), is one such expert. He saw a need for a new surgical device – and thus, began researching to bring this invention from idea to fruition.

Dr. Sayegh teamed up with a Bostonarea patent attorney Wendy Thai, and together they collaborated to obtain three United States patents for his device.

PIE Magazine spoke with Drs. Sayegh and Thai about the process of applying for a patent. And while these tips specifically speak to applying for

28

a patent in the United States, some of these tips may apply internationally.

Tip #1:

Act Promptly – File as Soon as Possible If you think you have an invention you’d like to protect with a patent, you want to act promptly. According to Dr. Thai, it is not enough to have invented, you must be the first inventor to file a patent application. And you know your invention is ready for patenting if you can answer three questions: XX What does it look like structurally?

XX How do you make it?

XX How do you use it?

“Once the inventor can relay in words . . . on paper using drawings as needed . . . what the invention looks like, how to build it, and how to use it, he is ready for the patent process,” added Dr. Thai.

Tip #2: Timing is Crucial Patent laws vary from country to country. Some provide a period of time to file a patent application after the invention is made public. Others do not, and in these countries, patent rights are lost when the invention is made public.

“If you have an idea, it is best to file a patent application before any public disclosure. US laws provide a one-year grace period to file a patent application once the invention is publicly available, but this is not so in many countries. To preserve patent rights, it is best to file a patent application before sharing the invention with others. To preserve U.S. patent rights, you must file an application within one year of a public disclosure,” said Dr. Thai.

Tip #3: Collaborate with a patent attorney.

Just as ophthalmologists are highly specialized experts in their field, patent lawyers practice in a fairly specialized legal area. “Although U.S. laws do not say an inventor must use an attorney to file a patent application, a patent is a pretty complex technical and legal document” explained Dr. Thai.

Drs. Sayegh and Thai say that applying for a patent is a collaborative process. “It requires input from the technical expert and the legal specialist,” said Dr. Thai. “The inventor provides technical guidance on what the invention is, how to make it, and how to use it, and the attorney provides the know-how for protecting that.”

It’s also important to select an attorney who has the background to understand the invention. Each patent attorney has a technical background.

For Dr. Thai, it’s the life sciences – with a Ph.D. in biology, she has the background to understand Dr. Sayegh’s ideas and its application. She also mentions that some inventions may be cross-disciplinary. For example, you might have a surgical device with mechanical parts that utilize computer software or systems to operate fully. In this instance, more than one attorney might be involved in preparing the application and guiding it through the patent office.

Tip #4: Pay attention to the patent literature

According to Dr. Thai, your patent application will be examined to determine if the claimed invention is new and non-obvious before a patent is granted. She suggests paying attention to the patent literature, not just scientific journals, before and after you file your patent application: “It can take years to get a patent. You don’t want to continue to put forth resources trying to patent something someone else has patented or have tried to patent,” she said.

“It is also important to understand that this does not mean you have to exhaustively complete background research before you can apply for a patent. Not at all. First, you must file your application before someone else does and within one year of a public disclosure in the U.S. Second, it is not possible to be exhaustive. Inventors actually have no legal obligation to conduct any research before filing a patent application. In my experience, inventors are almost always up to date on the scientific literature. I would just suggest paying attention to the patent literature as well,” explained Dr. Thai.

Tip #5: One patent can beget another.

For Dr. Sayegh, one discovery led to three patents – which is not unusual.

One of his patents, “Eye Fixation System for Anterior and Posterior Surgeries and Procedures,” can be used in anterior segment surgery (including cataract surgery and refractive surgery) as well as for vitreoretinal procedures

“

and posterior segment surgeries (like vitrectomy and intravitreal injections).

The invention provides a universal tool for stabilization, fixation and accurate positioning and manipulation of other instruments. He also holds two related patents for a “Positioning Device for Eye Surgery and Procedures.”

“The initial discovery can lead to modifications that allow us to have patents covering slightly different variations of the initial discovery. When you file a patent application, that first application can form the basis for additional filings of ‘child’ applications.

The parent and child applications issue into patents that have different scope of coverage,” explained Dr. Thai. “We can file as many applications as necessary to fully protect the invention.”

Dr. Sayegh is currently courting manufacturer interest for his patents: “Having a patent not only protects your idea, it also makes larger companies more comfortable with manufacturing your device,” he said.

For more information on applying for a U.S. patent, visit www.uspto.gov.

Having a patent not only protects your idea, it also makes larger companies more comfortable with manufacturing your device.

”

About the Contributing Doctors Dr. Samir Sayegh was born and raised in Alexandria, Egypt.

He has studied in Paris, France and throughout the American Midwest (USA) and holds a MSEE, M.D. and Ph.D. in physics. He is a member of the American Society of Cataract and Refractive Surgery (ASCRS) and the American Society of Retinal Specialists (ASRS), a fellow of the American College of Surgeons (ACS) and the American Academy of Ophthalmology (AAO) and is a fellowship trained surgeon with sub-specialties in anterior segment and vitreoretinal diseases. He is currently the medical director at The EYE Center and divides his time between medical and surgical care of his patients and researching and implementing methods of effectively reversing blinding diseases, including cataracts and macular degeneration.

[Email: sayegh@umich.edu] Dr. Wendy Thai, Ph.D., is an experienced intellectual property attorney who works with public and private research institutions, independent inventors, as well as small and large companies to develop patent protection for inventions that have agricultural, industrial, and medical diagnostic or therapeutic applications.

She also assists clients who are developing new products by providing evaluations of third party patents. Wendy is a graduate of The University of Minnesota Law School and was a Managing Editor of the Minnesota Journal of Law, Science & Technology and a post-doctoral fellow in the Department of Medical Microbiology and Immunology at the University of Alberta in Canada.

[Email: wthai@mccarter.com]

29

INNOVATION OPHTHALMIC TOOLS

Bringing Ophthalmic Innovation to

Southeast Asia

SWISSMED: Bringing superior innovative products to Asian ophthalmologists since 2012.

by Matt Young

S

ince 2012, independent medical devices distributor SWISSMED Pte Ltd (Singapore) has been bringing European and American technology to Asian ophthalmologists. Owned and founded by Pascal Aeschlimann, the Singapore-based company aims to establish long-term partnerships with ophthalmologists through its high-quality and proven products in specialist areas including cataract, refractive surgery, dry eye, glaucoma, diagnostic equipment and practice development tools.

“We want to change behaviors and help doctors think differently . . .

Introduce a new way of doing things,” said Mr. Aeschlimann. “We’re not in the business to offer cheaper options for mainstream products, but every product we offer adds value to its user and aims at achieving greater outcomes for their patients. That’s what makes us different in this market.”

30

The company has several innovative products in its catalog and has partnered with nearly 30 companies and proudly promotes their products, including Oculentis (Berlin, Germany), LENSAR (FLA, USA), 1stQ (Mannheim, Germany), STAAR Surgical (CA, USA), TearLab Corporation (CA, USA), E-Swin (Paris, France), Rysurg (FLA, USA), ASICO (ILL, USA), ISP Surgical (MA, USA), Glaukos Corporation (CA, USA) and New World Medical (CA, USA).

According to Mr. Aeschlimann, SWISSMED’s continued plan for growth hinges on introducing superior products to market. One such product is a varifocal intraocular lens (IOL) from Oculentis.

“We were able to introduce this lens at the right time, when surgeons started to lose confidence in diffractive lenses . . . and it blew the minds of the doctors who tried it,” he said. “Witnessing the positive impact that this premium lens

has had in our customers’ practices has encouraged us to keep looking for such game-changing technologies.”

SWISSMED’s catalog also includes various products to diagnose and treat dry eye disease. The company has partnered with TearLab Corporation to distribute the TearLab Osmolarity System, which is intended to measure the osmolarity of human tears and aid in the diagnosis of dry eye disease. In addition to this diagnostic platform, the company also sells E>Eye (E-Swin, Paris, France), a device that produces perfectly calibrated and homogenously sequenced light pulses to stimulate the meibomian glands in order for them to return to their normal function.

“We were able to introduce technologies in a space dominated by paper strips (Schirmer’s test) and lubricating eyedrops. Now our customers can perform high-tech diagnostic and offer state-of-theart procedures to provide long-term relief

to their patients suffering from MGD and blepharitis,” explained Mr. Aeschlimann.

The company has also set its sights on treating conditions that are more common in Southeast Asia. One such condition is blepharitis, a bacteriainduced inflammation of the eyelids.

According to Mr. Aeschlimann, wipes have generally been prescribed to improve lid hygiene, but they have poor patient compliance. To better treat the problem, the company sells BlephEx™ (Rysurg, FLA, USA), a revolutionary new patented hand-piece, used to very precisely and carefully, spin a medical grade micro-sponge along the edge of the eyelids and lashes, removing scurf and debris and exfoliating the eyelids. “It’s something nice that doctors can offer in their practice. Instead of selling a box of wipes for $10, doctors can now do this procedure, charge $150 and it improves the patient’s comfort for months.”

Another area of focus for SWISSMED is glaucoma (the company distributes the Glaukos’ iStent). In some countries, the company sells the Kahook Dual Blade 1(KDB) from New FA DRYEYE SUITE 2.pdf 14/09/2018 10:04 AM World Medical, which is a blade that

strips off the trabecular meshwork. “We strongly believe in the future of MIGS to prevent the need for more complicated surgeries down the road. We prefer an approach targeting the trabecular meshwork, which is safe and does not involve blebs management issues postop,” added Mr. Aeschlimann.

This smaller, surgically focused company now employs 40 people across six offices in Singapore, Kuala Lumpur, Bangkok, Hong Kong, Manila and Brisbane, making it perfectly positioned to cater to the Southeast Asian market. The company also serves ophthalmologists in Japan, Vietnam and Indonesia.

“Our goal is to become the number one independent supplier of ophthalmic surgical products in Southeast Asia in the next three years,” said Mr. Aeschlimann. “Our team of hardworking individuals takes pride in introducing these game-changing technologies to our customers. Creating and enjoying the partnership with pioneer-minded ophthalmologists is what keeps us going the extra-mile.”

Editor’s Note: For more information about SWISSMED, and to view their full catalog of partners and products, visit www.swissmed.asia.

About the Contributor Mr. Pascal Aeschlimann is the owner and CEO of SWISSMED Pte Ltd. He has over 15 years of experience in introducing new medical devices technologies (ophthalmology) in Europe, Middle East and Asia. [Email: pascal@swissmed.asia]

INNOVATION OPHTHALMIC TOOLS Yamane Double Needle Technique Sets the Standard There three key points which should be noted during the technique are: 1.

Positional relationship of the wounds: it is appropriate for the wound where the IOL is inserted and the sclerotomy site where the 30-G needle is inserted, to be in positions that are separated by 90 degrees or less. By ensuring that the two sclerotomies remain 180 degrees apart, this makes it easier to insert the leading haptic into the 30-G needle.

2.

Double-needle technique: If the leading haptic is pulled out together with the 30-G needle, the IOL will rotate in the counter clockwise direction. If insertion of the tip of the trailing haptic into a 30-G needle is attempted, the trailing haptic will touch the cornea. Placing the haptic in the inner cavity of the 30-G needle resolves this issue and makes insertion easier.

3.

Insertion angle: to reduce stress on the IOL haptic, the direction of the 30-G needle should be identical with that of the haptics. Each 30-G needle is inserted at an angle of 20 degrees with respect to the corneal limbus. And at 5 degrees with respect to the iris surface.

by Hazlin Hassan

T

he new double needle technique for intrascleral haptic fixation

by Dr. Shin Yamane introduces higher standards in intraocular lens (IOL) scleral fixation surgery, and eliminates the need for conjunctival incision, suture or glue.

When Dr. Yamane, Assistant Professor at the Department of Ophthalmology and Micro-Technology at Yokohama City University, Japan, created his technique, his aim was to minimize the sclerotomies created during IOL fixation.

After several attempts, he successfully developed a new surgical procedure (Flanged Intrascleral Intraocular Lens Fixation with Double Needle Technique) which can be done without conjunctival incisions, suture or glue. The technique allows the procedure to be performed in a minimally invasive way, and in a much shorter time. But he realized that surgeons may face several challenges while attempting the double needle technique, as tunneling in the sclera and sclerotomy entry may prove to be a challenge to reproduce.

In order to address these challenges, Dr. Yamane, in cooperation with Geuder AG (Heidelberg, Germany), one of the leading manufacturers for ophthalmic surgical instruments, successfully designed a novel instrument which will enable surgeons to perform the technique.

32

The â&#x20AC;&#x2DC;Yamane Double-Needle Stabilizerâ&#x20AC;&#x2122; is aimed at standardizing the intricate measurements and angles needed to create reproducible sclerotomy entries and scleral tunnels.

The tool helps surgeons simplify the identification of sclerotomy sites and provides control over the insertion angles when creating the sclera tunnels.

It incorporates two landmarks for ease of visualization of the sclerotomy sites, at 2mm from limbus and 180 degrees apart, eliminating the need for axis markers, calpers or ink.

It also enables surgeons to place an IOL precisely into an aphakic eye by scleral fixation only, without conjunctival incision or suture or glue.

Designed with a ring shape and fixating teeth, the stabilizer provides excellent fixation of the eye when piercing it with the needles. The haptics are strongly attached to the sclera, preventing IOL dislocation in future.

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ENLIGHTENMENT OPHTHALMIC FAMILY

Reaching the Unreached

The Arunodaya Story

by Khor Hui Min

During PIE Magazine’s whirlwind ophthalmological adventures in India, the team was fortunate to meet Dr. Arun Sethi of the Arunodaya Charitable Trust (ACT) and the Arunodaya Deseret Eye Hospital (ADEH). Through these enterprises, Dr. Sethi and his wife Dr. Reena Sethi have found success in giving back with their work to treat curable blindness among the poorer populations in Delhi, India.

Arunodaya Charitable Trust (ACT)

F

ounded in 1990 and located in Delhi NCR, India, ACT is a registered, non-profit, public, non-denominational, medical, welfare trust. The trust focuses on addressing curable blindness, with the primary objective of restoring sight to the poor and needy. Since its inception, ACT has been instrumental in treating more than 1,145,000 patients. Of this number, about 40,400 have had their sight restored through successful surgeries.

“I come from an extended family of doctors (over 145, at last count), and with my wife Reena Sethi, an ophthalmic surgeon and a highly respected phaco surgeon, we decided to divide our professional career into two parts – private practice and community eye care,” said Dr. Arun Sethi, who is

34

the managing trustee of ACT and the ophthalmic director of ADEH. Both Drs. Arun and Reena Sethi derive immense professional and spiritual satisfaction from their community work.

“The inspiration to undertake charity work, simultaneously, in an organized manner, came from my schooling at St. Xaviers (a Jesuit Catholic School), at Christian Medical College, at my residency at the Institute of Ophthalmology, AMU, and during a fellowship at Aravind Eye Hospital, Madurai,” added Dr. Sethi.

Arunodaya Deseret Eye Hospital (ADEH) ADEH is a state-of-the-art tertiary eye care facility, inaugurated on January 1, 2005. It is the first of its kind located in

New Gurgaon township in Delhi NCR. ​“Our chance meeting with Dr. E.W. Jackson, a visiting U.S.-based family physician, led to us join forces and see our first patient . . . under a tree, in a suburban village, in New Delhi,” recounted Dr. Sethi. “From there, we began and never looked back.”

Following a cross-subsidy model, nearly 70 percent of the out-patients at ADEH are treated for free, or at a nominal charge. These treatments are targeted to the low-income sections in the rural areas of Haryana. Meanwhile, the other 30 percent who can afford treatment help fund the institution with revenue for its operational expenditure.

In this way, ADEH is trying to effectively contribute towards the control of avoidable blindness, in Gurugram and other areas of Delhi NCR.

Reaching Out to Serve the Community To make eye care affordable to poor patients, free services are provided in their camps. There is a dedicated floor at ADEH for charity patients, who pay a nominal fee of INR Rs. 50 (about $0.70 USD) for a one-time registration, and receive two consultations per week, for only Rs. 100 (about $1.40 USD). ADEH also provides patients with subsidized spectacles and eye medicines in the charity clinics.

The paying patients pay about 75 percent of the current consultation fee charged by other hospitals. The hospital staff explain that a significant portion of that fee is used to subsidize needy patients.

“Super-Specialty” of the Sethi Family

Turning the Dream into a Reality The husband and wife team started with no infrastructure and no funds but held the firm belief that they could only improve as they had nothing to lose.

They felt that their passion, skills and professional zeal was enough – and it seems they were correct. To date, they have served 1.5 million needy patients.

“In business, you plan, strategize, and then implement. In charity, you fire, and then look around – what have I hit (achieved)?” joked Dr. Sethi.

By keeping their overhead expenses to the minimum and running a multi-tiered system, they have been able to provide free services, as well as dispense spectacles and medicines, at eye camps in designated villages.

Over the decades, eye care has become the Sethi family’s “superspecialty,” where they can serve across all sections of society, in an efficient and cost-effective manner – and with a spiritual touch.

“What we offer is of immense benefit to the patients, especially those with limited income. At the same time, it’s very professionally rewarding for young ophthalmologists who get to see a lot more ocular diseases and pathologies,” said Dr. Sethi.

“Our family consists of five ophthalmologists, plus two employed consultants who share our vision, and this enables us to work in a good-sized

footprint, covering nearly 50 villages, rural government schools, among others,” he said.

Dr. Sethi further added: “We have just launched a separate floor, as a Super-Specialty Eye OPD, to increase our footfalls in the various sub-specialties, including vitreo-retina, pediatric ophthalmology, glaucoma and refractive surgery. In addition to generating more paying patients and making all these viable . . . and when this surplus happens, we would like to extend more of these facilities with corporate support to the economically weaker sections of our society.”

They also plan to create a distinct cutting-edge facility for clinical research to reach out the population in that area.

When asked if he would like to convey a message to the readers of PIE Magazine, Dr. Arun Sethi said: “Follow your passion, and you will then enjoy your lifelong journey, with some marvelous rewards gained along the way.”

Dr. Arun Sethi (center, in gray), with PIE Magazine CEO Matt Young, at his home in New Delhi.

About the Contributing Doctors Dr. Arun Sethi and Dr. Reena Sethi have over 30 years of experience in clinical and surgical ophthalmic practice. They are consultants to leading hospitals in New Delhi, including Indraprastha Apollo Hospital, Escorts Heart Institute and Research Centre, Diplomatic Missions: including the American Embassy, British High Commission, and the Canadian High Commission. They are also members of leading professional ophthalmic societies such as the American Society of Cataract and Refractive Surgery (ASCRS), American Academy of Ophthalmology (AAO), and All India Ophthalmological Society (AIOS). [Email: flyingdoc16@yahoo.com]

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Clearly hiding something

2016

2018

This diabetic retinopathy (DR) patient’s clinical exam revealed nothing out of the ordinary.

And his OCT B-scans only showed changes in a small area. But the new AngioAnalytics® OCTA metrics clearly quantified retinal vessel loss throughout the entire scan area over the course of two years. For objective OCTA data analysis to aid clinical evaluation of DR, the logical choice is AngioAnalytics—only from Optovue.

Visit booth number 1026 at AAO 2018 for a demonstration. It will be revealing. © 2018 Optovue, Inc. AngioAnalytics is a registered trademark of Optovue. Images and diagnosis courtesy of Bernard C. Szirth, OD, Rutgers New Jersey Medical School Department of Ophthalmology and Visual Science.

Our vision is foresight

CONFERENCE HIGHLIGHTS DMS ASEAN MEDICAL CONFERENCE 2018

ASEAN Ophthalmologists Collaborate to Improve Healthcare Services in the Region

by Collins Santhanasamy

O

phthalmologists from across the ASEAN region and Taiwan and India, recently convened at the Sukosol Hotel in Bangkok, Thailand, to participate in the first Department of Medical Services (DMS) ASEAN Medical Conference 2018.

The crowd was warmly welcomed by the Director General of the DMS, Dr. Somsak Akksilp and Deputy Director General, Dr. Pannet Pangputhipong, who stressed the importance of proactive discussion and collaboration to jointly improve healthcare services across the ASEAN region.

The conference hosted two highly anticipated forums, namely the ASEAN Ophthalmology Society (AOS) Retina Forum and the AOS Cornea Forum.

The Taiwan-Thailand Retinal Meeting and the 3rd ASEAN Emergency Medicine Executive Meeting on ASEAN emergency medicine and disaster preparedness were also held during the three-day program.

During the retina forum, Dr. Hui-Chen Cheng from Taiwan shared findings from her study on the impact of air pollution in ophthalmology. Air pollution is a global hazard, with the highest particulate matter pollution found across the African and Asian continents. High amounts of nitrogen dioxide gas have shown to induce goblet cell hyperplasia as well as an

increase in the incidence of ocular irritation, conjunctivitis and dry eyes.

Research indicates that high levels of air pollution impact deep retinal microvasculature, resulting in the narrowing of central retinal artery equivalents (CRAE) and even central retinal artery occlusion (CRAO). Altering activity patterns on high pollution days, reducing traffic density and the combusting of fossil fuels are key strategies in lowering the risk of health-related issues associated with pollutants.

Dr. Sritatath Vongkulsiri from the Phramongkutklao Hospital in

Bangkok, spoke on 3-mm pars plana (PP) sutured fixation for posterior intraocular lens (IOL) dislocation using dislocated IOL. This is an alternative method to conventional treatment by transscleral ciliary sulcus (CS), which comes with risk of IOL complications including captured IOL and posterior iris rubbing. In his study, Dr. Sritatath found that there was good postoperative visual outcome and no significant postoperative complications associated with PP IOL fixation.

Dr. Tharikarn Sujirakul from the Ramathibodi Hospital at Mahidol University presented on paraneoplastic

Dr. Paisan Ruamviboonsuk (second from left) and dignitaries officially launch the 1st DMS ASEAN Medical Conference 2018.

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CONFERENCE HIGHLIGHTS DMS ASEAN MEDICAL CONFERENCE 2018

PIE Magazine CEO Matt Young and Dr. Paisan Ruamviboonsuk at the conference.

Conference delegates.

related retinopathies. Dr. Tharikarn highlighted that patients who suffer from retinal-based paraneoplastic syndromes present with a variety of clinical findings which differ from case to case and that diagnosis should be given due consideration in patients who present with bilateral rapid progressive visual loss, in spite of no history of previous malignancy. A thorough ocular and systemic history coupled with the use of multimodal imaging and electrophysiological testing is essential to achieving a diagnosis. Aggressive systemic work-up for primary or metastatic tumours should be done in every suspected patient.

In 2006, when optical coherence tomography (OCT) technology began to be widely available, macular telangiectasia (MacTel) was classified into type I and II: aneurysmal and perifoveal telangiectasia. Dr. Paisan Ruamviboonsuk from the department

of ophthalmology at Rajavithi Hospital in Bangkok, Thailand, spoke about MacTel and highlighted the characteristics of both types. MacTel is diagnosed clinically and tests like OCT and fluorescein angiography (FA) are only to be used for confirmation of the diagnosis. While type I is generally unilateral, type II usually affects both eyes and is three times more common than type I. There is however, data that indicates that the prevalence of MacTel type I may be more common in Asians as compared to type II, with 74% in a Japanese cohort and 62.5% in a Korean cohort.

Editor’s Note: The first DMS ASEAN Medical Conference 2018 was held in Bangkok, Thailand, on 2-4 August, 2018. Representatives from Media MICE Pte Ltd and PIE Magazine were there to cover this milestone event.

INDUSTRY UPDATE

The 514nm Coagulation Laser

Shows Benefits over 532nm System

A

ccording to Dr. Udo Heuer, ophthalmologist at Medical Eye-Care in Hamburg, Germany, the majority of his diabetes patients suffered from stress when he performed a grid/pan-retinal coagulation. He says that the procedure could take up to 25 minutes, and because the patients were in pain they would close their eyes or blink before the target number of expositions was achieved.

“In former days, the argon gas lasers delivered 514nm wavelength which was less aggressive . . . many of the first-generation ophthalmologists remember the difference when changing their equipment to solid state

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YAG lasers with 532nm,” explained Dr. Heuer. “Patients complained more and the coagulation spots appeared somehow faster. Today, microchip technology allows us to overcome this hurdle.”

This new Nano-Laser system – the 514nm endo FOX laser by A.R.C. Laser GmbH (Nuremberg, Germany) – is generating positive feedback from ophthalmologists, like Dr. Heuer.

Perhaps the smallest and most compact coagulation laser in ophthalmology today, this system has been shown to reduce patient stress, induce less pain and overall improve treatment success.

“The 514nm laser wavelength is

now offered to us, and I am quite happy about that,” continued Dr. Heuer. “With the new 514nm laser, we performed more than 500 treatment spots on the retina on all of our latest diabetes patients, without the need of any additional parabulbar anesthesia.”

He says that reducing the patients’ pain enhances their cooperation, which leads to quicker treatments. “This success is a result of completed and uninterrupted coagulation, which is much more likely with lasers causing less pain,” he added.

For more information about this, and other laser systems, visit www. arclaser.de.

CONFERENCE HIGHLIGHTS THAILAND OPHTHALMOLOGY FORUM

Color Vision Deficiency (CVD) 101 Based on a presentation about Policy Advocacy on Color Vision Deficiency (CVD)

by Dr. Warapat Wongsawad M.D., ophthalmologist and head of Vitreo-Retina Division at the Mettapracharak (Wat Rai Khing) Hospital, Thailand, at the recently held Thailand Ophthalmology Forum

C

olor vision deficiency or CVD affects approximately 1 in 12 men (8%) and 1 in 200 women across the globe. Patients who are not suffering from severe types of color vision deficiency may not even be aware of differences among colors that may be obvious to the rest of us and may only find about their condition after being tested.

The retina comprises three types of photoreceptor cells: rods, cones and the intrinsically photosensitive retinal ganglion cells (ipRGCs). While rod cells are responsible for scotopic vision (vision under low-light conditions), cones are responsible for color vision and function the best in relatively bright light. These cone cells are densely packed in the fovea centralis and reduce in number towards the periphery of the retina. There are about six to seven million cones in a human eye and they are most concentrated towards the macula. Three different types of cones (type S, M and L) are responsible for receiving short, medium and long wavelengths from the visible spectrum.

There are a variety of factors that may lead to color vision deficiency.

The cause of deficient color vision in the majority of people is due to genetic factors which are inherited. Other patients may become color vision deficient as a result of other diseases, such as diabetes and multiple sclerosis. They may acquire the condition over time due to the aging process, medication or other factors.

Chromosomes contain genes with instructions for the development of cells, tissues and organs. The 23rd chromosome is made up of two parts – either XX chromosomes if you are female or XY chromosome if you are male. If you are color vision deficient, it means that the instructions which are contained in the 23rd chromosome for the development of your cone cells are faulty and the cone cells might be missing or less sensitive to light. There

might be a development error in the pathway to the brain as well.

The “faulty” gene for color vision deficiency is found only on the X chromosome and so for a male to be color vision deficient the faulty color vision deficiency gene only has to appear on his X chromosome. For a female to be color vision deficient it must be present on both of her X chromosomes.

If a woman has only one color vision deficiency gene she is known as a carrier but would not be color vision deficient. When she has a child, one of her X chromosomes will be passed down to the child. If she gives the X chromosome with the faulty gene to her son he will be color vision deficient, but if he receives the “good” chromosome he would not be color vision deficient.

This inherited color vision deficiency is caused by abnormal photopigments. These color-detecting molecules are located in the cone cells and, in humans, several genes are required for the body to synthesize photopigments. Defects in these genes may lead to color vision deficiency.

There are three major types of color vision deficiencies, which depend upon photopigment defects in the three different kinds of cones that respond to blue, green, and red light.

Red-green color vision deficiency is the most common (affecting 99% of color vision deficiency patients), followed by blue-yellow color vision deficiency. A complete absence of color vision or total color vision deficiency – is rare.

Testing color vision Clinically, Ishihara color test plates are the most commonly used tool to test for color vision deficiency worldwide due to their easy usability and high accuracy.

However, in order to test for the severity of color vision deficiency, the gold standard is the Nagel’s anomaloscope.

Early symptoms in children The main symptom of color vision deficiency is a difficulty in distinguishing colors or in making mistakes when identifying colors. »» Using the wrong colors for an object –e.g. purple leaves on trees, particularly using dark colors inappropriately »» Low attention span when coloring in worksheets. Color vision deficient children may not like to color in pictures or want to play counting or sorting games with colored blocks or beads. »» Denial of color issues »» Problems in identifying red or green color pencils or any color pencil with red or green in its composition. (e.g. purple, brown) »» Excellent night vision »» Identification of color may be made worse by low level light, small areas of color and colors of the same hue »» Smelling food before eating »» Excellent sense of smell »» Sensitivity to bright lights »» Reading issues with colored pages or worksheets produced with color-on-color »» Children may complain that their eyes or head hurt, if looking at something red on a green background, or vice versa.

Treatment and management There is currently, no treatment for inherited color vision deficiency although research in gene therapy is ongoing.

Patients may use special color friendly contact lenses and glasses for the color vision deficiency which are able to aid in the perception of colors.

Editor’s Note: The Thailand Ophthalmology Forum was held at the Sukosol Hotel in Bangkok on 2-4 August 2018. The 3-day forum was held in collaboration with the ASEAN Ophthalmology Society (AOS) and the 3rd Taiwan-Thailand Retina Society Joint Meeting.

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CONFERENCE HIGHLIGHTS OPHTHALL 2018 COVERAGE Key Factors to Successful

Ophthalmic Entrepreneurship Highlighted at

OPHTHALL 2018

Ophthalmologists want to ROAR too, just like Katy Perry... and some cats.

by Collins Santhanasamy

O

PHTHALL, India’s most happening optical event, was held from August 18 to 19, 2018 at the Chennai Trade Center in Chennai, India. The event was designed as India’s first practice development conference for ophthalmologists, eye hospital managers, optometrists, technicians, nurses and anyone working in and for eye hospitals.

Following opening remarks by Dr. T. Senthil, the program was inaugurated by chief guest, Padmasri Dr. G. Bakthavathsalam Naidu, chairman of K.G. Hospitals, Coimbatore and the founder of K. G. Eye Hospital, an exclusive multi-speciality eye hospital where more than 90,000 low-income patients have undergone free IOL cataract surgeries.

OPHTHALL 2018 offered a unique insight into practice development and focused on the business aspect of ophthalmology. When an ophthalmologist steps into practice for the first time, they also become an entrepreneur, and have to factor in different variables and play multiple roles, which they may not be prepared for.

The conference sessions were focused on four major categories: XX Start-ups – Eye clinics and hospitals that have just started XX Sustenance – Eye clinics and hospitals which are less than 10 years old and in the growth stage and providing decent revenues XX Scale-ups – Established eye hospitals that want to move up to next level, i.e. opening multiple branches or new facilities XX Succession or Exit – Eye hospitals that are 30+ years in existence and planning on succession or exit Conference themes were designed to focus on a variety of topics including: hospital/clinic designs, new business models in eye care, impact of insurance on eye hospitals, training and retaining of staff in eye hospitals, telemedicine, artificial intelligence, robotics, improvement of safety and security of hospitals, among others.

One panel discussion on increasing patient footfalls was moderated by Dr. Anand Parthasarathy with four other panellists. The panel discussed several key points including

the need for market surveys, which would play a major role in pricing of services. One panellist, Mr. Sandeep, highlighted that a common error made in new businesses is to copy the service pricing and tariffs of other competitors without factoring in three key factors that are essential to pricing of services: •

the socio-demographic and economic profile of the target audience;

•

an evaluation of the cost of services provided through a costing exercise;

•

and a comprehensive study on the pricing of services provided by competitors, which would consider multiple factors including patient demographics, physical location and services provided.

Panellist Ms. Deepshika Shukla pointed out that although 20 percent of the population requires eye care every year, and that every household has at least one eye patient, new practices are facing difficulties with patient footfall.

This is in spite of good infrastructure, skilled surgeons and the availability of sophisticated treatment options.

The panel stressed the importance of intelligent billing and designing a business plan with a clearly defined vision and a mission statement to enable quality treatment with maximum patient engagement and satisfaction.

Several panel discussions were held over the two-day conference on various topics ranging from the Future of Ophthalmology to Group Practice and Scaling-up of Services. Other presentations on The Importance of the Internet, Social Media Marketing in this Digital Age and New Business Models in Eye Care drew large enthusiastic crowds.

Editor’s Note: PIE Magazine’s parent company Media MICE Pte Ltd was the official media partner of OPHTHALL 2018.

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CONFERENCE HIGHLIGHTS EURETINA 2018

BEST OF PIE Post

Artificial Intelligence,

Will Transform and Disrupt Ophthalmology

by John Butcher

A

rtificial intelligence will prove both disruptive and transformative to the ophthalmology industry, according to experts speaking on the opening day of the recently held 18th EURETINA Congress in Vienna, Austria.

Rapid advances in artificial intelligence (AI) driven by powerful computers and vast amounts of data will result in new models of care, financial savings, faster diagnoses, and improved patient services, experts told an audience on September 20. It will become an integral part of how the best in the profession operate, they added, and it could offer potential beyond human abilities.

“AI will offer sustained benefits to the ophthalmology industry,” Dr. Adnan Tufail, a consultant ophthalmologist at Moorfields Eye Hospital in London, told the audience.

Those benefits are already becoming apparent, according to Dr. Pearse Keane, a consultant ophthalmologist at Moorfields Eye Hospital, who also spoke at the same symposium.

According to Dr. Keane, Moorfields Eye Hospital linked up with leading AI company DeepMind in 2016, to conduct research on the use of AI in ophthalmology in analyzing data from optical coherence tomography (OCT) scans.

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“OCT scans have transformed ophthalmology, but to some extent they have become a victim of their own success with too many now being performed to allow deep analysis to be carried out on them,” noted Dr. Keane.

At Moorfields Eye Hospital on average 1,000 OCT scans are performed per day, he said. The result is that Moorfields and other hospitals are only “scratching the surface in terms of clinical and scientific insights we could get from those scans.”

He explained how the MoorfieldDeepMind collaboration had demonstrated how AI could be used to provide deeper analysis by taking it out of human hands to some extent.

“It has shown the exciting potential of artificial intelligence,” he said, with it able to make referral decisions and well as recognize the full context of a disease.

AI will add speed and scope to ophthalmology work and studies, Dr. Ursula Schmidt-Erfurth, head of the ophthalmology department at the Medical University of Vienna, shared to the audience.

“Models being developed will be able to identify disease features and classify them without interference, essentially conduction unsupervised anomaly detection,” she said.

As well as enhancing the ability of ophthalmologists, AI could also go

beyond human abilities, according to Dr. Tufail.

Studies have been conducted on training AI with non-structural data, he said, demonstrating the technology’s ability to see “hidden information” in OCT scans.

Studies at Moorfields looked into whether there was information on OCT scans that people cannot detect, but that AI can, which “infers flow.”

“To everyone’s amazement it worked,” he said, demonstrating a potential to “unlock a vast repository of OCT data to understand what is going on in these patients.”

Another future use of AI could be in conjunction with robotics, he added, as a means of reducing error in work conducted by surgical robots.

While AI will advance ophthalmology, it will also be disruptive, emphasized Dr. Konstantinos Balaskas, head of Moorfields’s Reading Centre.

The advent of AI will change how, when and where ophthalmologists provide care, he said, adding that it was important “be clever about it and ensure that it is to the benefit of patients.”

The infrastructure to do this already exists, he argued, in the form of reading centers, which can provide the technology, manpower and expertise, to analyze the benefits of AI and how best it can be used.

“It is evident the developments in AI are likely to transform our models of care and to raise all sorts of questions,” he said, and it will require large amounts of data that is well curated.

To get vast amounts of data all in one place, correctly labelled, is a “mammoth task” that requires knowledge and in many cases manual labor that reading centers can provide, he said.

“Reading centers have the power to consider this new tool and its impact on the industry,” he added.

Editor’s Note: A version of this article first appeared in PIE POST, PIE Magazine’s Daily Congress News on the Posterior Segment, published at the EURETINA 2018 congress, Issue #1 (page 5).

BEST OF PIE Post

Busting Myths in Vitreoretinal Surgery

Unicorns are another myth (that have nothing to do with ophthalmology).

by Brooke Herron lthough ophthalmology is a science, myths can still creep in. So how do we differentiate between facts, and what is simply not true?

According to Dr. Ramin Tadayoni, Professor of Ophthalmology at OphtalmoPôle in Paris, France, it comes down to research, studies and experiments. Knowledge comes from sensory experiences . . . after all, a hypothesis begins as a thought and evidence is discovered through experience – or in this case, experiments.

maneuver – although he notes this is not a recognized risk factor for RD and is very rare. He notes that statistics show that 1 in 500 45-year-olds who have a baby will have RD, while 1 in 1,500 30-year-olds will have one. He notes that in the United Kingdom, 1 retinal problem was observed per 137,000 normal vaginal deliveries, for an incidence of 0.0007% – none of which were RD. He says based on these numbers (and other research), this myth is based more on belief than evidence and there is an insufficient risk to modify childbirth.

Myth #1

Myth #2

One such myth concerns childbirth, which is patients with a history of retinal detachment (RD) should not push – and myopes should not push either. The myth comes from the statistic that 10.5% of maternal subconjunctival hemorrhage occurs following normal vaginal delivery. And according to a 2008 survey, 76% of surveyed obstetricians advocate interventional labor in patients with a history of RD – and 38% believed that raised intraocular pressure (IOP) during contractions would cause RD. According to Dr. Alistair Laidlaw, this could be attributed to the Valsalva

Another myth is that LASIK increases the risk for RD. But is that really so?

Dr. Thomas Wolfensberger, Director of Vitreoretinal Department at Jules Gonin Eye Hospital, University of Lausanne, Switzerland, says that when you Google “myths in retinal surgery” what comes up is not anything to do with retinal surgery, but instead with refractive surgery. What?!

We know that refractive surgery can be divided into two categories: intraocular and extraocular. For one intraocular procedure, phakic posterior chamber intraocular lens (PPCIOL), the retinal detachment rate is 0.8 to 1.2%

A

– meaning that the incidence appears to be below average for RD. A 2008 study hypothesized that if the PPCIOL is too large in diameter, it will irritate the ciliary body leading to inflammation with peripheral contraction of the vitreous.

“It’s not so much the technique, rather that the size of the implant isn’t right,” said Dr. Wolfensberger. In this case, the refractive surgery would not lead to RD. For extraocular procedures like LASIK, a 2001 study reported that the incidence of RD was low (0.06%).

Another study, this one published in 2006, found that there was a yearly incidence of RD following LASIK of 0.032%. The authors concluded that the incidence of RD was not increased

by LASIK. “In an apple tree, the apples hang on the tree and fall at some stage. But if you go in and kick the tree the apple might fall before it normally would,” said Dr. Wolfsenberger. “So, what happens with LASIK [in incidences of RD], is you accelerate a physiological event that would have happened later anyway.”

What about LASIK after RD and vice versa?

“If you apply LASIK after RD surgery, you may have problems with suction or regression of refractive changes,” he explained. On the other hand, vitreoretinal surgery after refractive surgery comes with its own set of problems. Dr. Wolfsenberger notes that there can be LASIK flap displacement during RD surgery, among other issues. So, while these procedures can have an effect on the other and cause complications, LASIK alone, wouldn’t be solely responsible for RD. Editor’s Note: A version of this article first appeared in PIE POST, PIE Magazine’s Daily Congress News on the Posterior Segment, published at the EURETINA 2018 congress, Issue #1 (page 11).

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CONFERENCE HIGHLIGHTS EURETINA 2018

BEST OF PIE Post

Real World Clinical Data on Aflibercept

Provides Lessons on Improving Patient Care

by Hazlin Hassan

T

he anti-vascular endothelial growth factor (anti-VEGF) agent aflibercept (EYLEA, Bayer), has recently been approved in Europe and elsewhere for use with a proactive treat-and-extend regimen starting in the first year of treatment in neovascular age-related macular degeneration (nAMD), delegates attending the Bayer Satellite Symposium at the recently held 18th EURETINA Congress in Vienna, Austria, heard.

“The new posology for aflibercept in nAMD reflects its suitability for a proactive treat-and-extend regimen,” said Professor Jean-Francois Korobelnik, of the University Hospital Centre, Bordeaux, France.

This allows extension of treatment intervals in 2- or 4-weekly increments in Year 1 at the discretion of the physician.

A total of 57% of patients in the Phase IV ALTAIR study in Japan had their next injection scheduled at an interval of 12 weeks or beyond at the Week 52 mandatory visit, he added.

Treat-and-extend means to initiate treatment with loading doses until the disease is stable. The doctor then gradually extends the treatment time between treatments until sub-retinal fluid recurs or visual acuity declines.

The symposium also showcased the evolution of Real World Evidence (RWE) within retinal ophthalmology. It is no longer enough to carry out controlled trials. RWE is now increasingly important to provide effective treatments for the patients’ diverse needs.

Hospitals are now moving from paper records into the era of “big data” using electronic medical records (EMRs), greatly benefiting both specialists and patients, Professor Adnan Tufail, consultant ophthalmologist at Moorfields Eye Hospital, United Kingdom, told the audience. EMRs are akin to an electronic case report form in a clinical trial but obtained as part of routine clinical care.

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Big data in ophthalmology included EMR, imaging data, and genetics data, said Prof. Tufail, whose spoke mainly on RWE and the evolution of a key information source. He said his first attempt at conducting a study using EMRs was in 2012, where 16 hospitals were approached and within two months, 11,135 patients were signed up with 92,976 injections administered, in patients who were as old as 108 years of age. Showing a graph of subgroups of mean visual acuity, he demonstrated that there is huge variability among patients. RWE can also go beyond outcomes of a single disorder and can be used to look at interaction between interventions, he said.

“When you’re looking at big data, you need to actually look at the quality of how you measure information as well” he said.

“In summary, there is a wealth of real world data out there, we initially used it to benchmark outcomes, but we are now moving into health economics and personalized medicine using data, and looking at novel ways to help us understand it,” he concluded.

“Historically, there has been a disparity between results observed in randomized controlled trials (RCTs) and real-world studies of ranibizumab,” said Dr Peter Kaiser, of the vitreoretinal faculty of the Cole Eye Institute at Cleveland Clinic in Ohio, United States.

His lecture on aflibercept’s latest evidence from clinical practice discussed the reasons for the disparity, citing differences in baseline characteristics, and disease progression, poor understanding and application of the treatment outcomes, irregular or no auditing and/or benchmarking of the treatment outcomes, and a high visit and/or treatment burden on patients and caregivers.

He suggested that in real-world clinical practice, maintaining a sufficient frequency of injections may be critical for achieving good visual acuity

outcomes. “Good visual outcomes were achieved in some countries where strict monitoring and retreatment criteria were followed. However, poor outcomes were reported in many countries, particularly where PRN (pro re nata or as needed) regimens are typically used in clinics.”

On aflibercept, he said that its dual mechanism of action and strong binding affinity made it suitable for proactive extended dosing. “Aflibercept is known to bind VEGF-A with a higher affinity than its native receptors, ranibizumab, or bevacizumab,” he said. In individual patients with nAMD, aflibercept was shown to have an intraocular VEGF-A suppression time of around twice that of ranibizumab.

Citing an ongoing 4-year study known as RAINBOW, which assesses real-world outcomes with aflibercept to treat nAMD in routine clinical practice across 55 centers in France, he said that treatment-naive patients receiving proactive q8 aflibercept achieved significantly greater visual acuity gains at Month 12 than those receiving irregular dosing.

Similarly, another ongoing 2-year study called PERSEUS across 66 centers in Germany, also saw the same result, he said. “Further real-world studies are providing evidence to support the comparative effectiveness of proactive dosing with aflibercept.”

Bayer is currently funding multiple studies assessing the real-world effectiveness and safety of aflibercept in more than 20,000 patients.

Professor Paul Mitchell, professor of clinical ophthalmology and eye health at the University of Sydney Westmead Clinical School in Australia, was also present and took part during the panel discussion.

Editor’s Note: A version of this article first appeared in PIE POST, PIE Magazine’s Daily Congress News on the Posterior Segment, published at the EURETINA 2018 congress, Issue #2 (page 3).

BEST OF PIE Post

Oh, the Agony!

by Brooke Herron

W

ithout a doubt, Mozart was a legendary composer. But even with his genius, we have to wonder . . . did Mozart ever agonize over any parts of his masterpieces? Did he ever question whether what key the music should be in, or perhaps what instruments should play which piece?

As an ophthalmologist – and even with his superior intelligence – Mozart would undoubtably be faced with some difficult choices. As many posterior segment diseases remain challenging to treat – some even without a standardization of care – he likely would have agonized over treatment options (like the rest of us mere mortals).

One condition that causes treatment decision agony is subretinal macular hemorrhage. Dr. Carl Ardnt,MD, PhD, professor of ophthalmology, Université de Reims Champagne-Ardenne, Reims, France, discussed this conundrum in his presentation, titled: “Agony of Choice.”

Currently there are multiple treatment options available to manage subretinal hemorrhage, this includes: pneumatic displacement, intravitreal or subretinal recombinant tissue plasminogen activator injection (subretinal rt-PA), intravitreal anti-VEGF drugs, retinal pigment epithelial patch, macular translocation and/or a combination of these therapies. That’s a lot of choices.

Of those, Dr. Ardnt says there are two combinations that work best.

The first is vitrectomy with subretinal rt-PA, fluid air exchange with anti-VEGF (in cases of AMD) – this combination

produces the greatest visual acuity improvement (VA). For the best final VA, he recommends intravitreal injections of gas, subretinal rt-PA and anti-VEGF. He then presented several cases to explain his recommendations, some of which are included below.

The first case involved a 56-yearold patient with VA of counting fingers (CF), a history of branch vein occlusion – and she was taking an oral anticoagulant for vein occlusion.

“Here, we chose to do the vitrectomy with fluid gas exchange and subretinal rt-PA,” said Dr. Ardnt. “Visual acuity is going up after three months . . . the patient went up to 0.8 which is quite good.” He added oral anticoagulants were suspended and that there’s a better outcome in non-AMD eyes with subretinal hemorrhage.

Another case included a patient with AMD with VA of CF who was treated with vitrectomy, gas, subretinal rt-PA and anti-VEGF. “This patient did surprisingly well – they started with CF and VA continuously improved,” said Dr. Arndt. “At each visit, we also reinjected anti-VEGF.” So, should ophthalmologists perform surgery every time? Or just inject into the vitreous? Dr. Arndt says not all the time – it can go very bad.

In the final case, the patient was treated with vitrectomy, subretinal rt-PA, gas and anti-VEGF. “At month 1, we had a hemorrhage. At month 2 we had retinal detachment – and the nightmare isn’t finished – then we had recurring hemorrhage under silicone,” he said.

“These procedures don’t go well every time.”

Dr. Arndt says that the STAR study will hopefully determine the best line of treatment, provide a clearer understanding of these hemorrhages and answer questions like “is rt-PA really necessary, or is vitrectomy gas enough?”

Dr. Alireza Mirshahi also discussed this “agony of choice” when treating macular hemorrhages.

Among the various therapy options, his presentation focused on anti-VEGF as monotherapy. To determine treatment, he says that classification is key.

According to Dr. Mirshahi, the rationale for using anti-VEGF monotherapy is that it’s a causative treatment (inactivation of CNV); it’s minimally invasive, it’s broadly available; its efficacy is independent of postoperative position; it has a very high level of safety; as well as an acceptable level off efficacy.

“Patients with subretinal bleeding in a centrally scarred, peripherally active CNV (with the FLATCAPS classification of F0 P1) are the most suitable for antiVEGF monotherapy,” he explained. “To goal is to preserve the visual field.”

He notes several studies that support his claims with the evidence stating that results depend on the following: size of the hemorrhage, duration of symptoms and central foveal thickness. Similar results were shown in hemorrhages secondary to PCV. “Anti-VEGF monotherapy is safe and effective in macular hemorrhages, particularly if classified F0 P1,” he concluded. “Classification is key in the decision-making process.” And as long as comparative studies are not available, he gives the following advice: primum non nocere (Latin for “First, do no harm.”)

It’s clear that the agony of choice remains and there are no guidelines for best or first line treatment. This means, for now, ophthalmologists must use their instincts and rely on studies and real-world experience to create their Mozart approved musical (or surgical) masterpieces.

Editor’s Note: A version of this article first appeared in PIE POST, PIE Magazine’s Daily Congress News on the Posterior Segment, published at the EURETINA 2018 congress, Issue #3 (Mozart Says column, page 13).

PIE Post is PIE Magazine’s Daily Congress News on the Posterior Segment.

Media MICE, publisher of PIE Magazine and the APVRS and APAO official congress newspapers, has landed in Europe and for the first time, published PIE POST at the recently held EURETINA 2018 Congress in Vienna, Austria.

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CONFERENCE HIGHLIGHTS APAO 2019 PREVIEW

The Countdown to APAO 2019 Begins

by Brooke Herron

P

reparations for the Asia-Pacific Academy of Ophthalmology’s 34th annual meeting (APAO 2019) are well underway in Bangkok, Thailand. Held in conjunction with the 43rd meeting of the Royal College of Ophthalmologists of Thailand, the event will run from March 6 to 9, 2019. This year’s event will also be cosponsored by the European Society of Ophthalmology (SOE), which includes 44 national ophthalmic societies from around the European continent.

Event organizers recently announced the confirmation of both the International Advisory Board and the Scientific Program Committee for APAO 2019. Including experts from AsiaPacific and beyond, these committee members have begun developing a creative and innovative scientific program featuring 17 subspecialties.

“With an anticipated number of over 1,000 international experts speaking on all areas of ophthalmology and visual sciences, the APAO 2019 Congress provides an excellent opportunity for delegates to keep abreast with the latest cutting-edge scientific innovations, knowledge, new

46

medications, surgical techniques and technologies,” said Dr. Dennis Lam, M.D., chair of the APAO 2019 Scientific Program Committee. An attendance figure of at least 5,000 delegates is anticipated.

In addition to the scientific program, planning for the social program is also underway. Events include the Opening Ceremony, Welcome Reception, Presidential Dinner and Gala Dinner. There will also be a charity 5km run during the Congress.

Three new member societies will also send official representation to APAO for the first time in 2019. APAO has announced two of those societies thus far. One of APAO’s Associate Member Societies is the Asia Pacific Tele-Ophthalmology Society (APTOS), which was founded in May 2016 and aims to promote communication, exchange and collaboration in teleophthalmology. APTOS, led by President Prof. Ming Guang, hopes to reach ophthalmologists who share the same vision to further the use of teleophthalmology to improve eye care in remote areas. The Asia-Pacific Ocular Imaging Society (APOIS), has also joined as an associate member. This

newly formed society aims to facilitate collaboration between ophthalmologists and vision scientists in the region, with a focus on development and application of ocular imaging.

APAO 2019 will be held at the Queen Sirikit National Convention Center (QSNCC), Thailand’s first world-class convention and exhibition venue. With a total floor space of 65,000-square-meters, QSNCC has state-of-the-art equipment and facilities, including the exhibition and function area, Plenary Hall, ballroom and meeting room. There is also a business center, restaurants, coffee shops, a food court and a beverage corner on-site. It boasts a convenient location for APAO attendees who are keen to stay nearby.

Located in Bangkok’s central business district, it’s situated close to many 3- to 5-star hotels, as well as popular attractions and shopping centers.

For more information about the 2019 congress, visit http://2019. apaophth.org.

Editor’s Note: PIE Magazine’s parent company Media MICE Pte Ltd was the official media partner of the APAO 2018 congress held earlier this year in Hong Kong.

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