CAKE & PIE POST (WOC2020 Virtual® Edition) - DAY 3

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ISSUE

& cataract • anterior segment • kudos • enlightenment

29 | 06 | 20 posterior segment • innovation • enlightenment

C A K E A N D P I E M A G A Z I N E S ’ D A I LY C O N G R E S S N E W S O N T H E A N T E R I O R A N D P O S T E R I O R S E G M E N T S

HIGHLIGHTS

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Every eye surgeon’s most un-wanted: moving IOLs!

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Whatever ‘road’ one chose, there’s only one common goal: the patient’s desired refractive outcome

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Clinical pearls abound in conquering the rock hard cataracts...

Achieving Equity in Eye Care Delivery

by Joanna Lee

Published by

Matt Young

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Gloria D. Gamat Chief Editor

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

piemagazine.org cakemagazine.org

S

peaking of eye care within the context of the World Health Organization’s 2030 agenda on sustainable development, Dr. Fatima Kyari, in her presentation on Equity as Guiding Principle in Provision of Integrated Health Care at the 37th World Ophthalmology Congress (WOC2020 Virtual®) highlighted a few important dimensions of equitable universal eye health – equitable access and quality of care.

Strategies in equity proposal

Adapting efficient tech Structuring a solution would need systems in place to ensure the right people get the right help. Peek Vision’s co-founder Dr. Andrew Bastawrous’s talk on Using Technology to Support Equity by Design in Eye Health Programmes and Surveys Cont. on Page 3 >>

HOTSHOT

Equity should be considered in terms of geographic location, gender, cultural norms and influences, population structures and socioeconomic status, financial literacy and health education. People in poor households are three times more likely to be blind. The risk also escalates with age.

Dr. Kyari, the consultant ophthalmologist at University of Abuja Teaching Hospital and Associate Professor at London School of Hygiene and Tropical Medicine, highlighted the stark disparities between rural unmarried women who represent 14% of the sample population but comprise 48% of those with cataract blindness. Only 1 in 4 women (versus 1 in 2 men) who need cataract surgery actually get it. Access to care by those who most need it, like the rural unmarried women, and having financial means that help them access it feature as part of Dr. Kyari’s delivery strategies proposal.

Matt Young interviews the inventor of the Jacobovitz Multifunctional Chopper (which has great utility for Africa and beyond), Dr. Sergio Jacobovitz himself.

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29 June 2020 | Issue #3

TREAT WITH

Achieve unsurpassed and sustained visual acuity (VA) gains with proactive extended dosing1–5

nAMD

DME

RVO

EYLEA® is indicated for adults for the treatment of neovascular (wet) age-related macular degeneration (AMD), visual impairment due to macular edema secondary to retinal vein occlusion (branch RVO or central RVO), visual impairment due to diabetic macular edema (DME), and visual impairment due to myopic choroidal neovascularization (myopic CNV).

REFERENCES: 1. EYLEA® approved package insert Singapore March 2019, Bayer (South East Asia) Pte Ltd. 2. Wells JA, Glassman AR, Ayala AR, et al. Aflibercept, bevacizumab, or ranibizumab for diabetic macular edema: two-year results from a comparative effectiveness randomized clinical trial. Ophthalmology. 2016;123:1351-1359. 3. Korobelnik JF, Do DV, Schmidt-Erfurth U, et al. Intravitreal aflibercept for diabetic macular edema. Ophthalmology. 2014;121:2247-2254. 4.

Eleftheriadou M, Gemenetzi M, Lukic M, et al. Three-year outcomes of aflibercept treatment for neovascular age-related macular degeneration: evidence from a clinical setting. Ophthalmol Ther. 2018;7:361-368. 5. Pielen A, Clark WL, Boyer DS, et al. Integrated results from the COPERNICUS and GALILEO studies. Clin Ophthalmol. 2017;11:1533-1540.

Bayer (South East Asia) Pte Ltd 2, Tanjong Katong Road #07-01, Paya Lebar Quarter 3, Singapore 437161.

Tel: +65 496 1888 Fax: +65 6496 1491 Website: www.bayer.com

PP-EYL-SG-0054-1(09/19)

ABBREVIATED PRESCRIBING INFORMATION EYLEA SOLUTION FOR INJECTION IN VIAL 2MG. Approved name(s) of the active ingredient(s) One ml solution for injection contains 40 mg aflibercept. Each vial provides a usable amount to deliver a single dose of 50 µl containing 2 mg aflibercept.

Indication EYLEA is indicated for the treatment of neovascular (wet) age-related macular degeneration (AMD), macular edema secondary to retinal vein occlusion (branch RVO or central RVO), diabetic macular edema (DME) and myopic choroidal neovascularization (myopic CNV). Dosage Regimen wAMD: The recommended dose for EYLEA is 2 mg aflibercept, equivalent to 50 µl. EYLEA treatment is initiated with one injection per month for three consecutive doses, followed by one injection every two months. Based on the physician’s judgement of visual and/or anatomic outcomes, the treatment interval may be maintained at two months or further extended, such as with a treat-and-extend dosing regimen, where treatment intervals are increased in 2- or 4- weekly increments to maintain stable visual and/or anatomic outcomes. If visual and/or anatomic outcomes deteriorate, the treatment interval should be shortened accordingly to a minimum of two months during the first 12 months of treatment. There is no requirement for monitoring between injections. Based on the physician’s judgement the schedule of monitoring visits may be more frequent than the injection visits. Treatment interval greater than 4 months between injections have not been studied. Branch RVO or central RVO: The recommended dose for EYLEA is 2 mg aflibercept, equivalent to 50 microliters. After the initial injection, treatment is given monthly until visual and/or anatomic outcomes are stable. Three or more consecutive, monthly injections may be needed. The interval between two doses should not be shorter than one month. If there is no improvement in visual and anatomic outcomes over the course of the first three injections, continued treatment is not recommended. If necessary, treatment may be continued and the interval may be extended based on visual and/or anatomic outcomes (treat and extend regimen). Usually, monitoring should be done at the injection visits. During treatment interval extension through to completion of therapy, the monitoring schedule should be determined by the treating physician based on the individual patient’s response and may be more frequent than the schedule of injections. DME: The recommended dose for EYLEA is 2 mg aflibercept, equivalent to 50 microliters. EYLEA treatment is initiated with one injection per month for five consecutive doses followed by one injection every two months. There is no requirement for monitoring between injections. After the first 12 months of treatment with EYLEA, and based on visual and/or anatomic outcomes, the treatment interval may be extended, such as with a treat-and-extend dosing regimen, where the treatment intervals are gradually increased to maintain stable visual and/or anatomic outcomes; however there are insufficient data to conclude on the length of these intervals. If visual and/or anatomic outcomes deteriorate, the treatment interval should be shortened accordingly. The schedule for monitoring should therefore be determined by the treating physician and may be more frequent than the schedule of injections. If visual and anatomic outcomes indicate that the patient is not benefiting from continued treatment, EYLEA should be discontinued.

Myopic CNV: The recommended dose for EYLEA is a single intravitreal injection of 2 mg aflibercept, equivalent to 50 microliters. Additional doses should be administered only if visual and anatomic outcomes indicate that the disease persists. Recurrences are treated like a new manifestation of the disease. The monitoring schedule should be determined by the treating physician based on the individual patient’s response. The interval between two doses should not be shorter than one month. Method of administration Intravitreal injections must be carried out according to medical standards and applicable guidelines by a qualified physician experienced in administering intravitreal injections. Following intravitreal injection patients should be instructed to report any symptoms suggestive of endophthalmitis (e.g., eye pain, redness of the eye, photophobia, blurring of vision) without delay. Each vial should only be used for the treatment of a single eye. Contraindications Hypersensitivity to the active substance aflibercept or to any of the excipients, active or suspected ocular or periocular infection, active severe intraocular inflammation. Special warnings and special precautions for use Endophthalmitis, increase in intraocular pressure, immunogenicity, systemic adverse events including non-ocular haemorrhages and arterial thromboembolic events. As with other intravitreal anti-VEGF treatments for AMD, the safety and efficacy of Eylea therapy administered to both eyes concurrently have not been systematically studied. When initiating Eylea therapy, caution should be used in patients with risk factors for retinal pigment epithelial tears. The dose should be withheld and treatment should not be resumed earlier than the next scheduled treatment in the event of: a decrease in best-corrected visual acuity (BCVA) of ≥30 letters compared with the last assessment of visual acuity; a subretinal haemorrhage involving the centre of the fovea, or, if the size of the haemorrhage is ≥50%, of the total lesion area. The dose should be withheld within the previous or next 28 days in the event of a performed or planned intraocular surgery. EYLEA should not be used in pregnancy unless the potential benefit outweighs the potential risk to the foetus. Women of childbearing potential have to use effective contraception during treatment and for at least 3 months after the last injection of aflibercept. Undesirable effects Very Common: Conjunctival hemorrhage, eye pain. Common: Retinal pigment epithelial tear, detachment of the retinal pigment epithelium, retinal degeneration, vitreous haemorrhage, cataract (cortical, nuclear, subcapsular), corneal erosion, corneal abrasion, intraocular pressure increased, vision blurred, vitreous floaters or detachment, injection site pain, foreign body sensation in eyes, lacrimation increased, eyelid edema, injection site hemorrhage, punctate keratitis, conjunctival hyperemia, ocular hyperemia. For a full listing of precautions and undesirable effects, please refer to the full product insert. For further prescribing information, please contact: Bayer (South East Asia)Pte Ltd. 2 Tanjong Katong Road #07-01 Paya Lebar Quarter 3 Singapore 437161. Date of revision of text March 2019.

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

>> Cont. from Page 1

addressed how to ensure effectiveness in screening those with unmet needs that would open the way to referral adherence and ultimately, in reaching service effectiveness for those who truly need eye care services. Highlighting that cataract services are leaving widows in Nigeria and Sri Lanka behind, the social impact organization’s co-founder proposed that if we reach the “highhanging fruits” (those left behind by the system) by building taller ladders or better systems to reach them from the stage of screening coverage, poor, rural women would have the chance to see again. If the services are targeted specifically with that group in mind, and predominantly waiting and reaching that subgroup, that is the best way to meet population level targets of universal healthcare coverage,” he said. Also, Dr. Bastawrous highlighted that there can be a doubling of percentage in effective coverage, by targeting intervention in the subgroups left behind. What it means is this: “Data driven decisions can support the most marginalized in our community,” he said.

“To promote integrated quality care, we must deliberately find (the equity) and consciously address it.”

Dr. Fatima Kyari University of Abuja Teaching Hospital Abuja, Nigeria

The Arabian eye care model Looking at the equation, the Kingdom of Saudi Arabia perhaps demonstrates what equity in eye care delivery could look like with free healthcare provided for its citizens. At the tertiary healthcare level, the King Khaled Eye Specialist Hospital (KKESH) in Riyadh shows the way with its e-services.

CEO of KKESH and Senior Consultant in Anterior Segment Dr. Abdulaziz AlRajhi shared about their online referral system available to rural areas outside of Riyadh. The hospital’s e-services also enable accessibility to patient data and ability to process their requests without having to physically attend the hospital.

“COVID-19 had accelerated many of

Only 1 out of 4 Nigerian women get access to eye surgery when needed compared to 1 out of 2 men. Equity of access to eye care needs to be further addressed, especially for rural, poor, unmarried women.

the programs we had in mind,” said Dr. AlRajhi.

KKESH’s impressive telemedicine programs includes the Kingdom’s national ROP program, virtual clinic (doctor-patient) video calls for virtual consultation and an oculoplasty virtual clinic established in April 2020. There is also an “emergency room” teleconsultation through phone calls and WhatsApp. There are also patients and community services where KKESH ophthalmologists hold live streamed consultations to answer common patients’ concerns and provide public health education.

Engaging the stakeholders But making sustainable healthcare a success requires the participation of various stakeholders. Dr. Adekunle Hassan, Chief Medical Director of Eye Foundation Hospital Group in Nigeria and ex-president of AOC shared about Sustainable and Equitable Eye Care Programs in Sub- saharan Africa. The Eye Foundation Hospital Group that Dr. Hassan established in 1993 is the first private post-graduate training institution in Nigeria. In Nigeria, Dr. Hassan is the pioneer leader of modern ophthalmological practice, including vitreoretinal surgery. In his talk, Dr. Hassan identified challenges to a sustainable system of eye delivery: infrastructural deficit and decay, educational and training challenges, public health deficit, governmental limitations, brain drains and human resource issues, plus a gap in leadership.

His pragmatic approach, which involves partnerships with various stakeholders, has helped him build his successful

hospital group through “business model group practice versus individual practice”, apart from cultivating leadership in healthcare.

“Equity is not equality,” said Dr. Sidi Sidi Cheikh, the head of the ophthalmology department in Nouakchott Medical University in Mauritania, when he spoke about How Health Systems Support Equitable Eye Care Delivery: Case Study from Mauritania. Developing countries lack financial resources, qualified staff, health spending, health awareness and are missing rigors in health policies. Equity, to him, is giving intervention to people with greater clinical needs as opposed to treating people with equal needs all the same.

He shared about Mauritania’s National Program Against Blindness which has resulted in successful cataract surgeries, trachoma on the path of being eradicated and spectacles available to schoolchildren in need.

So... what’s next?

The insightful discussion thereafter focused on long term strategies for developing better systems to target those with unmet needs. Dr. Bastawrous noted the use of data (not just for postevaluation) is needed to drive equitable practices. Dr. Hassan also said it’s important for partners collaborating or investing in your healthcare endeavors to be assured you can deliver results in order to gain their support. Dr. Kyari brought up the issue of how poorer countries can be helped even better. There is still much to be done. She summed it up as this: “To promote integrated quality care, we must deliberately find (the equity) and consciously address it,” she concluded.

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29 June 2020 | Issue #3

Subluxated & Dislocated IOLs on the Move

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hen subluxated or dislocated lenses require surgical management, technique is important — not only surgically to prevent complications — but also in the intraocular lens (IOL) fixation technique.

To unpack the various options, the Middle East and Africa Council of Ophthalmology (MEACO) put on a session titled Subluxated and Dislocated Lenses: The Way to Go from Pole to Pole on the third day of the 37th World Ophthalmology Congress (WOC2020 Virtual®).

Dislocated IOLs can be complicated Lens dislocation can be congenital, as in the cases of systemic disease, or acquired — most commonly as a result of cataract surgery or ocular trauma, began Prof. Remzi Avci from the Retina Eye Hospital in Turkey.

Unfortunately, dislocated lenses or fragments can result in a variety of complications including cystoid macular edema (CME), phacoantigenic uveitis, phacoantigenic glaucoma, retinal tears or detachment and corneal edema, he continued. “The [severity] of the complication is also concerned with the size of the retained lens fragments, the severity of the trauma, and the length of time between dislocation and surgery.”

For anterior segment surgeons encountering this issue, Prof. Avci cautioned that there are several things not to do: “They should avoid manipulation that could cause vitreous loss and/or vitreoretinal traction — such as, do not perform phaco in case of vitreous prolapse into the anterior chamber; do not perform sponge vitrectomy; and do not introduce instruments into the vitreous to remove fragments.

“Every attempt to the vitreous creates the potential for retinal tear or detachment,” continued Prof. Avci.

by Brooke Herron

Watch for complications “Subluxated lenses are a real challenge with different scenarios,” said University of Cairo Professor Yehia Mostafa, adding that it might be seen preoperatively, or it could occur intraoperatively or as a result of a complication.

He also advised that surgeons should be ready with different ideas, plans and tools (i.e. capsular tension rings, 3-piece IOLs, capsular hooks and iris hooks, among others).

So, how to proceed? While dropped cortical fragments might resolve themselves with observation, Prof. Avci said that dropped nucleus/fragments should be removed with vitrectomy.

“Treatment of a dislocated lens with pars plana vitrectomy (PPV) is a safe and effective approach,” he said. “The most important predictor of final VA is a less complicated clinical course without any associated complications like retinal detachment, CME or glaucoma.”

you have to find another way to fixate your IOL.” This can be achieved through scleral (one-point or segmental) or iris fixation.

In segmental fixation, a big segment of the loop is fixated into the sclera, and this is either the glued IOL or Yamane technique, explained Dr. Rabiah before going into a detailed, step-by-step instruction for the glued IOL technique.

Dr. Abdul Aziz Badla from the Saudi German Hospital in Dubai, United Arab Emirates, also commented on scleral fixation: “IOL scleral fixation with Gortex suture is a safe procedure with encouraging results, especially when PPV is needed,” he concluded.

Further, the surgical technique depends on the grade of nucleus, continued Prof. Avci. “In soft nucleus, you can use the vitrectomy probe, in hard nucleus (grade 3-4) we prefer phacofragmentation, and in hard grade 5 cataracts, extraction via limbal incision may be preferred.”

IOL fixating techniques In addition to surgical management, there are also various ways to implant an IOL. In the absence of capsular bag support, Dr. Sami Al Rabiah from the Al Rabiah Medical Center in Kuwait, recommends the glued IOL technique.

For an IOL to be fixated in the eye, the best anatomical, pathological and optical position is in the capsular bag,” said Dr. Rabiah. “But if you have an absent or insufficient capsular support,

While ophthalmologists (and patients) would really prefer that lenses stay put . . . sometimes they just gotta move.

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

The Many Roads to Refractive Surgery Success

by Hazlin Hassan

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n order for refractive surgery for myopia to be a success, it needs to safely achieve a patient’s desired refractive goal.

But there are several ways of doing this, from laser refractive surgery to implantation of phakic intraocular lens (PIOL).

ICL, the winner

PIOLs beyond myopia

Phakic intraocular lens (PIOL) debates over the last two decades have pitted it against laser vision correction (LVC), with vigorous discussions over design, material, and patient selection.

PIOLs can not only correct myopia but it has a therapeutic role in anisometropic myopic amblyopia in children, said Prof.

Ahmad El-Massry from the Faculty of Medicine at the Alexandria University in Egypt.

“PIOLs ICL is the way to go,” Dr. Alaa Eldanasoury of Magrab Hospital in the Kingdom of Saudi Arabia, told the session on Sunday at the still on-going 37th World Ophthlmology Congress (WOC 2020 Virtual®).

What are the advantages of implantable collamer lens (ICL) over LVC? It preserves quality of vision for the rest of the patient’s life, retains the cornea biomechanics and there is no risk of ectasia. So why hasn’t ICL replaced LVC yet? Patients prefer LVC as the perception is that it is less invasive.

LVC in low and moderate myopia is good enough to make them happy. But the cost of ICL is lower compared with laser.

“They [patients] don’t know what they are missing. If they have an ICL, they will have better vision,” said Dr. Eldanasoury.

An ideal PIOL needs to be biocompatible, stable, and predictable.

It has to preserve quality of vision, allow fast recovery and be easy to remove or exchange. It must also possess a safe and long track record.

“ICL’s superiority over LVC is documented. The safety of the collamer material has been proven over more than 25 years,” he concluded.

He shared a study on PIOLs to correct high myopia amblyopia in children which yielded the following results: More than 3 Snellen’s lines improvement of BCVA in all children, and no loss of BCVA in any patient. PIOLs were also very well tolerated in the pediatric eye. Results at 24 month showed a mean pre-operative BCVA of 0.2 (range 0.05-0.7), and mean postoperative BCVA of 0.8 (range 0.5 - 1.0).

Anatomical outcomes included an excellent tolerance of ICLs, no inflammatory reaction, no elevation of intraocular pressure (IOP), good position of ICLs, and no cataract or secondary increase of IOP. “Collamer copolymer phakic ICL to correct high unilateral myopia is a good option in cases of moderate amblyopia with two years follow-up with good predictability, stability in refraction and IOP, no significant endothelial cell loss, better stereoscopic vision, and increasing in quality of life,” he said.

To SMILE or not to SMILE “Although SMILE is a promising technique for the correction of myopia and myopic astigmatism with

predictable, efficient, safe refractive and visual outcomes, complications can occur,” said Dr. Catherine Albou-Ganem of the Clinique de la Vision in Paris, France – the first French center entirely dedicated to refractive surgery, of which Dr. Albou-Ganem is a founding member.

Most of these complications are related to inexperience, are included in the learning curve of the technique, and have a favorable resolution with no lasting effect on the patient’s final visual acuity, she noted.

SMILE possesses several advantages.

It is a less invasive corneal surgery, respects the biomechanical properties of the cornea and corneal nerves. There is also a lower risk of developing dry eye and recovery is simplified and shortened.

SMILE is safe, predictable, stable, provides quality of vision, and at a high precision.

Due to the absence of flap, the complications of SMILE are less numerous than in LASIK. Epithelial defects, according to published literature, are the most common complication at 41.9%. It is a mild problem solved in 1 to 2 days with the use of artificial tears, has no effect on visual acuity and presents only in the incision zone. Other complications include DLK, hazy interface, epithelial ingrowth, infection, interface fluid syndrome, dryness of the corneal surface, and ectasia. Overall frequency of postoperative complications was 8.6% which is comparable to what is expected after LASIK.

“Although SMILE is a promising technique for the correction of myopia and myopic astigmatism with predictable, efficient, safe refractive and visual outcomes, complications can occur.”

Dr. Catherine Albou-Ganem Clinique de la Vision Paris, France

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29 June 2020 | Issue #3

Experts Weigh in on Controversies in Vitreoretinal Surgery

by Brooke Herron

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itreoretinal surgery is no stranger to controversy — and individual circumstances, like comorbidities, age, cost or even geography, can influence surgical decisions. Of course, this means there isn’t necessarily a one-size-fits-all solution to When vitreoretinal procedures go head-to-head, which every surgical dilemma — will rise to the top? thus, surgeons should have as many tools and techniques in their armamentarium as possible.

In retinal detachment (RD): So, which techniques are most widely used? To answer, ophthalmologists discussed their preferences during a session called Surgical Controversies in Vitreoretinal Surgery: The Debate on the third day of the 37th World Ophthalmology Congress (WOC2020 Virtual®).

Also, during the session, a live poll asked delegates to vote on their preferences for the conditions discussed. Here are those results:

In non-tractional diabetic macular edema (DME): • 18% prefer early vitrectomy The cost of vitrectomy is equal to two doses of aflibercept or ranibizumab. So pars plana vitrectomy (PPV) is less expensive than multiple injections of antiVEGF agents. It has also been shown to be effective in both tractional and non-tractional DME, according to Dr. Makoto Inoue of Kyorin Eye Center in Tokyo, Japan.

• 81% prefer repeated IVT injections “Repeated injections carry much lower risk compared with vitrectomy,” noted Prof. Timothy Lai of the Chinese University of Hong Kong.

• 33% prefer lens sparing vitrectomy “Surgery must be performed in two steps because: not all patients develop cataracts; surgery affects the eye’s anatomy and therefore alters final refraction, especially if scleral buckling was performed; IOL power can be properly calculated; final refraction is also altered due to silicone oil use; IOL does not affect intraoperative visualization; and there is a lower incidence of intraoperative complications,” concluded Dr. Arturo Alezzandrini of the University of Buenos Aires in Argentina.

• 66% prefer vitrectomy with routine lens extraction “I am pro-routine lens extraction, and the association between phacovitrectomy and IOL implantation in phakic eyes is an alternative to increase the success rate of the primary vitrectomy for RD and may be considered for specific cases,” stated Dr. Mauricio Maia of the Federal University of São Paulo in Brazil.

In rhegmatogenous retinal detachment (RRD): • 12% prefer scleral buckling “Best final outcomes with

fewest surgical procedures and complications — that’s what your patients are looking for. So, certainly I use buckling in phakic eyes with attached vitreous, dialysis, young myopes, or myopes in their 50s or 60 with multiple tears/ lattice; in pseudophakic RDs, where there’s multiple breaks with inferior retinal detachment, vitreous hemorrhage, an abnormal vitreous base with significant adherent vitreous, and extensive lattice degeneration,” said Dr. Gaurav Shah of The Retina Institute in St. Louis, Missouri, USA.

• 87% prefer vitrectomy “When vitrectomy is chosen for repair of primary uncomplicated RRD, through a simple but thorough PPV, you can get high anatomic and functional success rates, and low complication rates.

Adjunct procedures like scleral buckling are unnecessary in eyes without PVR or without significant risk factors for PVR — these adjuncts increase both the cost and morbidity of the procedure,” said Dr. Mark Johnson of the University of Michigan, USA.

For high myopic macular hole detachment: • 100% prefer vitrectomy and ILM peel “I think the pars plana vitrectomy with large ILM peeled area and an inverted flap should be the first option to increase the retinal elasticity and macular hole closure rate. Less complex surgery is always a better surgery, and more complex surgeries have to be reserved for failed cases,” explained Dr. Carlos Mateo of the Instituto de Microcirugía Ocular in Barcelona, Spain.

• 0% for macular buckling “Macular buckling appears to improve the success rate on its own, or in combination with PPV, especially in the presence of chorioretinal atrophy,” said Prof.

Marco Mura of the King Khaled Eye Specialist Hospital in Saudi Arabia.

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

said AI could potentially be applied to diagnosis; it can be used for serial follow-up, prognosis and modeling also, among other areas. He made an insightful comparison of how patients’ health records or case notes went from narrative text to structured text when using traditional paper to write versus being entered as electronic data. He said this shows that the technology we give people to work with affects their process of cognition.

“There’s a need to integrate AI within clinical pathways. For now, we may need “humancentered AI” in order to get deep learning to work better for us.”

- Dr. Fred Hersch, Google Health

AI in Ophthalmology: Myths, Controversies and Evidence

by Joanna Lee

This session on Day 3 of the 37th World Ophthalmology Congress (WOC2020 Virtual®) was an excellent starter course for ophthalmologists seeking to understand how deep learning could be integrated into clinical practice, its current developments and limitations.

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n a presentation titled How to decipher an AI paper in Ophthalmology. Prof.

Daniel Ting from the Singapore National Eye Centre shared several helpful parameters and comprehensive overview of artificial intelligence (AI) papers and questions to ask as guidelines when reading an AI literature.

What questions do the study answer, what are core components in an AI system, what are good test datasets, appropriate deep learning techniques, how to assess clinical diagnostic performance and so on. Prof. Ting also answered some questions like what is enough in terms of numbers to train: “The more unique a condition is, the less number to train,” he noted. Also, Prof.

Ting reiterated Ali Rahimi’s assertion that AI learning “has been a form of alchemy”.

Talking about the Progress Update for AI in Ophthalmology, Dr. Fred Hersch, program manager at Google Health,

Singapore, gave a broad picture of what AI, machine learning and deep learning are all about. Besides explaining how AI is being applied to ophthalmology currently, he also addressed three myths in particular. First, while data is an essential ingredient, the quality of labels is equally as important, he said. It is also a myth that a high accuracy model is sufficient for clinical impact. Rather, there’s a need for “translational research to reach clinical and system impact.”

Third, translation into clinical settings is unfortunately not as straightforward. Dr. Hersch proposed that human centered AI could be the solution with mixed methods that could help researchers and clinicians, engineers and patients unlock the potential of AI for healthcare.

Currently, a prospective trial of AI in 9 clinics within the National DR Screening Program is ongoing (Rajavithi Hospital in Thailand) while the Singapore Eye Research Institute is utilizing AI in its health economic assessment study.

During a presentation titled Where would AI fit in clinical care pathways in ophthalmology?, Dr. Michael Chiang, associate director of OHSU Casey Eye Institute in Oregon, United States,

Dr. Stephen Cook from South Africa made an engaging case about using AI in ophthalmology from a developing country’ perspective; his presentation has that same title! Dr. Cook addressed the issue of how screening for the eyes usually have less priority in the government compared to the “big fish” like hypertension or chronic kidney disease. His assertion is that, fundus photos can very well predict the end of organ damage. “If we can prevent progression by using technicians and technology, we can greatly improve the cost of healthcare,” he said. Dr. Cook also said the cost of AI can also be reduced when you have a human and AI working together. AI can not only be applied to help in diagnostics but also help inform best practices in eye care such as not overprescribing treatment modalities.

Hong Kong’s Dr. Carol Cheung, on the other hand, shed light on ocular imagingbased AI solution for Alzheimer’s disease. Besides showing recent studies that demonstrated a link between retinal measures with dementia, Dr. Cheung also said AI deep learning has huge potential to automatically interpret retinal images for stratification of high-risk age-related macular degeneration.

Further, the discussion segment revealed current limitations of AI. “The bigger problem is how we integrate technology into clinical pathways,” said Dr. Cook. Dr. Cheung concurred and gave an example of the need for AI in triage conditions. “AI needs to be integrated into a human operation system. We have to train graders to recognize normal and advanced diseases themselves and use AI in the interim of the disease and spread the spectrum of the disease in between more accurately,” she explained.

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29 June 2020 | Issue #3

Preventing Vision Loss Around The Globe

by Hazlin Hassan

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ging populations, changing lifestyles and limited access to eye care, particularly in lowand middle-income countries, are among the main factors behind an increasing number of people with vision impairment, according to the first World Report on Vision launched last year by the World Health Organization (WHO).

Stronger integration of eye care is needed within national health services, as well as the key basic steps of prevention, early detection, treatment and rehabilitation to ensure that the eye care needs of more people are met.

In light of the World Report on Vision’s findings, several esteemed speakers from around the world discussed at the 37th World Ophthalmology Congress (WOC2020 Virtual®) the ways in which global eye care can be advanced.

The right to sight Back in 1999, 80% of global blindness was avoidable.

“Eighty per cent was really embarrassing for eye care professionals because we recognized that with more efforts and services, we could have saved many more people from blindness,” said Dr. Ivo Kocur, CEO of the International Council of Ophthalmology (ICO).

A joint project by WHO and the International Association for the Prevention of Blindness (IAPB) set out to decrease the numbers by working with national governments and nongovernment organizations (NGOs) to

provide training, interventions and infrastructure development. It showed that an international collaboration in eye care through a unified approach can help to fight the scourge.

The first contact, or primary eye care, needs to be strong so that the eye conditions which are vision-threatening are properly recognized, treated in a primary manner or the patients are referred for advanced care, and also that the eye care is integrated in the system of health care.

Advocating for the prevention of blindness At least 2.2 billion people live with vision impairment, and in at least 1 billion of these cases, vision impairment could have been prevented or has yet to be addressed, said Mr. Peter Holland, the CEO of IAPB. Unaddressed refractive error makes up 23.7 million cases, while cataracts, glaucoma, corneal opacities, diabetic retinopathy (DR), trachoma and unaddressed presbyopia make up 65.2, 6.9, 4.2, 3.0, 2.0 and 826 million cases, respectively.

The impact of the COVID-19 pandemic has seen most services heavily curtailed or stopped, and restarting services has not been straightforward. As such, there is a risk that eye health will lose ground, he warned.

The role of the IAPB has been to conduct webinars, share stories, and adopt a coordinated sector approach, working

with the World Health Organization, United Nations and other global bodies.

Recognizing the seismic impact of COVID-19, IAPB is working hard to inform and persuade global leaders about the magnitude and unacceptability of vision loss globally.

“Eighty per cent was really embarrassing for eye care professionals because we recognized that with more efforts and services, we could have saved many more people from blindness.”

Dr. Ivo Kocur CEO, International Council of Ophthalmology (ICO)

Only the best will do “We need to reach everyone who needs eye care,” said Dr. R.D. Ravindran of the Aravind Eye Hospital System in India. He stressed the importance of making ophthalmic services accessible, affordable and trustworthy.

There should be an informed decisionmaking and consenting process for patients. Patient-centered goals revolve around creating access for patient care, being responsive to patient needs, transparent pricing, minimizing the cost of the treatment, and ensuring follow-up for all patients.

“High quality eye care should be safe,” said Dr. Ravindran. Treatments must minimize harm, including medical errors such as the wrong lens implant, wrong site, and wrong procedure.

There needs to be clear guidelines to prevent infections such as endophthalmitis and preventable surgical complications should be minimized.

Clear instructions should be given on follow-up care after surgery and when to return for postoperative assessment.

At the end of the day, the aspiration is to eliminate needless blindness by providing high quality, safe, compassionate and affordable eye care to all.

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

Conquering the Rock Hard Cataract

by Brooke Herron

H

ard cataracts can complicate just about every step of surgery, from incision, to capsulorhexis and phacoemulsification. For the lowdown on these hard-to-breakdown cataracts, ophthalmologists shared their tips on these challenging cases during a session titled Conquering the Rock Hard Cataract on the third day of the 37th World Ophthalmology Congress (WOC2020 Virtual®).

“When you want to do a very dense cataract surgery, make sure you have strategies for all the different parts of the surgery.”

Dr. Steve Arshinoff University of Toronto Canada

Managing hard cataracts isn’t easy “Phacoemulsification in rock hard cataracts poses challenges for even the most experienced cataract surgeon,” said Prof. Alaa El Zawawi from the University of Alexandria, Egypt. One reason? Hard Grade 4 (brown) and very hard Grade 5 (brown-black) cataracts come with their own comorbidities: loose zonules, a low endothelial cell count, a shallow anterior chamber, pseudoexfoliation and inadequate pupillary dilation.

These brown cataracts are usually present in older, fragile persons — they

have associated systemic disease, and are on medication. All of these must be considered when operating in these cases, he continued.

So, what about surgery?

“Phacoemulsification itself is a real challenge [in these cases],” said Dr. Zawawi, who then offered a few tips on the different techniques. “The sleeve must be retracted to better impale the nucleus if you are using the chopping technique; using the vertical chopper, it must be very sharp to incise the dense nucleus without displacing it; and at the end of the surgery, you will change to horizontal chopping for the remaining large brunescent fragments.

Other tips and techniques “When you want to do a very dense cataract surgery, make sure you have strategies for all the different parts of the surgery,” said Dr. Steve Arshinoff from the University of Toronto, Canada, who extensively covered the use of OVDs (ophthalmic viscosurgical devices) in hard cataract surgery.

“If you want to remember OVDs, there’s a very simple way: The higher viscosity cohesives create space and induce and sustain pressure, while the lower viscosity dispersives have prolonged retention and you can partition spaces,” he summarized.

Next, speaking on surgical techniques was Dr. Vladimir Pfeifer from the University Eye Hospital in Ljubljana, Slovenia, who asked and answered: “Why would we perform quick chop?

“Because in a lot of difficult, complicated cases that’s the best technique to use, especially in brunescent cataracts and in other cases,” he explained. “This technique has only three steps: 1) impale the nucleus with the phaco tip; 2) incise the nucleus with the chopper; and 3) crack the nucleus.”

Lastly, Dr. R.D. Ravindran from the Aravind Eye Hospital in India, compared phaco and manual small incision cataract surgery (MSICS) in cases of hard cataract – he explained that with phacoemulsification, there is less induced astigmatism, better uncorrected vision and early refractive stabilization. “At the same time, it needs good equipment and some of that is quite expensive; it also needs special viscoelastics, which can cost a lot; and in addition, the surgeon should have higher skill and additional resources, like femtosecond laser,” added Dr. Ravindran.

“MSICS can be done in all cases, it’s faster and less expensive… and in a country like ours [India], it’s an affordable option for us.”

Dr. R.D. Ravindran Aravind Eye Hospital India Furthermore, Dr. Ravindran highlighted that not all cataracts are suitable for phacoemulsification and in these cases MSICS is the best option. Besides, this procedure uses less sophisticated equipment; requires less skill, the cost is lower; the complications are fewer; and the surgical time is shorter as well.

After reviewing both procedures, Dr. Ravindran concluded that both phacoemulsification and MSICS achieved excellent outcomes with low complication rates in patients with certain types of brown cataract — although he emphasized that phacoemulsification cannot be done in all cases. “MSICS can be done in all cases, it’s faster and less expensive . . . and in a country like ours [India], it’s an affordable option for us.”

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29 June 2020 | Issue #3

Learning from the Drama

with Oculoplastic Trauma

by Joanna Lee

W

hat would you do if a patient presents with 75% of his face “eaten up” in a cannibalistic attack for 18 minutes? Dr. Andrea Kossler of Stanford University in California, United States, brought her audience at the 37th World Ophthalmology Congress (WOC2020 Virtual®) through a detailed but structured account of her patient, a 65-year-old homeless man who suffered total hyphema in the right eye, flat globe in the left complex eyelid laceration after having his face chewed by an assailant.

To enucleate or not to enucleate?

After much deliberation, she performed bilateral enucleation (evisceration) with implants. She also advanced a pericranial flap for the posterior lamella.

The patient eventually recovered but had declined additional ocular or nasal surgery or prosthesis fitting. “Don’t be intimidated” she said, as she shared her learning points. “Remember the principles of surgery in any situation,” she added. On hindsight, she would avoid primary enucleation when possible, especially if bilateral.

The next case presented in the same session was a bear attack victim with complex and unusual facial laceration. Dr. Rohit Saiju of the Tilganga Institute of Ophthalmology in Kathmandu, Nepal, presented two cases. The first was a 19-year-old victim who has had extensive facial laceration, huge tissue loss from periorbital region with traumatic avulsion of his right eyeball and exposed left eyeball. Subsequently, Dr. Saiju used the medial forehead flap to reconstruct the lower retracted eyelid while donor scleral graft became the posterior lamella.

When dealing with bear attacks, or any other traumatic injuries, it is best to cling to basic surgery principles at all times in oculoplastic trauma cases.

Unfortunately, the forehead flap did not work. Eventually, Dr. Saiju performed the free radial forearm flap (Chinese flap). The second case was a 55-year-old bear attack victim from Nepal. Dr. Saiju concluded that extensive periorbital laceration repairs were difficult as the lacerations were a threat to vision due to exposure. He found a multidisciplinary approach necessary.

Of deformed structures from trauma The next two presentations dealt with dacryocystitis. Prof. Kyung In Woo from Sunkyunkwan University School of Medicine, in Seoul, South Korea, learned that for this type of trauma, the periciliary v-line incision was useful for both medical canthoplasty and external dacryocystorhinostomy (DCR). She also learned that deformed structures from trauma around lacrimal sac were managed efficiently during external DCR. Dr. Jane Olver said: “In lacrimal trauma, all roads lead to the Jones’ tube,” when she discussed her presentation titled All Post-traumatic Dacryocystitis-Managed Endoscopically. For Dr. Olver, lacrimal trauma remains a challenge because the orbito-naso-ethmoid fractures affect the nasolacrimal duct (NLD) obstruction.

Orbital fracture revisions could present as challenges as Dr. Suzanne Freitag from Harvard Medical School in Boston, Massachusetts (USA) had found out.

A 39-year-old healthy male had had a motor vehicle accident 7 months ago and was referred to her. His orbital fracture had been repaired with a titanium mesh by a general plastic surgeon two weeks after the accident. He suffered from vertical diplopia in all directions of gaze even though he has no diplopia prior to surgery and cicatricial entropion.

A call for custom orbital implants After correcting his surgery, he had no improvement in his globe position, and still had diplopia and entropion. She then introduced a patient-specific porous polyethylene implant to create symmetric bony volume. Two months post-implant, his diplopia is gone and globe position has improved. Dr. Freitag concluded that orbital fracture repairs should only be done if there are clear indications (like enophthalmos or diplopia issues). The patient had neither, pre-operatively. Also, she thinks titanium mesh is not an ideal orbital implant. It’s traumatic to insert and remove and it causes significant scarring. Lastly, patient-specific custom orbital implants should be considered.

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

Experts Discuss Challenging Cases in Neuro-Ophthalmology

by Hazlin Hassan

W

e use almost half of the brain for vision-related activities, including sight and moving the eyes. Sometimes, when problems occur for the eye, brain, nerves and muscles, they may involve conditions that can cause permanent visual loss, or become life threatening.

Several speakers at the 37th World Ophthalmology Congress (WOC2020 Virtual®) on Sunday shared their insights on a few hot topics in neuroophthalmology.

Cerebral venous stenting for idiopathic intracranial hypertension Idiopathic intracranial hypertension (IHH) is a rare condition but becoming more common, said Dr. Susan Mollan of the University Hospitals Birmingham in the United Kingdom. Some 90% of those affected are obese women of childbearing age. Symptoms range from headaches, visual disturbances, pulsatile tinnitus, double vision and mild cognitive changes. The majority is benign with a low risk of visual loss but the minority is bad with a high risk of rapid visual loss.

“There are no clear trials helping to guide us when patients are losing vision rapidly, and the drug treatments for symptoms are quite poorly tolerated and the care is very variable around the world,” said Dr. Mollan.

going to be replaced by artificial intelligence? The right answer is that ophthalmologists who use AI will replace ophthalmologists who don’t,” he said.

Controversies in the treatment of NA-AION Nonarteritic ischemic optic neuropathy (NA-AION) is a multicomplex disorder with predisposing and precipitating factors, said Prof. Dr. Sansal Gedik of Selcuk University Faculty of Medicine in Turkey.

In order to treat the condition, doctors must avoid risk factors and night time antihypertensive medication. Aspirin therapy may reduce associated disorders like CVE and MI. Can optic nerve decompression surgery (ONSD) be used to treat NA-AION? Dr. Gedik’s short answer is no. “It is not effective and may be harmful,” he noted.

The rationale for stenting in IIH includes partial occlusion, or stenosis with resultant venous sinus hypertension. A link between venous sinus hypertension (a cerebral venous system disease that obstructs venous blood outflow) and IIH was demonstrated in 1995 when manometry was performed on nine patients with IHH. Raised pressure in the SSS and proximal TS was found in all of them.

The reported incidence of venous sinus stenosis in patients with IHH ranges from 30 to 93% compared with 6.8% among the general population. Dr. Mollan feels that clinical trials are needed to look into the matter further.

AI in neuro-ophthalmology Artificial intelligence (AI) is playing an increasingly important role in the detection of neuro-ophthalmic optic disc abnormalities on ocular fundus images instead of ophthalmoscopy. The use of deep-learning methods to discover abnormal optic discs could revolutionize the practice of neurologists and other non-ophthalmic healthcare providers.

“We had high accuracy for papilledema detection which can be very useful for emergency rooms, in neurological clinics, or in situations where ophthalmologists are not readily available,” said Prof. Dan Milea of the Singapore Eye Research Institute (SERI). “Are ophthalmologists

According to a National Institute of Health (NIH) report from the United States in 1995, there was a 12% additional visual loss in the observation group, 24% additional visual field loss in ONSF administered group, and 42% improvement of visual loss in the observation group.

Other controversies in NA-AION include questions over whether it is a cerebrovascular event of the eye, is iatrogenic NA-AION possible, what is the role of heredity and do erectile dysfunction drugs cause it?

Although the etiology of NA-AION is still debated, the lesion is based on a sudden or rapidly progressive ischemic insult to the anterior optic nerve, resulting in capillary and retinal ganglion cellaxonal dysfunction, followed by astrocyte activation, oligodendrocyte distress and death, and inflammation.

The timing of the ON inflammatory response, oligodendrocyte death, and multiple effects of inflammation on repair and recovery are poorly understood. A study showed that steroids may reduce the capillary permeability and stabilize cell membrane in the acute phase and inhibit damage by free radicals.

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We Stand With The World of Ophthalmology during this time of challenge, and also of hope.

All around the globe we stand united with colleagues, organizations, ophthalmologists and industry, to make 2020 and beyond what it should be:

Clearly, a better future.

In partnership with: