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& cataract • anterior segment • kudos • enlightenment
30 | 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 from 05 Ophthalmologists Africa and the Middle East discussed the various surgical options to treat corneal ectasia. pharmacology 09 Retinal has come a long way from the discovery of anti-VEGFs, but it doesn’t sit on its laurels... the quest to innovate continues.
Glaucoma in Populations of African Descent Assessing the Surgical Options
SICS in cataract 15 Manual surgery works perfectly
by Brooke Herron
in India...maybe in Africa too? Members of the All India Ophthalmological Society shared their clinical pearls to delegates of WOC 2020...
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On the last day of the 37th World Ophthalmology Congress (WOC2020 Virtual®), experts from Africa and around the world discussed some of the major challenges in glaucoma treatment during the “Surgical Options in Populations of African Descent” session.
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frica leads the world in glaucoma prevalence — and in this diverse continent, there are substantial barriers to treatment. As Dr. Tony Realini of the West Virginia University Eye Institute, in the United States, stated simply (and factually), “Glaucoma is a huge problem in Africa.” Africans (and people of African descent worldwide) experience much higher rates of both glaucoma and its related blindness — and the disease burden is great. “There aren’t enough providers and there are significant economic limitations [in Africa],” continued Dr. Realini. He said there are solutions, but it’s a multi-faceted issue. “The problem of glaucoma in Africa is not a single problem — it’s multiple problems, there is no monolithic Africa. It’s a continent filled with many different political, geographical and socioeconomic landscapes, each of which require different solutions to solve the glaucoma problem,” explained Dr. Realini.
Assessing the surgical options Dr. Susan Williams from University of the Witwatersrand in Johannesburg, South Africa, said there are two main challenges Cont. on Page 3 >>
HOTSHOT
We were delighted to welcome the President and CEO of the Glaucoma Research Foundation, Thomas Brunner, to the CAKE & PIE Radio Show at WOC2020 Virtual®. Mr. Brunner discussed exciting treatments emerging in glaucoma... that cataract surgeons are now treating cataracts and glaucoma — a valuable development... and so much more related to Africa, where glaucoma is a major issue.
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30 June 2020 | Issue #4
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
she encounters in her patients of African descent: The patients are young and have advanced disease. “For example, the median age of my primary open angle glaucoma (POAG) patients is 60,” she explained. “And more than half (53%) of my patients have severe visual impairment in one eye by the time they seek help. More than one quarter (27%) are bilaterally blind.” When it comes to the needs of these patients, she has to balance the need for aggressive therapy to preserve some sort of visual function for a long lifetime, with the risks to vision for such surgical procedures. “My surgical procedure of choice is deep sclerectomy with mitomycin-C. I also commonly perform trabeculectomy,” she said, adding that she finds similar pressure lowering between the two procedures. However, she prefers deep sclerectomy for a few reasons: “For my anxious, young patients, the eyes are very comfortable postoperatively. And for the anxious surgeon, I know there will be no surprises. On day 1, the intraocular pressure (IOP) is usually between 5 and 10 mm Hg and a quiet eye. “For those with advanced disease, sclerotomy really is safe surgery,” said Dr. Williams.
In Togo, where Dr. Komi Balo practices at the Teaching Hospital of Lome, glaucoma accounts for 12% of blindness. In his experience, trabeculectomy remains the gold standard for glaucoma surgery, with a couple of considerations: “Early monitoring is compulsory; if target IOP is not achieved, then you have options like needling or revision of the previous surgery — and if those two fail, then another trabeculectomy in a virgin area with antifibrotic agents,” he concluded.
However, the frequency of serious complications was lower in the tube shunt group.
Tube or trabeculectomy first?
Selecting the appropriate procedure
That was the question asked by Dr. Wisam Shihadeh of Yarmouk/JUST University in Jordan — and he answered that, “There really isn’t a consensus.” To take a deeper look, he presented from two major randomized trials that compare the two. In the PVT trial where participants had previous glaucoma or cataract surgery, investigators found that both achieved sustained intraocular pressure in the low teens over the period of the follow-up. The reoperation rate was 29% in the trabeculectomy group versus 9% in the tube group. There were more complications early in the trabeculectomy group, although it equaled out later on. Then Dr. Shihadeh described the PTVT study which also compared the two procedures, but on eyes without previous ocular surgery. At one year, patients in the trabeculectomy group had lower IOP with fewer glaucoma medications.
“When it comes to the choice for glaucoma surgery, it’s pretty much safety versus efficacy . . . so the choice between trabeculectomy and tube shunt will ultimately come down to this issue,” continued Dr. Shihadeh. “There seems to be an inevitable tradeoff between the safety and efficacy in glaucoma surgery.”
It is clear that there are different variables to consider when determining which procedure to select, especially in a continent like Africa, with varying levels of access to healthcare. However, there are several general tips that can help. “First, it’s very important to assess the surgeon’s skills and experience,” Dr. Shihadeh explained, adding that surgeons should do procedures they’re comfortable with, or otherwise, refer the patient to another specialist. It’s also important to address the follow-up issue, from both the surgeon’s and patient’s points of view. Another factor is availability: There are also some countries where tube shunts are not available at all, or where other ocular factors could favor the decision, concluded Dr. Shihadeh.
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30 June 2020 | Issue #4
Treating Cataract Patients with Ocular Comorbidities by Hazlin Hassan
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reating a cataract patient who has ocular comorbidities can be a conundrum. How do you handle it? Which do you treat first? Experts weighed in on the matter on the last day of the 37th World Ophthalmology Congress (WOC2020 Virtual®), with some suggesting that the first goal should be to stabilize the cornea before performing any surgery.
Abnormal ocular surfaces Pterygium is relatively common in the general population, and in tropical countries, and is linked to ultraviolet-B radiation exposure. Cataracts also tend to occur at an earlier age in tropical countries. It is not surprising that many patients coming in for cataract surgery are also found to have an associated pterygium, noted Dr. Ewa Mrukwa-
“For cataract patients with pterygium, what’s important is the decision about simultaneous versus sequential surgery. We can decide after careful silt lamp examination, repeated topography measurements, discussions with the patient, and careful IOL calculation. Choose the right IOLs and the right surgical method.” Dr. Ewa Mrukwa-Kominek Silesian University of Medicine Katowice, Poland
Kominek of Silesian University of Medicine, in Katowice, Poland. Early in the disease, pterygium patients are usually asymptomatic. However, there can be symptoms of dry eye. As the disease progresses, the lesion increases in size and becomes more apparent to the naked eye and may become cosmetically unpleasant for patients. Should you do simultaneous or sequential surgery for pterygium and cataract? The proponents for simultaneous surgery would cite reasons such as single versus two procedures, reduced cost, morbidity, and work day loss. If the patient lives far from health care delivery services, this argument may be valid. Yet others favor a sequential surgery. Pterygium is known to induce refractive astigmatism which can affect the outcome of the cataract surgery. Though there is no consensus, it is logical that any pterygium that interferes with the keratometry readings should be removed before cataract surgery. Highly vascularized, inflamed, active and elevated pterygia are likely to induce change in the corneal shape.
Accurate and stable keratometry is crucial in avoiding postoperative refractive surprises. Large pterygia extending on to the visual axis should undoubtedly be removed before any cataract surgery. If pterygium excision is performed before the cataract surgery, one should wait 6-8 weeks for the corneal keratometry/ topography to stabilize before planning cataract surgery. “We can summarize that for cataract patients with pterygium, what’s important is the decision about simultaneous versus sequential surgery. We can decide after careful silt lamp examination, repeated topography measurements, discussions with the patient, and careful IOL calculation. Choose the right IOLs and the right surgical method,” concluded Dr. Mrukwa-Kominek.
Management of cataract patients with keratoconus Cataract patients with keratoconus (KC) need to be stabilized first, said Prof. Ahmad Elmassry, of Alexandria University, Egypt. “Stability is a must,” he stressed. Cont. to Page 10 >>
CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments
Surgical Options for Corneal Ectasia Problems by Brooke Herron
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orneal ectasia — where the thinning of the cornea causes it to change shape — is a group of progressive eye disorders, under which several sight-debilitating conditions fall (e.g. keratoconus). Treatment options can range from the conservative contact lens or to more invasive alternatives, like corneal transplantation (or keratoplasty). Therefore, during the last day of the 37th World Ophthalmology Congress (WOC2020 Virtual®), ophthalmologists from Africa and the Middle East discussed the various surgical options to treat corneal ectasia during the session titled Surgical Management in Corneal Ectasia and Other Corneal Problems.
Femtosecond AK for high astigmatism post-keratoplasty “We know that keratoplasty is a common procedure for treating many corneal problems — but one of the main problems with keratoplasty is postoperative astigmatism,” said Dr. Tamer Gamaly of the Magrabi Eye Hospitals and Centers in Abu Dhabi, United Arab Emirates. “Plus, the functional visual acuity of the patient can take up to one year, usually after removing all the sutures from the graft,” he added.
that further adjustment and refinement will help in treating more patients.
Femtosecond endothelial keratoplasty Endothelial cell loss can result in increased corneal edema and decreased visual acuity. According to Dr. Saeed Algehedan of Global Eye Care in The Kingdom of Saudi Arabia, penetrating keratoplasty has long been the goldstandard of treatment in these cases. However, it’s not without drawbacks: visual recovery is slow (6-24 months), and 50% of patients require a contact lens or refractive surgery to achieve useful vision. It’s also associated with postoperative astigmatism, suture-related complications, graft failure, infectious keratitis, among others. “Now femtosecond endothelial keratoplasty (FEK) is providing us with an excellent alternative,” shared Dr. Algehedan. FEK has several benefits: it is performed under topical anesthesia; it’s suture-less; visual recovery is faster; it has less-induced astigmatism; and there are fewer intra- and postoperative complications. “This procedure has been done and is expanding worldwide,” he continued. In addition to the positive outcomes in
his own patient cases, he then shared results from recent studies which also reported excellent results. “FEK is a new surgical technique for endothelial transplantation that has a high success rate, a short learning curve, fewer complications, lower rate of rebubbling need, proper graft centration and faster recovery,” explained Dr. Algehedan.
Endothelial keratoplasty in glaucoma patients The coexistence of corneal endothelial disease and glaucoma is not uncommon: Elevated intraocular pressure (IOP) is associated with endothelial cell loss. And on the other hand, keratoplasty can lead to glaucoma, especially with the long-term use of steroids or from surgical complications, began Dr. Fouad El Sayyad of Sayyad Eye Center in Giza, Egypt. Over keratoplasty, procedures like DSAEK (Descemet stripping automated endothelial keratoplasty) and DMEK (Descemet membrane endothelial keratoplasty) have several advantages in glaucoma cases. Studies have shown that endothelial keratoplasty can be performed with great outcomes in pre-existing glaucoma patients, said Dr. El Sayyad. However, Dr. El Sayyad also conceded that there are challenges: “History of glaucoma surgery can cause increased graft dislocation.” Studies have reported graft dislocations in up to 26% of DMEK cases and up to 36% in DSAEK. Therefore, these patients should be monitored closely, he concluded.
Dr. Gamaly then presented a patient case where the patient’s astigmatism gradually worsened at each follow-up — from -2D, eventually to -9D at month 3 — after removing the sutures. However, he noted that the patient’s BCVA was still 20/28. After considering the various treatment options, Dr. Gamaly chose femtosecond astigmatic keratoplasty (AK). Following the procedure, he reported the astigmatism dropped to -1D, while the BCVA remained at 20/28. He concluded that femtosecond AK can reduce astigmatism in cases of highastigmatism post-keratoplasty, noting
Progressive steepening: Okay for roads, bad for corneas.
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30 June 2020 | Issue #4
Understanding Uveitis Replacing Fear with Love
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earning to diagnose and classify uveitis is now made easier with the help of researchers from the IUSG group working on the SUN criteria and “infecting” others with their passion. “The idea of this [course] is, it will help get rid of your fear when you see uveitis patients,” said Prof. Dr. Manfred Zierhut from the University of Tuebingen, Germany in his warm welcome to the congress audience at the 37th World Ophthalmology Congress (WOC2020 Virtual®) on Monday. In a session titled How to Make a Clinical Diagnosis and Reduce the Number of Special Investigations, participants received a comprehensive lecture on how to detect uveitis.
Anterior uveitis, an overview In his overview of anterior uveitis and how to diagnose it, Prof. Zierhut who is also president of the International Uveitis Study Group (IUSG) advised doctors to essential tools: patients’ history, slip lamp and funduscopy which would be helpful to cross out the possibilities of posterior uveitis and to measure the intraocular pressure (IOP). “These things will help you later on to
by Joanna Lee
limit your laboratory work and to have a good corrected adequate treatment for your patients,” he explained. Besides knowing the anatomic localization of anterior uveitis, he pointed to the Standardization of Uveitis Nomenclature (SUN) criteria to determine if the uveitis is acute, recurrent or chronic. To find out the different types of anterior uveitis, there are differential diagnostic (DD) criteria. It’s always unilateral unless there are systemic disorders and only 10% of cases are bilateral. If it changes sides like a ping-pong mechanism, it may be HLA-B27 (acute anterior uveitis - AAU). HLA-B27 is commonly found in more men, has low IOP and has preclinical sensations of having red eyes. If there’s corneal involvement (keratouveitis), it may indicate the presence of syphilis, Lyme disease, sarcoidosis, tuberculosis, leprosy, recurrent polychronditis, Cogan syndrome and the HSV (herpes simplex virus) and VZV (varicella-zoster virus). Other DD criteria would be to watch out for pigment defects, iris color irregularities, endothelial-precipitates (especially granulomatous), iris nodules
and hypopyon as well as sanguis. Typically, anterior uveitis is often associated to systemic disorders.
Diagnostic and classification criteria In order to improve the accuracy of diagnosis of uveitis, it’s important to be familiar with its diagnostic and classification criteria. Prof. Peter McCluskey of Save Sight Institute, University of Sydney, Australia, covered and differentiated between these two criteria. The classification criteria for uveitis is used primarily for clinical research and is more homogenous as opposed to diagnoses criteria’s broader cohort, but it may be used as de-facto diagnostic criteria as well. Its criteria are more or less similar with using the gold standard such as the PCR (polymerase chain reaction) test for viral uveitis. The best example of classification criteria are the SUN classification criteria. The SUN project is about to be completed by end of 2020 after 16 years of developing the most common criteria for 25 uveitis phenotypes. The SUN criteria, Prof. McCluskey said, brings hope and excitement and will allow for disease specific clinical studies rather than looking at “non-anterior, non-infectious” uveitis.
Recognizing infectious uveitis Infectious uveitis is common in India, Prof Zierhut said. Thus, Dr. Soumyava Basu of LV Prasad Eye Institute in Hyderabad, India, was at hand to explain four components by which we could recognize infection in patients with uveitis. First, demographics – what infections are common to certain regions, what is the age and occupation of the patient? Lyme infections for instance are more common among those working in forests, for example, or leptospirosis in sanitation workers.
Uveitis may be difficult to differentiate like these cute creatures, but the SUN criteria is set to rise on the horizon by end of 2020 for the benefit of future clinical studies on the disease.
Second, clinical red flags of infection would be signs like having granulomatous anterior uveitis alone (without sarcoid or VKH). Another red flag would be raised IOP which is common in HSV, VZV and CMV (cytomegalovirus) cases or hypopyon with Cont. to Page 10 >>
CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments
There are opportunities and prospects for ophthalmic research, generally associated with clinical work, and isolated ophthalmic research opportunities in larger ophthalmic institutions, he added. YOSI is one of the newest members of International Council of Ophthalmology (ICO). YOSI activities include holding webinars, organizing international collaborations, and running a website, as well as a YouTube channel.
Young doctors are the future
Global Young Ophthalmologist Colloquium An Update on International YO Activities, Training and Research by Hazlin Hassan
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ighting a global pandemic on the frontlines. Standing up to racial injustice. These are just some of the things young ophthalmologists did this year (besides treating patients, of course!).
and police brutality. Most protests were peaceful, but even then some were met with teargas, pepper spray and rubber bullets,” said Dr Simon Fung, adult and pediatric cornea specialist, United States.
And it has certainly been a hectic year, with several historic and unprecedented events worldwide. Some of the most successful Young Ophthalmologists (YO) societies around the world shared updates on what they have been up to lately.
The AAO released a statement on social media calling on domestic law enforcement officials to stop using rubber bullets to control or disperse protestors which attracted over 22,000 views in just over 48 hours, he said.
Using your voice shouldn’t mean losing your vision #NoRubberBullets Over in the United States, the American Academy of Ophthalmology (AAO) YOs, being on the frontlines at the epicenter of the coronavirus pandemic, responded to the outbreak by creating a dedicated webpage, packed with information about the COVID-19 virus and eye health, such as guidance on how to self treat at home. It has also launched a daily COVID-19 newsletter, filled with breaking news, resources and webinars. The AAO YOs were also engaged in advocacy issues, speaking on behalf of the profession and patients to legislators at the state and federal levels. “The death of George Floyd sparked global protests against racial discrimination
For those who were looking forward to attending the AAO 2020 but are unable to, video conversations taken during the annual meeting will be posted online, he added.
Postgraduate training opportunities abound in India In India, there are a myriad opportunities to prepare the next generation of YOs to take things forward, said Dr. Digvijay Singh, President of the Young Ophthalmologists Society of India (YOSI). “Overall, India produces over 1,500 new ophthalmologists every year,” he said. There are 400 long term fellowships in 45 institutions, with many more short term fellowships or observerships in over 100 institutions, a few of which accept foreign students.
Working hard to serve the people The Singapore Society of Ophthalmology (SSO) YO Chapter takes its duties very seriously. “Its mission is to serve the needs of ophthalmologists who are in training and support them in their first five years of specialist practice in Singapore in the areas of education, professional development, mentorship, community, and giving back to society,” said Dr. Wong Chee Wai of the Singapore National Eye Centre, Singapore. The SSO YO chapter has been very busy, helping with education and professional development, mentorship, building the community and giving back, as well as being involved in international engagement. “Almost all YO leaders indicated a need for more interaction and networking with global YO counterparts,” he said. The SSO YO chapter successfully organized its inaugural Global YO Symposium earlier this year (from January 17-19) with some 200 attendees from Europe, Africa, Asia-Pacific and America. As part of efforts to give back to society, it also set up a YO Mobile Eye Clinic, bringing eye care to vulnerable members of the society who have slipped through safety nets. And it’s not just providing eye screening but also opportunities for education, research, collaboration and exploring innovation. “YOs are the future of our profession. Invest in their growth!” concluded Dr. Wong.
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30 June 2020 | Issue #4
Management of Retinal Vein Occlusion by Hazlin Hassan
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etinal vein occlusion (RVO) is the second most common cause of visual loss due to retinal vascular disease after diabetic retinopathy. The standard-of-care treatment for macular edema due to central retinal vein occlusion (CRVO) is the use of intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents or intravitreal corticosteroid implant. However, the optimal treatment protocol regarding the choice of anti-VEGF agent and dosing regimen remains unclear. The results of several studies on the matter were presented by several renowned experts from around the world on the final day of the 37th World Ophthalmology Congress (WOC2020 Virtual®) on Monday.
Ranibizumab versus aflibercept versus bevacizumab (LEAVO trial) The LEAVO study, a multicenter phase 3 double-masked randomized controlled non-inferiority trial, has found that mean changes in vision after treatment of macular edema due to CRVO were no worse using aflibercept compared with ranibizumab. Mean changes in vision using bevacizumab compared with ranibizumab were inconclusive regarding vision outcomes (the change in visual acuity from baseline, on average, may be worse or may not be worse when using bevacizumab compared with ranibizumab). “Comparing aflibercept versus ranibizumab, aflibercept was non-inferior to ranibizumab but it was not superior,” said Prof. Sobha Sivaprasad of the world renowned Moorfields Eye Hospital in the United Kingdom, who is a co-lead of the LEAVO study. The comparative clinical effectiveness of ranibizumab, aflibercept, and bevacizumab for the management of macular edema due to central retinal vein occlusion (CRVO) is unclear. The trial was aimed at evaluating the efficacy of three widely
available intravitreal anti-VEGF agents: ranibizumab (Lucentis), aflibercept (Eylea), and bevacizumab (Avastin) for macular edema due to CRVO. Results showed that although aflibercept was non-inferior (no worse than) to ranibizumab in terms of mean bestcorrected visual acuity (BCVA) change through 100 weeks, bevacizumab was not non-inferior (inconclusive) to ranibizumab for treating CRVO macular edema. Post-hoc analysis also demonstrated that bevacizumab was not non-inferior to aflibercept in terms of mean BCVA change at 100 weeks.
The use of laser in macular edema There are two types of retinal vein occlusion: central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO). The main cause for visual impairment in CRVO is macular edema (ME) while neovascularization of the retina and/or the anterior segment is the most serious complication leading to vitreous hemorrhage, retinal detachment and neovascular glaucoma.
“There is a very interesting trial showing the need for retreatment in the second year, and if you are looking at up to six years after the randomization, we can see there is only one patient needing intravitreal treatment in the laser treated group compared to two thirds of the patients which were treated initially only with ranibizumab,” he said. However, there is strong evidence for laser treatment only in neovascular complications, in patients with vitreous bleeding, or patients with secondary glaucoma, he said, noting that evidence for targeted laser treatment is still weak. Large randomized trials are ongoing, he concluded, with results expected in 2-3 years.
Anti-VEGF keeps the doctor away Branch retinal vein occlusion (BRVO) cannot be cured. The main goal of treatment is to keep the patient’s vision stable, usually by sealing off any leaking blood vessels in the retina. This helps prevent further swelling of the macula. Patients with greater vascular reduction had less recurrences of macular edema in BRVO, noted Prof. Hiroko Terasaki from Nagoya University Hospital, Japan.
In serious cases, there is loss of vision. To date, no treatment has been proven to be effective in large trials. “It is still not clear how to treat it,” said Prof. Matus Rehak of Leipzig University, Germany. Intravitreal anti-VEGF injections are the current treatments of choice for ME due to CRVO. Two different anti-VEGF drugs (ranibizumab and aflibercept), and a biodegradable dexamethasone implant are approved for treatment but they provide only temporary relief while the need for repetitive treatments is a major burden for patients.
A retrospective study was carried out at the Nagoya University Hospital in Japan to investigate the correlation between the number of intravitreal injections of the anti-VEGF agents and the vessel density determined by OCT-angiography (OCTA) in eyes with macular edema (ME) secondary to BRVO. A total of 29 eyes of 29 patients with macular edema secondary to BRVO were treated with intravitreal injections of anti-VEGF agents.
Prof. Rehak cited a study which looked at the use of a combination of ranibizumab injections and laser for the treatment of ME due to CRVO. Patients were randomized to receive intravitreal ranibizumab versus ranibizumab plus selective laser photocoagulation to areas of peripheral non-perfusion.
“In summary, local macular vessel density reduction rate one month after the initial intravitreal injection was correlated with the total number of intravitreal injections until 6 months in eyes with macular edema associated with BRVO, suggesting that it would be a useful index for predicting the frequency of anti-VEGF intravitreal injections,” said Prof. Terasaki.
CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments
Other new delivery systems on the block include the encapsulated cell technology (ECT) where cells genetically have been modified to produce a desired agent that are encapsulated in a semi-permeable hollow fiber membrane. It is retrievable when implanted in the vitreous. Another interesting drug delivery system is the Ophthalmic MicroPump™ (Replenish, Pasadena, California, USA) that delivers continuous drugs to the anterior and posterior segments, among other innovations. Dr. Mieler’s presentation’s co-author, Dr. Jennifer Kang-Mieler of the Illinois Institute of Technology in Chicago (USA) has invented the microspherethermo-responsive hydrogel drug delivery system (U.S. patents pending) which uses a biodegradeable thermo-responsive hydrogel in the in-vitro release.
Innovations in Retinal Pharmacology by Joanna Lee
Retinal pharmacology has come a long way ever since anti-VEGF drugs came onto the scene 15 years ago. Today, new delivery methods are being developed as the quest for more effective medicine continues.
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“nuanced approach” to assessing fluid is important,” Dr. Srinivas Sadda of the Doheny Eye Institute in Los Angeles, California (USA) said during his presentation on fluid management in neovascular age-related macular degeneration (nAMD) at the 37th World Ophthalmology Congres (WOC2020 Virtual®).
Review of literature Clinical trial data over the decades have shown that uncontrolled exudation in nAMD is bad for vision. He cited previously published studies like CATT1, IVAN2 and PIER3, among others, which demonstrated how intraretinal fluid, subretinal fluid and sub-RPE fluid, their absence or presence thereof, in exudative-based treatment approach influenced the visual outcome. For instance, the PIER study indicated that patients who had no residual fluid tend to have better visual outcomes compared to those who had fluid. However, the HARBOR study, of which Dr. Sadda
is a part of, showed that eyes with residual sub-retinal fluid only at 12 and 24 months experienced the greatest baseline characteristic visual acuity (BCVA) improvement. This led to his hypothesis that perhaps some residual SRF may be tolerated in the short-term. However, controlling exudation, in Dr. Srinivas’ estimation is still the key to achieving optimal visual outcomes in nAMD patients.
Drug delivery devices Providing an overview of retinal pharmacology, Dr. William Mieler of the The University of Illinois College of Medicine in Chicago (USA) noted that intravitreal injections (i.e. anti-VEGFs) and the use of sustained-release solid implant intravitreal devices are currently the most common methods used. However, the need for less invasive, safer and more effective drug delivery methods continues to drive innovation. Latest developments include microneedles, a micrometer-sized needle and injector which can deliver drug into suprachoroidal space (SC). There’s also the microcannula with (or without) light illumination for SC drug delivery as well as a microcatheter with potentials for stem cell delivery and delivery of corticosteroid.
Molecules and substances of note In another exciting development, Kyoto University’s Dr. Hanako Ikeda’s team found that VCP (valocin containing protein) ATPase inhibitors known as KUS121, KUS187 is shown to reduce death [Editor’s Note: KUS stands for ‘Kyoto University Substance’, developed by Prof. Kakizuka at the university.] KUS, a small-molecule compound, showed neuroprotective effects on the ganglion cells/photoreceptors in animal models of ocular diseases. These compounds show promising new avenues for glaucoma or retinal degeneration treatment using neuroprotective agents. The research team tested it on a small sample of patients with central vein artery occlusion (CRAO) in humans. The results demonstrated that KUS could prevent retinal ganglion cell (RGC) loss and improved visual acuity. Further tests after these two phases of study will be done in a larger scale in the future, Dr. Ikeda said. The chair of this session, Dr. Taiji Sakamoto from Kagoshima University in Japan, said: “So far, there’s been no drug to increase VA in CRAO so we’re looking forward to Phase 3 of this study.”
The role of imaging Further, Dr. Seung-Young Yu from Kyung Hee University in South Korea shared Cont. to Page 10 >>
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While the condition requires delicate surgical maneuvers, well-controlled perioperative inflammation will produce excellent results in cataract with uveitis.
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The signs of progression of KC include thinning of the cornea more than ten microns per year, and increase of the curvature of the cornea more than one diopter per year. For patients under age 30 with unstable cornea, surgeons may stabilize the cornea by corneal collagen cross linking (CXL), and wait three to six months before conducting cataract surgery. Prof. Elmassry also warned that toric IOLs do not have good results in irregular cornea. His take home message: “Provide a complete explanation to the patient, carry out all preoperative investigations, protect the cornea, and allow enough time for the compromised cornea to heal.”
Management of cataract with uveitis There should be no uveitis activity in a cataract patient for at least three months before surgery, said Prof. Hatem Ammar of Sohag University, Egypt. Cataract is a common complication from uveitis. It occurs in 50% of patients with anterior and intermediate uveitis, and 83% of juvenile idiopathic arthritis. Phacoantigenic uveitis is an absolute indication for cataract extraction, he noted. For pediatric patients, the risk of amblyopia needs to be considered when cataract surgery is delayed. “Managing patients’ expectations with regards to visual prognosis is paramount,” said Prof. Ammar. Surgery could be more complicated and longer due to abnormal anatomy and there is a possibility of significant postoperative inflammation. Cataract surgery success is critically related to careful control of perioperative inflammation.
aflibercept improved both visual and anatomical outcomes in patients with nAMD for the first year of treatment. The fixed dosing also induced a “comparable decrease in pigment epithelial detachment (PED) volume, size of CNV and vessel density of the neovascular membrane at all follow-up visits.” It also recorded vessel density reduction which was significantly related to anatomical activity reflected on the OCT. This was shown to be significantly higher in patients who had improvements in BCVA compared with patients without any progress in their BCVA.
PDT versus anti-VEGFs in PCV a yellow glow. Dr. Basu reminded the audience that posterior segment uveitis is commonly infectious compared to anterior segment. Third, laboratory investigations could also indicate infection with evidence of infection versus evidence of the immune response (ocular fluids, biopsy, blood, radiology). Lastly, response to treatment like antimicrobial therapy could be observed to determine the type of infection present. Also, Prof. Zierhut invited those interested to learn more about uveitis to engage with the International Uveitis Study Group. “If you are a little more familiar with uveitis, you’ll start to love it,” he said.
Finally, Dr. Joo Yong Lee of the University of Ulsan in South Korea, shared about polypoidal choroidal vasculopathy (PCV), focusing on studies involving its treatment using photodynamic therapy (PDT), anti-VEGF agents. PCV, as many know, is more prevalent in Asians compared with Caucasians. Clinical trials reviewed in this presentation included the PLANET study and Everest II, comparing the two, and more recently the DRAGON study.4 His conclusion was that both monotherapy with anti-VEGF agents and combination therapy with antiVEGF agents or PDT can achieve visual improvement and reduction in disease activity.
References: 1
Maguire MG, Ying G-S, Jaffe GJ, et al. (CATT Research Group). Single-Nucleotide Polymorphisms Associated With Age-Related Macular Degeneration and Lesion Phenotypes in the Comparison of Age-Related Macular Degeneration Treatments Trials. JAMA Ophthalmol. 2016;134(6):674-681
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Dakin HA, Wordsworth S, Rogers CA, et al. (IVAN Study Investigators). Cost-effectiveness of Ranibizumab and Bevacizumab for AgeRelated Macular Degeneration: 2-year Findings From the IVAN Randomised Trial. BMJ Open. 2014;4(7):e005094.
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Abraham P, Yue H, Wilson L. Randomized, Double-Masked, Sham-Controlled Trial of Ranibizumab for Neovascular Age-Related Macular Degeneration: PIER Study Year 2. Am J Ophthalmol. 2010;150(3):315-324.e1.
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Chen S-N, Cheng CK, Yeung L, et al. One-year real-world outcomes of ranibizumab 0.5 mg treatment in Taiwanese patients with polypoidal choroidal vasculopathy: a subgroup analysis of the REAL study. Int J Ophthalmol. 2018; 11(11): 1802–1808.
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findings from her study, titled Treatment Interval of Anti-VEGF: Imaging Analysis. The study’s purpose was to evaluate the efficacy of intravitreal aflibercept for neovascular membrane, pigment epithelial detachment secondary to type 1 choroidal neovasculaization (CNV). The study found that fixed dosing of
CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments
WOC2020 Virtual® was great but we can’t wait to return to physical conferences. See you at WOC in Melbourne 2022!
APAO 2019 Bangkok, Thailand
APAO 2019 Bangkok, Thailand
AAO 2019, San Francisco, Calif., USA
DOSCON 2019 New Delhi, India
ASRS 2019 Chicago, Ill., USA
AIOC 2019 Indore, India
ARVO 2019 Vancouver, Canada
EURETINA/ESCRS 2019 Paris, France
APVRS 2019 Shanghai, China
ASCRS 2019 San Diego, Calif., USA
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New Insights into Glaucoma Genetics by Hazlin Hassan
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hile glaucoma is a leading cause of blindness for people over 60 years old, blindness from glaucoma can often be prevented with early treatment. And with new insights in glaucoma genetics today, this could alter the way the disease is diagnosed and treated in the future. Speakers discussed how genetics can affect one’s glaucoma risks during a session on the final day of the 37th World Ophthalmology Congress (WOC2020 Virtual®).
Family is thicker than water Primary angle closure glaucoma (PACG) is an important cause of glaucoma worldwide, especially in Asia, where it reportedly affects more than 20 million people. Researchers have discovered that siblings are at risk of angle closure. “In Singaporean Chinese, the sibling recurrence risk for having narrow angles is 49%. If one has PACG, there is almost a 50% chance that the sibling has narrow angles,” Prof. Tin Aung, from the Singapore National Eye Center, Singapore, explained to delegates.
developing the disorder compared with the general population. Sample collections were taken from around the world for a PACG Genomewide association study (GWAS). However, genes identified from GWAS only explain less than 10% of the genetic basis of ACG and cannot explain racial differences in ACG prevalence as there is currently a small number of non-Asians in GWAS so far.
Genetics and glaucoma care: now and into the future
The sibling relative risk is 7.6, so if one has PACG, a sibling has almost 8x greater risk of narrow angles compared to the general population. There were also similar findings in South Indians, where there is a family history of predisposing risk factors.
Genetic testing can be useful for patients with early-onset disease, said Prof. Janey Wiggs of Harvard Medical School, United States. It helps to inform genetic counseling, and can identify people at risk, allowing for early treatment. “Some early onset glaucoma genes are emerging as targets for novel therapies,” she said. Genetic testing for early-onset glaucoma targets patients or their family members with disease onset before age 40.
The prevalence of angle closure among first degree relatives of subjects with ACG was higher than the general population. Caucasians had 1-12% higher risk than the general population while Inuits had 3.5 times greater risk of
Adult onset glaucoma is inherited as a ‘complex’ trait. Polygenic risk scores can identify people at high genetic risk for POAG to improve surveillance and treatment, and potential for screening, she said. In the future, more work
is needed to know more about early onset glaucoma, to identify new genes and disease-causing mutations, she concluded.
Links between POAG and Alzheimer’s disease Recent work by the International Glaucoma Genetics Consortium (IGGC) has shown that POAG and Alzheimer’s disease (AD), the most common cause of dementia, share joint heritability of 0.14 using LD score, said Prof. Michael Hauser of Duke University, United States. This means that the two disorders share 14% of the genetic variants that increase risk of disease. While there has long been debate of possible links between AD and POAG, this is the first concrete evidence that both diseases show the same mechanism of neuronal cell death. Recent studies have shown joint heritability between AD and POAG in Caucasian populations. As researchers discover shared underlying mechanisms connecting diseases, there is potential to come up with new ways in which to better treat patients suffering from these diseases.
CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments
New Insights into Diabetic Retinopathy by Brooke Herron
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nnovation is the name of the game when it comes to improving (or developing new) methods for screening, diagnosing and treating patients with diabetic retinopathy (DR). Technology like artificial intelligence (AI) has entered our vernacular — although perhaps not our personal practice yet — and new developments in medical treatments and drug delivery devices are of keen interest for their longer lasting agents and durability. These topics and more were covered during the New Insights into Diabetic Retinopathy session on the final day of the 37th World Ophthalmology Congress (WOC2020 Virtual®).
Developments in screening and diagnosis Over the past few years, new developments have risen to the surface for patients with diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR). These can be separated into several categories, according to Dr. Chaitra Jayadev from Narayana Nethralaya Eye Institute in India. These include newer diagnostics, pharmacological treatments (both systemic and ocular), new surgical techniques and novel drug delivery systems.
Gavin Herbert Eye Institute at University of California Irvine, USA. He says he uses OCTA daily: “The images are fantastic, but I don’t always let them guide my treatment. In fact, I rarely do.” So, what is the best imaging modality for DR patients? “OCTA is a novel and promising technique for non-invasive, non-dye based imaging of the retinal and choroidal circulation, but due to numerous limitations and artifacts, fluorescein angiography (FA) is still the gold standard for DR,” concluded Prof. Dr. Kuppermann.
Developments in treatment Anti–vascular endothelial growth factor (anti-VEGF) therapy has replaced laser photocoagulation as the mainstay treatment for DME, said Dr. Jayadev. And now, we have some additional data about these agents thanks to the Protocol T Extension. This study looked at the five year outcomes of bevacizumab, aflibercept and ranibizumab in order to answer the question: What happens after Protocol T patients were released from the structured study and into standard clinical care?
Regarding newer diagnostics and automated screening, Dr. Jayadev said: “AI, as we know, is the next big thing that’s going to happen, not only in screening, but also in deciding which patient is going to need an earlier followup,” she explained, adding that ultra widefield imaging has also been helpful as a screening tool, as are imaging modalities like optical coherence tomography angiography (OCTA), sweptsource OCT (SS-OCT), enhanced depth imaging OCT (EDI-OCT) and adaptive optics (AO). Continuing the discussion on imaging was Prof. Dr. Baruch Kuppermann from
Innovation is not as far away as it seems. . .
Dr. Jennifer Sun from the Joslin Diabetes Center at Harvard Medical School, USA, presented the results. It was found that after leaving the study, 95% of patients received retinal care and 68% received at least one intravitreal injection. They reported that on average, patients demonstrated visual acuity gains from baseline, but mean VA worsened between years 2 and 5. She also noted there was no change to central subfield thickness from years 2 to 5. “These results differ from prior clinical trials in DME that have demonstrated better maintenance of visual gains. Protocol T clearly demonstrated much better maintenance than what we saw in this extension study,” said Dr. Sun. “This suggests the need for strategies to improve long-term visual outcomes in clinical care among eyes with DME.” Stepping away from anti-VEGFs and advocating for vitrectomy in DME was Dr. Stratos Gotzaridis from My Retina Athens Eye Center in Greece. “The current treatments we have for DME are suboptimal. They have a short duration, they’re time consuming, they’re extremely expensive (even with regimens using bevacizumab), and they’re not completely risk free.” Therefore, he prefers pars plana vitrectomy (PPV), which he said reduces or resolves DME in a large percentage of patients. “The sight-threatening complications of PPV are low or equal to an extended series of anti-VEGF injections,” he explained, adding that PPV also costs less and has more durable edema-resolving results.
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Looking Through Therapeutic Contact Lenses by Joanna Lee
Therapeutic contacts lenses seem to be at the cusp of a new edge with its indications for dry eyes and even for stem cell regeneration. Read on to get beyond its surface of innovations.
The bandage contact lenses The first therapeutic or bandage contact lenses were approved for use in the United States in the 1970s. They were effective at pain management for keratopathy and surface defects. Fast forward to today, therapeutic contact lenses (TCL) are used to manage ocular surface diseases, particularly to improve epithelialization, for mechanical protection, structural support and most recently, as a means to deliver medication. Prof. Christina Grupcheva of Medical University of Varna in Bulgaria introduced the background of therapeutic lenses, current developments and its use in general, sliding into an easy introduction to these lenses also known as bandage lenses. Soft hydrogels were used in the past. But today, silicone hydrogel lenses are the gold standard. There are also scleral and semi-scleral lenses, cellulose lenses and biodegradable lenses. She said it’s important for lenses to be an optimal fit for the patient as well as having a wellselected diameter. These two parameters are vital for minimal mechanical impact on the ocular surface. TCL should have sufficient oxygen and stable water content. Ideally, it should have an inert structure and slow-release capability for medicines. Today, we have diagnostic lenses that are much better than disposable lenses but the new frontier belongs to TCLs with “nanotechnologies, programmed materials, and microelectronic opportunities”.
Contact lenses for dry eyes Since dry eye was identified to increase one’s chances of dropping out of wearing contact lenses, Dr. Oliver Woo from Australia, spoke about using scleral lenses and soft contact lenses for dry eyes in his presentation titled Latest Contact Lenses Technology Can Solve My Dry Eye Problem. In speaking about scleral lenses he showed a case study example where a patient experienced all of her corneal staining and filaments resolved with daily scleral lens use. For soft contact lenses, he brought up Johnson & Johnson’s tear-infused designed Acuvue contact lenses and likens its hydrating Hydraluxe™ canal technology. Another interesting innovation is the SmarTears™ Technology (developed by Alcon) where phospholipids in the eyes are drawn out of the lens from the wearer’s tear film once he or she wears the contact lens. This technology combined with water Gradient technology gives birth to Dailies Total1® lenses. Dr. Woo summarized his segment saying advanced contact lens designs (scleral lenses) can be “primary therapy to restore ocular surface physiology back to homeostasis” besides giving patients quality of life, confidence and enjoyment.
Stem cell-carrying contact lenses The next speaker, Prof. Sorcha Ni Dhubhghaill who is based in Antwerp University Hospital in Belgium, painted a unique and ironic situation in her presentation titled Contact Lens Carriers – Stem Cells where contact lenses which
can cause limbus stem cell deficiency (LSCD) are also able to treat LSCD. Using en vivo cultivated limbal epithelial stem cells (CLET), you can make the stem cells grow again through composite graft from the other eye. Prof. Dhubhghaill cited an Australian-based group of researchers who successfully carried out a study on using contact lenses for LSCD.1 The next step was to introduce a xenofree2 expansion (stem cells cultivation without using animal products). “The idea is you can avoid any possibility of disease from an animal source migrating to a human. And that in a time of COVID-19 seems to be extremely relevant,” she said. “Using a lens as a carrier is really a simple and elegant way to avoid a lot of the surgical missteps of handling a composite graft. The cell layer can be placed exactly where you want it on the stroma and the most exciting part of this is it will likely reach the commercial markets soon,” she concluded.
Contact lens innovation beyond 2020 Lastly, Dr. John Gelles of the Cornea and Laser Eye Institute in New Jersey (USA) delved into current and future contact lens innovation. The innovations are a heady mix of surface-based lens designs, higher order aberration (HOA) correcting optics, drug-releasing lenses, wearable displays, photonics and combined extended reality lenses. One of the most impressive innovations he showed from his clinic is the impressionbased “EyePrint Prosthetics” lens for keratoconic patients. Impression based lenses also require less lenses to finalize than diagnostic lenses.
References: 1
Di Girolamo N, Bosch M, Zamora K, et al. A Contact Lens-Based Technique for Expansion and Transplantation of Autologous Epithelial Progenitors for Ocular Surface Reconstruction. Transplantation. 2009;87(10):1571-1578
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Bobba S,Chow S, Watscon S, Di Girolamo N. Clinical Outcomes of Xeno-Free Expansion and Transplantation of Autologous Ocular Surface Epithelial Stem Cells via Contact Lens Delivery: A Prospective Case Series. Stem Cell Res Ther. 2015;6(1):23.
CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments
Lessons on Manual SICS, From India to the World by Tan Sher Lynn
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anual small incision cataract surgery (MSICS or manual SICS) is a low-cost, small-incision form of extracapsular cataract extraction chiefly employed in the developing world as it provides the advantage of selfsealing sutureless wound. Speaking on the importance of MSICS in today’s world at the 37th World Ophthalmology Congress (WOC2020 Virtual®), Dr. Parikshit Gogate of Dr. Gogate’s Eye Clinic, India, noted that MSICS and phacoemulsification (phaco) are the two most common kinds of cataract surgery done in the world which can help patients achieve excellent vision without spectacles.
MSICS versus phaco Dr. Gogate and his team did a meta-analysis comparing MSICS and phacoemulsification using the DerSimonian-Laird method by looking at 70 to 80 studies. “We found no difference between phaco and SICS on best corrected and unaided visual acuity at the 6/18 and 6/60 cut-offs, though phaco gives better unaided vision at 6/9 visual acuity cut-off. There was no difference for endothelial cell loss or intraoperative and postoperative complications score. SICS was safer for beginner surgeons, while astigmatism is less in phaco,” the investigators reported. “Phaco and SICS are comparable and each has its own merits. Nevertheless, SICS is easier and can give better outcome than phaco in patients with very hard cataracts, very old patients with poor endothelial cell counts, post keratoplasty patients, or patients with uveitic cataracts or subluxations,” concluded Dr. Gogate. According to Dr. Debashis Bhattacharya, founder of the Disha Eye Hospitals in India, wound construction is the mainstay in SICS. He explained about external incisions, frown incision,
Chevron incision and a straight incision with a back-cut. He noted that incisional length is designed based on nuclear size and hardness. “The cataract is not only wide but thick and the scleral pockets are like pleats in the trousers to accommodate the thickness. It is safer to have a bigger incision and stitches if required, than to give a smaller incision that can cause tissue damage,” he advised. “The advantage of SICS is even though we have a very hard cataract nucleus, we are still able to remove it safely through a good incision. The incision is always a delicate balancing between safe sutureless wound closure and astigmatism, versus the facilitation of nucleus delivery,” explained Dr. Bhattacharya.
Modified instruments and incisions Meanwhile, Dr. Amulya Sahu, chairman of Sahu Eye Hospital, India, shared his experience with 2mm topoguided MSICS which he made possible through the modification and innovation of various instruments, thus contributing to emmetropia, postoperative correction in astigmatic error and quick postoperative recovery. These modified instruments included the single jet cannula with a small blunt tip at the front to help remove the lens from the posterior capsule and bring it to the anterior chamber, the vectis with a hanging surface at the front to hold and retrieve the lens, the modified Visco cannula, modified Simco cannula and revolving axis marker. Presenting on the topic of Astigmatismfree MSICS by Wound Modulation, Dr. Jagannath Boramani from Surya Netralaya, India, noted that literature review shows that in phacoemulsification and MSICS, different lengths, locations (superior, superotemporal or temporal) and shapes of the incision can cause different degrees of surgically induced astigmatism (SIA).
Having studied different types of scleral incision, Dr. Boramani found that the shorter the length of a straight incision is, the lesser the SIA. “Make the incision slightly curved, and the incision is further reduced. If you have a perfect U shape incision, there is almost no astigmatism. With meticulous tunnel engineering, it is possible to wipe out or at least minimize the stigma of astigmatism,” he shared.
Software matters Talking about software-assisted SICS, Dr. Rajeev Raut, chairman of the Life Science Research Trust, India, said that the principle is to deform the cornea before incision in order to get a spherical cornea after incision. “The software asks for preoperative corneal curvatures, corneal thickness, white-towhite diameter and intraocular pressure. It calculates how much to deform the cornea to achieve optimum postoperative shape. “Postoperative assessment found that corneal thickness values were consistent with earlier published reports on outcomes after SICS. Visual outcomes at the end of two months in 30 cases showed that 27 out of 30 patients could see TV and mobile phones without glasses. Subjective happiness was high.” Dr. Raut concluded that using an online algorithm based software to achieve the desired pre-incision shape makes the technique reproducible. “Infinite possibilities to study and improve the algorithm by artificial intelligence ensures continuous betterment of results. Low cost and friendly serverbased software maybe also be attractive to surgeons,” he said. Last but not least, Dr. M.S. Ravindra from Karthik Netralaya, India, shared surgery videos to help practitioners aspiring to explore phacosection, which according to him, is a safe cataract surgery which yields excellent results. “Performed under topical anesthesia, it harnesses the surgeon’s skills and uses less equipment. Fine manual control of fluidics makes surgery safer. The control on SIA is tunable and endothelial loss is at the lowest. Challenging cataract presentations can be comfortably handled with less risks,” explained Dr. Ravindra.
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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:
