Ophthalmologists from Africa and the Middle East discussed the various surgical options to treat corneal ectasia

Surgical Options for Corneal Ectasia Problems

by Brooke Herron

Corneal 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 37 th 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. 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. 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.

Understanding Uveitis

Replacing Fear with Love

by Joanna Lee

Learning 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 37 th 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 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

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.

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.

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

Young doctors are the future

Global Young Ophthalmologist Colloquium

An Update on International YO Activities, Training and Research by Hazlin Hassan

Fighting 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 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.

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 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.

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.

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. 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.

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.

Management of Retinal “There is a very interesting trial showing the need for Vein Occlusion by Hazlin Hassan retreatment in the second year, and if you are looking at up to six years after the randomization, we can

Retinal vein occlusion (RVO) is the available intravitreal anti-VEGF agents: see there is only one patient needing second most common cause of ranibizumab (Lucentis), aflibercept intravitreal treatment in the laser treated visual loss due to retinal vascular (Eylea), and bevacizumab (Avastin) for group compared to two thirds of the disease after diabetic retinopathy. macular edema due to CRVO. patients which were treated initially only The standard-of-care treatment for with ranibizumab,” he said. macular edema due to central retinal Results showed that although aflibercept vein occlusion (CRVO) is the use of was non-inferior (no worse than) to However, there is strong evidence for intravitreal anti-vascular endothelial ranibizumab in terms of mean bestlaser treatment only in neovascular growth factor (anti-VEGF) agents or corrected visual acuity (BCVA) change complications, in patients with vitreous intravitreal corticosteroid implant. through 100 weeks, bevacizumab bleeding, or patients with secondary was not non-inferior (inconclusive) glaucoma, he said, noting that evidence However, the optimal treatment protocol to ranibizumab for treating CRVO for targeted laser treatment is still weak. regarding the choice of anti-VEGF macular edema. Post-hoc analysis also Large randomized trials are ongoing, he agent and dosing regimen remains demonstrated that bevacizumab was not concluded, with results expected in 2-3 unclear. The results of several studies non-inferior to aflibercept in terms of years. on the matter were presented by several mean BCVA change at 100 weeks. renowned experts from around the world on the final day of the 37 th World Ophthalmology Congress (WOC2020 Virtual®) on Monday. The use of laser in macular edema Anti-VEGF keeps the doctor away Branch retinal vein occlusion (BRVO) Ranibizumab versus There are two types of retinal vein occlusion: central retinal vein occlusion cannot be cured. The main goal of treatment is to keep the patient’s vision aflibercept versus bevacizumab (LEAVO trial) (CRVO) and branch retinal vein occlusion (BRVO). The main cause for visual impairment in CRVO is macular edema stable, usually by sealing off any leaking blood vessels in the retina. The LEAVO study, a multicenter phase (ME) while neovascularization of the This helps prevent further swelling 3 double-masked randomized controlled retina and/or the anterior segment is the of the macula. Patients with greater non-inferiority trial, has found that mean most serious complication leading to vascular reduction had less recurrences changes in vision after treatment of vitreous hemorrhage, retinal detachment of macular edema in BRVO, noted Prof. macular edema due to CRVO were no and neovascular glaucoma. Hiroko Terasaki from Nagoya University worse using aflibercept compared with Hospital, Japan. ranibizumab. In serious cases, there is loss of vision. To date, no treatment has been proven to A retrospective study was carried out at Mean changes in vision using be effective in large trials. “It is still not the Nagoya University Hospital in Japan bevacizumab compared with clear how to treat it,” said Prof. Matus to investigate the correlation between ranibizumab were inconclusive regarding Rehak of Leipzig University, Germany. the number of intravitreal injections of vision outcomes (the change in visual Intravitreal anti-VEGF injections are the the anti-VEGF agents and the vessel acuity from baseline, on average, may current treatments of choice for ME due density determined by OCT-angiography be worse or may not be worse when to CRVO. Two different anti-VEGF drugs (OCTA) in eyes with macular edema using bevacizumab compared with (ranibizumab and aflibercept), and a (ME) secondary to BRVO. A total of ranibizumab). biodegradable dexamethasone implant 29 eyes of 29 patients with macular are approved for treatment but they edema secondary to BRVO were treated “Comparing aflibercept versus provide only temporary relief while the with intravitreal injections of anti-VEGF ranibizumab, aflibercept was non-inferior need for repetitive treatments is a major agents. to ranibizumab but it was not superior,” burden for patients. said Prof. Sobha Sivaprasad of the world “In summary, local macular vessel renowned Moorfields Eye Hospital in Prof. Rehak cited a study which density reduction rate one month after the United Kingdom, who is a co-lead looked at the use of a combination of the initial intravitreal injection was of the LEAVO study. The comparative ranibizumab injections and laser for the correlated with the total number of clinical effectiveness of ranibizumab, treatment of ME due to CRVO. Patients intravitreal injections until 6 months aflibercept, and bevacizumab for the were randomized to receive intravitreal in eyes with macular edema associated management of macular edema due to ranibizumab versus ranibizumab plus with BRVO, suggesting that it would be a central retinal vein occlusion (CRVO) selective laser photocoagulation to areas useful index for predicting the frequency is unclear. The trial was aimed at of peripheral non-perfusion. of anti-VEGF intravitreal injections,” said evaluating the efficacy of three widely Prof. Terasaki.