EyeWorld Asia-Pacific March 2011 Issue

32 March 2011 EW NEWS & OPINION ACS 2010: One time, one meeting by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer Highlights of the 2nd Asia Cornea Society Biennial Scientific Meeting I chigo ichie is a Japanese saying that literally means “one time, one meeting.” One of those exotic, “untranslatable” phrases for which literal translation falls tragically short—the full meaning usually loaded with all sorts of social, cultural, philosophical, and/or historical back-stories that add some typically non-verbal dimensions—it is probably better translated into a phrase like “once in a lifetime,” but with the “now or never” vibe of a childhood summer romance and that twinge of regret that comes with the realization of an opportunity’s transience, that “once it has passed, it will never come again”; to the Japanese—or so one gathers from the dramatic narration that accompanied the dazzlingly earnest musical performances at the opening ceremony of the recently concluded Asia Cornea Society (ACS) meeting, which delivered all the above quotes plus a number of other similar stock phrases in a valiant attempt to convey the full sense, the complete pathos of ichigo ichie—the words elicit a sense of something “miraculous”; supremely hopeful, if also preemptively nostalgic. The Japanese—who hosted the ACS meeting at the Westin Miyako Hotel in the appropriately charming, picturesque city of Kyoto—seemed determined to deliver. Or maybe it’s simply that we are, said Shigeru Kinoshita, MD, Ph.D, President and Organizing Committee Chairman of the meeting, “at a time when cutting edge advances are being made,” and truly exciting things are happening all over the world in transitional and clinical research. Eye banking Before this heartfelt introduction to ichigo ichie at the meeting’s opening ceremony, members of the Association of Eye Banks of Asia (AEBA) held a symposium which immediately made it clear that, at least in eye banking, different countries encounter vastly different sets of challenges. While it seems impractical to expect every country to practice eye banking exactly the same way, AEBA is working out a set of minimum quality standards for practice. Experts say developments in eye banking over the next few years will be critical, particularly for ocular surface reconstruction, which, despite advances in keratoprosthesis techniques and devices, is still heavily reliant on donor tissue supplies. A major part of AEBA’s strategy to increase global donor tissue supplies is the development of the National Eye Bank of Sri Lanka (NEBSL). NEBSL started operating in 14 January, and promises to become one of the world’s largest eye banks, and a model for future eye banks in the region. The symposium involved members of the Eye Bank Association of America (EBAA) and SightLife, an international eye bank working with surgeons in over 30 countries. Medical cornea Some particularly exciting developments on show at the meeting were summarized in Dr. Kinoshita’s Asia Cornea Foundation lecture, “Towards sophisticated therapeutic modalities for corneal diseases.” The most exciting of these developments is the use of Rho- associated kinase (ROCK) inhibitor in the treatment of endothelial cell dysfunction. Known to diminish the disassociation-induced apoptosis of endothelial cells, ROCK inhibitor has now been shown by Dr. Kinoshita and his colleagues to actually induce cell proliferation. Naoki Okumura, MD, who presented some of the results of their work with Dr. Kinoshita at the meeting, said they are now in clinical trials with patients, and, so far, use of the ROCK inhibitor Y-27632 has resulted in thinner, clearer corneas with stable endothelial cell densities in patients with corneal endothelial dysfunction up to six months after end of treatment. Advances in our understanding of fundamental mechanisms influencing corneal disease have also been made in recent years, such as the specific mechanisms and substrates by which corneal epithelial cells and fibroblasts “converse,” as elucidated by the work of Teruo Nishida, MD, which he presented in his ACS Special Recognition lecture, “Conversation between epithelial cells and fibroblasts.” This “conversation” influences the expression of junctional proteins, affecting barrier function and synchronization. Surgical cornea Ocular surface reconstruction in even the worst cases is now possible, thanks to current transplant techniques and keratoprosthetic devices; perhaps most significant to the Asian region is the development of one particularly radical alternative. The osteo- odonto-keratoprosthesis (OOKP) procedure pioneered by Strampelli and modified by Falcinelli, is now being used by surgeons like Donald Tan, MD, in Singapore and Masahido Fukuda, MD, in Japan to successfully restore vision to patients with severe conditions “when all else has failed.” Dr. Tan, who is president of the ACS, is also working with colleagues at the Singapore National Eye Centre (SNEC) on developing refractive lens exchange (ReLEx) procedures. These procedures— which include femtosecond lenticule extraction (FLEx), small incision lenticule extraction (SMILE) and pseudo-SMILE (SMILE with a full but unlifted flap)—offer essentially incisional alternatives to ablative LASIK, using the femtosecond laser alone, sans excimer laser. Researchers at SNEC are currently investigating the potential reversibility of ReLEx procedures in non-human primates; more information should be available on these experiments early next year (2011). Dry eye The assessment of osmolarity provides a way of identifying patients with dry eye that linearly correlates with the disease severity, said Michael A. Lemp, MD, Hyperosmolarity, he said, is “probably the operative characteristic” of dry eye disease. Although dry eye disease is typically not considered as big a problem in Asia as it is in the U.S., researchers in the region are making some interesting contributions to the field. Norihiko Yokoi, MD, has developed a noninvasive way to assess the pre-corneal tear film. Dr. Yokoi’s technique is to visually assess the velocity of spread of the tear film lipid layer (TFLL spread) and noninvasive tear breakup time (NIBUT). These parameters correlate well with more invasive parameters and tests such as fluorescein breakup time, ocular surface epithelial damage (OSED) scoring, and Schirmer’s test. Corneal infections In 2006, Noriko Koizumi, MD, and her colleagues were the first to identify cytomegalovirus (CMV) as the cause of what had previously been considered an idiopathic form of corneal endotheliitis. Since then, said Dr. Koizumi, the condition has been reported in about 13 published papers. While all the reports so far have been from Asia, “idiopathic” corneal endotheliitis has been documented elsewhere, and some experts expect to eventually find the same CMV endotheliitis prevalence in other parts of the world that have yet to publish reports. Surprisingly, said Dr. Koizumi, reported cases involve otherwise healthy, immunocompetent patients. Fortunately, she said, the condition responds to systemic and topical treatment with ganciclovir, although prompt treatment is necessary to prevent “unrecoverable damage” to the endothelium. The full significance of the condition, both for the region and the rest of the world, is still being ascertained. Closing remarks The 2nd ACS Biennial Scientific Meeting held from 1 to 3 December 2010, in collaboration with the Cornea Society, the ASCRS, and the Japan Cornea Society—called an unqualified success by Dr. Kinoshita—was attended by 630 delegates, about two thirds of whom were international delegates hailing from 29 different countries, including countries in Europe and the Americas. The 3rd ACS meeting is scheduled to take place from 27 to 29 November 2012, at the SMX Convention Center in Manila, Philippines. EW