eyeworldap.apacrs.org The Asia-Pacific Association of Cataract and Refractive Surgeons ASIA-PACIFIC Vol. 19 No. 2 June 2023 www.eyeworldap.apacrs.org
EWAP JUNE 2023 3 EDITORIAL EyeWorld Asia-Pacific • June 2023 • Vol. 19 No. 2 Nexus describes connection and was a very apt theme for the recent APACRS meeting in Singapore. Those of you who were able to attend will agree that this was one of our most successful APACRS meetings, particularly after the virtual meetings, which kept us going during the COVID experience. Of particular interest was the session on “What they don’t teach you during Residency” where we canvassed such topics as how to create an award-winning video, better presentations, and even considering life balance issues. Meanwhile, the APACRS Lim Lecture this year was delivered by Gerd Auffarth who provided a comprehensive survey of refinement in lens optical design and new materials. The meeting confirmed how important our annual meeting is in maintaining personal contact and sharing information on new technologies and techniques which is the core of the APACRS philosophy. In addition to the summary of our annual meeting in Singapore, this month’s issue of EyeWorld Asia-Pacific also contains many topics of interest. I was particularly drawn to the articles on managing patient expectations and dealing with unhappy patients after cataract surgery. The core issue evident in the relevant articles is the importance of ensuring patient expectations are managed appropriately. The long-standing adage of “under promise and over deliver” is true for cataract and implant surgeons. The use of multifocal IOLs promises spectacle freedom but with the occasional patient who is disappointed either in the quality of vision or unwanted optical phenomena. When using this technology, it is important to have personnel with some expertise or access to the treatment of minor residual refractive errors which have more impact in this context. One of the reasons for the increased interest in extended depth of focus IOLs is preserving better quality vision while still providing practical solutions to patients requiring intermediate and even near vision. The focus on total spectacle independence may not be the most important criteria to patients’ satisfaction. A related article reminds us how invariably a patient’s perception of their second eye surgery differs from their first eye experience. They are more aware of the second eye surgery and the “wow factor” may be less. I have found that second eye comparison is less of an issue with modest monovision as they anticipate the second eye will be different reducing the unavoidable comparison inherent when both eyes are targeted for distance. I hope you find the highlighted articles as well as the other topics covering corneal disease, endothelium transplantation, and glaucoma of interest. Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific • China • Korea • India
4 EWAP JUNE 2023 CATARACT 20 Potential issues after cataract surgery by Ellen Stodola 26 Patient perceptions of second eye cataract surgery by Ellen Stodola FEATURE NEXUS – Connecting everyone and everything 06 NEXUS – Highlights from the 35th APACRS Annual Meeting by Christina Chintanaphol and Michelle Dalton 16 35th APACRS LIM Lecture: Current and Future Development in Intraocular Implants with New Materials by Christina Chintanaphol 17 CSCRS: Trending Technologies - Highway to the Future by Michelle Dalton CONTENTS 03 Editorial REFRACTIVE 28 The role of preoperative ‘IQ’ by Liz Hillman 30 Mixing and matching IOLs by Ellen Stodola CORNEA 32 The status of DSAEK and DMEK by Liz Hillman 36 An update on corneal ulcer management by Liz Hillman 39 Amniotic membrane: When it’s useful vs. overused by Liz Hillman GLAUCOMA 41 Lens options in glaucoma patients by Ellen Stodola 45 MIGS and IOP control by Ellen Stodola 48 Overview of visual aids: New technology and dependable tools by Liz Hillman NEWS & OPINION 51 Review of ‘Visual recovery after immediate sequential bilateral cataract surgery at a veterans’ hospital’ by Steven Carrubba, MD, and Sheel R. Patel, MD 53 Review of ‘Impact of personality on the decision process and on satisfaction rates in pseudophakic presbyopic correction’ by Daniel Lee, MD, Adam Hanif, MD, Ashlin Joye, DO, Kaitlin Kogachi, MD, Claire Mueller, MD, Daniel Tu, MD, PhD 23 Advanced-technology IOLs: Formulas and adaptation by Liz Hillman
CORNEA 34 Innovations in the treatment of endothelial dysfunction by Ellen Stodola GLAUCOMA 37 Combining MIGS procedures by Ellen Stodola 40 MicroPulse for the anterior segment surgeon by Liz Hillman EYEWORLD ASIA-PACIFIC APACRS Publisher: EyeWorld Asia-Pacific Edition (ISSN 1793-1835) is published quarterly by the Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Printed in Singapore. Editorial Offices: EyeWorldAsia-Pacific Edition: Asia-Pacific Association of Cataract &Refractive Surgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. AdvertisingOffice: EyeWorldAsia-PacificEdition:Asia-PacificAssociationofCataract&RefractiveSurgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (1-703) 975-7766, email don@apacrs.org. Copyright 2021, Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Licensed through the American Society of Cataract & Refractive Surgery (ASCRS), 4000 Legato Road, Suite 700, Fairfax, VA 22033-4003, USA. All rights reserved. No part of this publication may be reproduced without written permission from the publisher. Letters to the editor and other unsolicited material are assumed intended for publication and are subject to editorial review and acceptance. The ideas and opinions expressed in EyeWorld Asia-Pacific do not necessarily reflect those of the editors, publishers or its advertisers. Subscriptions: Requests should be addressed to the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Back copies: Subject to availability. Contact the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Requests to reprint, use or republish: Requests to reprint or use material published herein should be made in writing only to the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@ apacrs.org. Change of address: Notice should be sent to the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, six weeks in advance of effective date. Include old and new addresses and label from a recent issue. The APACRS publisher cannot accept responsibility for undelivered copies. KDN number: PPS1766/07/2013(022955) MCI (P) 039/02/2022 CHINESE EDITION Regional Managing Editor Yao Ke, MD Deputy Regional Editor He Shouzhi, MD Zhao Jialiang, MD Assistant Editors Zhouqi, MD Shentu Xingchao, MD INDIA EDITION Regional Managing Editor S. Natarajan, MD Deputy Regional Editor Abhay Vasavada, MD KOREAN EDITION Regional Managing Editor Hungwon Tchah, MD Deputy Regional Editor Chul Young Choi, MD EDITORIAL BOARD Chief Medical Editor Graham Barrett, MD Chief Publisher Ronald Yeoh, MD Executive Director Kathy Chen kathy.chen@apacrs.org Publishing Consultant Donald R Long don@apacrs.org PUBLISHING TEAM Senior Staff Writer Chiles Aedam R. Samaniego chiles.samaniego@apacrs.org Production Team Javian Teh Gretel Tan Christine Shimmon Aileen Bian ewap@apacrs.org Chan Wing Kwong, MD, Singapore Ronald Yeoh, MD, Singapore John Chang, MD, Hong Kong SAR Pannet Pangputhipong, MD, Thailand YC Lee, MD, Malaysia Hiroko Bissen-Miyajima, MD, Japan Kimiya Shimizu, MD, Japan Sri Ganesh, MD, India Chee Soon Phaik, MD, Singapore Johan Hutauruk, MD, Indonesia EDITORIAL MEMBERS
NEXUS: Highlights from the 35th APACRS Annual Meeting by Christina Chintanaphol and Michelle Dalton SINGAPORE, 8 – 10 June 2023 – Last year, the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS) returned to a full in-person format for its annual meeting with an abbreviated 2-day scientific program. The 35th APACRS Annual Meeting was the Society’s first in-person meeting with a fully loaded 3-day scientific program since the beginning of the pandemic. Here compiled and lightly edited is EyeWorld Asia- Pacific’s coverage of the meeting. ‘NEXUS’ brings together all at the Opening Ceremony Taking place in one of the most vibrant and cosmopolitan cities in the world, the Opening Ceremony for the 35th APACRS Singapore brought together delegates from all over the world. Chan Wing Kwong, MD, excitedly told the packed hall that this year’s meeting promises to be an exciting and informative event. “As ophthalmologists, we owe it to each and every one of our patients that we are kept abreast in our field,” he said. With this year’s meeting being the first 3-day in-person meeting since 2019, “there is nothing better than an in-person conference. There are some things a webinar cannot achieve. We cannot replicate the atmosphere, the vibe, the buzz,” Dr. Chan said. The ceremony’s guest-of-honor, Vivian Balakrishnan, MD, Minister for Foreign Affairs, joined the session; Dr. Chan called it a special treat, as Dr. Balakrishnan has close ties to APACRS since he is a trained pediatric ophthalmologist. In Dr. Balakrishnan’s address to the audience, he spoke about the importance of technological advancements across the globe. “We live in a world in which, on one hand, there are enormous technological revolutions in AI, in biotechnology, in renewable energy, and in precision engineering and robotics,” Dr. Balakrishnan said. These technologies are all upon us, and the best brains of the world’s scientific community have come together over the last 7 decades to work on research and innovation. Dr. Balakrishnan described how the common stack of technology, techniques, machines, and implants propels our community forward into a better future. “If this technological stack is broken, then the rate of progress will slow,” he said. “As a result, there will be higher inflation because the development of good ideas will slow down. At a diplomatic level, there will be a more uncertain and volatile world.” The 35th APACRS Singapore, then, is an opportunity to bring together the best of ophthalmology to share, transform, and innovate for the future ahead, he said. Yao Ke, MD, gave the opening address, noting that APACRS has grown to become one of the key medical conferences in the Asia-Pacific region. “We are very excited to enter a new era as the world emerges from the COVID-19 pandemic and as we reconnect and exchange cutting edge topics and techniques,” Dr. Yao said. “I hope all the delegates, colleagues, and friends enjoy a stimulating conference in the beautiful garden city of Singapore.” The 2023 APACRS Gold Medal award was presented to Dr Fam Han Bor, MD, for his outstanding contributions to the development of ophthalmology, particularly in visual optics, wavefront science, IOL calculations, corneal topography biofilms and phacoemulsification technology in the Asia-Pacific region.
Also recognized at the Opening Ceremony were 3 surgeons for the 2023 APACRS Certified Educators (A.C.E.): Jodhbir Mehta, MD, Mahipal Sachdev, MD, and Mohamad Rosman, MD. MasterClass: What They Don’t Teach You in Residency One of the more highly anticipated sessions (and making its debut at the 35th APACRS Singapore), the What They Don’t Teach You in Residency MasterClass played to a standing-room only crowd. With an emphasis on skill sets not often taught, topics ranged from how to deliver a memorable lecture to how to be a better surgeon to how to conduct meaningful research. Course director Ronald Yeoh, MD, advised attendees to use PowerPoint as a starting point for presentations, and “less is more!” he said. “You don’t need complicated slides to deliver a memorable lecture.” But what makes a lecture memorable in the first place? Having a clear message and conclusion — start by telling your audience what you’re going to teach them, then teach it, then remind them you taught it,” he said. “Also, knowing the other topics in the session will help you plan your talk accordingly,” he said. “Inject humor if you can. Use memorable moments from your real life.” He cited one of his favorite examples of not relying on high tech (“A real doctor doesn’t need a slit lamp”) as he showed an image of a baby chimpanzee evaluating its mother’s eye. But most importantly, he said, is to communicate with your audience and develop a relationship with them. “Speak with them, not to them,” he advised. Prof. Graham Barrett, MD, spoke to creating a work-life balance, something he joked he doesn’t really know much about. An informal audience poll showed only 30% to 40% of attendees are satisfied with their balance, and even fewer thought they had adequate time for health, recreation, and family. “People are short on time,” he said. “My personal view is that there is no such thing as a perfect balance. It may not even be desirable. You need to feel satisfied. ‘Perfect balance’ is not static; it’s a pendulum that swings back and forth.” He’s culled that concept from “a retrospective analysis.” His secret? “Passion. If you have passion in your work and in your life, there will be a feeling of fulfillment. But it takes commitment to be excellent in all you do. You have to have a desire to be perfect,” even when that is unattainable. “And have the same amount of enthusiasm for your hobbies as you do your career,” he advised. This MasterClass was part of a complete set of APACRS MasterClasses held on the first day of the meeting. Becoming a better surgeon, better filmmaker, better researcher Chee Soon Phaik, MD, offered advice on how to be a better surgeon, including watching your own videos rather than asking for your attending’s. “Critique yourself,” she said. “If you control the eye, the surgery will always look simple. Is the eye centered?” Pay attention to “the little things,” like the patient’s head and face position. Evaluate your external video, not just the actual surgery, to ensure you’re saving your neck or not pushing the eye nasally. “Think about your incisions,” Dr. Chee said. “Respect the ocular tissue — don’t just push the incision, lift the incision.” She highly recommends adapting NEXUS CoNNECtiNg EvEryoNE & EvErythiNg
bimanual procedures as they provide better eye control and visualization. Finally, she advised surgeons deal with problems as soon as they occur and “think out of the box for simple solutions,” which may be as simple as lowering the microscope. “Implement these techniques, and even difficult surgeries will not be difficult.” Making an award-winning movie does not have to be costly, said Samaresh Srivastava, MD. “It’s a lot of hard work,” he agreed, “but most importantly, you need an idea that can make a point.” He recommended filming every surgery “because you never know when the magic will happen.” Next, prepare a script so the film tells the story you envision. If movie-making is daunting, conducting meaningful research may not be, said Tin Aung, MD. Conducting research and getting that research published “can potentially impact many more patients than you could ever see in your own clinic.” He boiled down how to conduct meaningful research to a few key points: always ask questions and think about the bigger picture; plan and think about the study design and of potential collaborations; plan the research and how to reduce any potential bias; and give a substantial amount of time to planning and writing the protocol. “Many studies fail due to poor study design,” he said. Collaborate “with scientific partners. Both scientists and researchers need to understand each other’s needs. That’s what is really meant by translational research.” Phaco-MIGS for Angle Closure According to Prin Rojanapongpun, MD, using minimally invasive glaucoma surgery (MIGS) to treat primary angle closure disease (PACD) may always be controversial, but glaucoma specialists also need to remember that angle closure “is a surgical disease first.” Traditional first-line therapies (namely, trabeculectomy) are effective, but come with a high rate of complications. Lens extraction alone has shown promise (as in the EAGLE study), but “lens removal is not a definitive treatment for angle closure,” as post-surgical intraocular pressure (IOP) spikes can be commonplace. He presented his thoughts during the Angle Closure Surgery – New Insights symposium. “But combined phaco-trab is not necessarily a better option,” Dr. Rojanapongpun told attendees. “So what is safer?” He believes MIGS “offers better postop refractive stability [than filtering surgery] and allows surgeons the ability to implant both toric and multifocal intraocular lens (IOL).” The combination “may offer permanent, or at least long-term, solutions,” he said. “We are entering an era of interventional glaucoma,” Dr. Rojanapongpun said. “Some of these will be temporary measures, while others will be permanent.” During the same session, David Lubeck, MD, noted the MIGS timelines “are linked closely to our advanced IOL timelines as well,” and suggested MIGS can be successfully used in a multitude of glaucomas. For example, he noted, in those with mild-to-moderate primary open-angle glaucoma or narrow-angle glaucoma, medically controlled on 1 to 2 medications, he would recommend phaco in conjunction with a stent, but would recommend phaco-canaloplasty for those with severe uncontrolled glaucoma on up to 4 medications. Dr. Rojanapongpun suggested a surgical approach for patients with PACD and coexisting cataracts (regardless of whether or not IOP is medically controlled) is to perform phaco and keep the patient on medications. For patients without cataracts, however, medication and MIGS may be preferred. In short, Dr. Rojanapongpun said that phaco-MIGS in PACD is less controversial and offers “lots of potentials.” The combined surgery offers effective treatment in most PACD, with variable ranges of IOP-lowering capabilities depending on the surgery of choice and a variable duration of IOP control (“although long-term IOP control is not guaranteed”). Combined surgery also tends to have a better safety profile. “Performing angle MIGS trabecular surgery should only be done if the angle can be widely opened with phaco,” he said. “Subconjunctival MIGS is a safe option when used in combination with phaco, but bear in mind MIGS is less effective in lowering IOP than trabeculectomy.” But it may still be the best option when medication is an issue and trabeculectomy is not an appropriate approach. Dr. Lubeck concurred, noting “the evolution and implementation of MIGS should be considered along with phaco and IOL technology.” New trends and technology for infectious keratitis Artificial intelligence (AI) is a big buzzword these days, and Venkatesh Prajna, MD, told attendees just how AI is among the new trends in
diagnosing infectious disease in ophthalmology care. “Why do we want novel approaches in diagnostics?” Dr. Prajna asked during the symposium Updates on Infectious Keratitis. “One important thing to know is that different fungi respond to different antifungals.” Thus, surgeons should know how to differentiate fungi. “If you show photographs to clinicians, they will correctly distinguish bacterial from fungal etiology 66% of the time,” he explained. With AI, computer vision models (such as MobileNet or DenseNet) can achieve superhuman performance in identifying the underlying infectious cause of microbiologically-positive corneal ulcers when compared to the ability of experienced cornea specialists. Another new diagnostic tool is the SmartProbe, which rapidly evaluates corneal scrapes from patients as an alternative to using a Gram stain. Two activatable peptide-based fluorescent imaging probes that have been previously developed for pulmonary applications are BAC One (reports on presence of bacterial or fungal microbes) and BAC Two (reports presence of gram-negative bacteria). “Initially, you may be thinking we require a fluorescent microscope for diagnostics. But, we just published a paper in which we designed a cost-effective fluorescent instrument costing around $10 USD, which can be used as point-of-care testing,” Dr. Prajna said. He next described another tool in which isothermal amplification is combined with CRISPR, a family of DNA sequences, to produce an assay (RID MyC) to detect fungal nucleic acids. Advantages of this technique include rapid turnaround time, improved specificity, and accessible reporting formats such as lateral flow strips and fluorescent readouts. The RID MyC assay costs only USD$6 and boasts a 93.6% sensitivity and 91.1 specificity, whereas the cost of PCR remains US$25 with a range of 70-98% sensitivity and 56-95% specificity. The excitement of these new advancements in diagnostics could be felt by all in the room. “I will leave you with one message,” Dr. Prajna said. “The way we get a finding from microbiology in the future is going to be completely different from what we are getting today.” Allogenic cell therapy approval among highlights in corneal innovation session Less than 3 months after the first-ever regulatory approval for an allogenic cell therapy to treat corneal endothelial disease, Shigeru Kinoshita, MD, PhD, spoke to attendees at the 35th APACRS Singapore What’s New in Cornea session about the approval that meant so much to him personally. Two main concepts of regenerative medicine products are being studied: what Prof. Kinoshita calls “pseudo-regenerative medicine,” which is the sustained release of cytokines by regenerative medicine products, and “true” regenerative medicine, which is the restoration of tissue structure and function by regeneration medicine products. Prof. Kinoshita is studying the latter, and told attendees that cultivated human corneal endothelial cells (HCEC) are heterogenous. Published studies by his group have shown the superiority of mature differentiated cultured HCEC injection therapy. “Cell injection therapy is going to be the treatment for endothelial cell failure in the future,” he said, adding that restoring corneal endothelial health to patients by innovating with cell therapy “has been my life’s work.” To date, more than 130 patients worldwide have been treated with the therapy, Vyznova (Aurion Biotech). Similarly, Gerd U. Auffarth, MD, said endothelial keratoplasty (EK) comprises 60% of the corneal tissue replacement market. Endoart, an artificial corneal endothelial implant, was originally developed to decrease corneal edema by preventing aqueous humour from entering the cornea. The implant works in two stages: first, a gas bubble creates surface tension that holds the implant in place and then natural healing promotes adhesion protein to adhere to the implant’s surface. A total of 123 patients have up to 4-year follow-up data available, the longest follow-up being 9 years. “There have been no device-related complications, and we have shown long-term safety,” he said, with one patient up to 9 years who “still has a clear cornea.” In general, Dr. Auffarth said the surgical implantation “is easier than conventional Descemet’s membrane endothelial keratoplasty,” the implant is “very forgiving” in terms of intraoperative handling, there have been no observations of material degradation, patients do not require immunosuppression therapy, corneal swelling is effectively reduced, and “pain from bullous keratopathy resolves.” Other key attributes, he said, is that there are no waiting lists for human tissue for patients, and the overall procedure is at a lower cost than traditional EK surgery. NEXUS CoNNECtiNg EvEryoNE & EvErythiNg
Tackling myopia-associated glaucoma Myopia continues to be an increasing global healthcare issue, and accurate diagnosis and appropriate management remain challenging. With myopia and high myopia as risk factors for glaucoma and incident open-angle glaucoma (OAG), clinicians must be aware of how to handle these cases. Beginning with diagnosis, Wong Chee Wai, MD, PhD, noted fundus photography can be used to identify the pathology of high myopia and determine whether the cause is maculopathy or glaucoma. “Myopia macular degeneration (MMD) mainly affects the outer retina,” Dr. Wong said. “Look out for the external limiting membrane, the ellipsoid zone junction, and the retinal pigment epithelium.” He noted that it is important to perform optical coherence tomography (OCT) routinely in highly myopic eyes. Structural change was an important theme during this symposia session, and surgeons need to be cognizant of several details. Jin Wook Jeoung, MD, PhD, explained that in highly myopic eyes, the lamina cribrosa of the optic disc is significantly thinner and, in turn, decreases the distance between the intraocular space and the cerebrospinal fluid space. With the stretching of the optic nerve fibers during optic disc tilt and torsion, this eyeball elongation can lead to optic nerve head damage. Another factor in tackling high myopia is controlling intraocular pressure (IOP). “Changes in IOP influence axial length,” said Xiulan Zhang, MD, A 1 mmHg increase in IOP correlates to an increase of 0.1 mm in axial length. Lowering IOP can help high myopic patients and thus control axial length elongation. “A longer duration of using antiglaucoma medication is more effective in slowing axial length elongation,” said Dr. Zhang. “There is no blanket approach to treating patients,” said Ho Ching Lin, MD. She hopes that surgeons will treat each patient differently and exercise high caution in surgery, leaning towards safety. It is important to choose non-invasive options first before treating with surgery. As the prevalence of myopic cases rises, especially in the Asian population, the greatest changes patients may see with their vision is an enlarged blind spot and a generalized reduction in sensitivity. He Mingguang, MD, PhD, recommends always observing the fundus photography for changes in the optic disc and visual field. “Don’t forget to refer patients to a retinal specialist if necessary,” he reminded the audience. Everything Everywhere All at Once in the Cataract Metaverse This 2-part symposium gathered top phacoemulsification surgeons for a discussion on various techniques used in surgery and to answer, what happens when something goes amiss? John Wong, MD, began by sharing a unique situation. Upon entering the surgical room in the morning, he heard a loud humming from the ceiling vent and the room felt colder than usual. Although the temperature and humidity sensor readings were normal, Dr. Wong decided to proceed with his morning case. As the case progressed, though, his surgical view started to fog. Dr. Wong had to intermittently wipe the undersurface of the microscope, breaching the sterile field, until the surgery was complete. The humidity sensor had read 95%. No complications occurred, but Dr. Wong realized there was no anti-fog solution set up for emergencies like this. An anti-fog solution may consist of using isopropyl alcohol, surfactant, and water to lower the surface tension of the condensing surface. “In this part of the world, in the tropics, this is a real problem so this is very useful information,” Ronald Yeoh, MD, chair of the symposia, said. One member of the audience chimed in with a trick: “put a cloth in hot water, and place it under the microscope allowing it to become warm. The glass will never fog this way.” Surgical environment aside, Filomena Ribeiro, MD, PhD, stated that for patients with keratoconus, an implantable collamer lens (ICL) provides a safe and effective option. “ICL can provide very good quality of vision in patients with a stable condition. The problem we have is that we need to assess the correct sizing of these ICLs,” Dr. Ribeiro said. “We need to measure the posterior surface of the cornea. We need a map of the corneal power distribution.” Part 2 of Everything Everywhere All at Once in the Cataract Metaverse brought together even more cataract surgical discussions. Fluorescein eye staining has come a long way in the past two and a half decades. In 1904 trypan blue was introduced as the first anionic diazo dye in which its high molecular weight does not permeate cell membranes. “Trypan dye stains only dead cells; it doesn’t stain living cells,” Sathish Srinivasan, MD, said. “It very beautifully stains the anterior capsule and stays where we put it.” Unfortunately, one big issue with trypan blue is that the market is flooded with different brands of dye. Dr. Srinivasan explained that the most common impurity is monoazo dye; up to 1.7% of trypan dye may contain this impurity compared to
VisionBlue, which has been shown to contain only 0.4%. Dye impurities are commonly analyzed, and Dr. Srinivasan said surgeons may see differences in pH values, osmolality values, and varying ranges of purity (86-97%). Papers have even published cases of toxic anterior segment syndrome from generic trypan blue dye. Furthermore, there are no international standards in place for anterior segment intraocular dyes. “Clinicians should be aware of the varying concentrations and impurities in commercially available trypan blue and be vigilant when making their choices,” Dr. Srinivasan warned. On a different note, Lee Mun Wai, MD, brought up a controversial topic: immediate sequential bilateral cataract surgery (ISBCS). There are many reasons surgeons do not do ISBCS, Dr. Lee explained, including increased risk to the patient. “Tradition has taught us the risks of bilateral surgery, which is why we stay away,” he said. However, Dr. Lee argued that ISBCS can be done safely and offers a wide range of benefits: faster visual rehabilitation, patient convenience (fewer clinic visits), cost savings to both patient and surgical center, and reducing the carbon footprint of cataract surgery. “We need to make sure the complication rate is low,” Dr. Lee said. Dr. Fam, the chair of this session, chimed in: “You also need to have protocol so you don’t put the wrong lens in the wrong eye.” Additionally, Dr. Lee recommends treating each eye as a separate “patient.” Finally, the COVID-19 pandemic pushed surgeons to reconsider ISBCS. “COVID-19 taught us to reduce infection exposure risk,” Dr. Lee said, and thus ISBCS fits the bill as a more efficient and less expensive procedure that ensures less contact between the patient and healthcare professional. Cataract Complications can be Managed Managing or preventing negative dysphotopsia can be achieved with a reverse optic capture, said Shail Vasavada, MD, during The Network is Down — Managing Cataract Complications symposium. “Reverse optic capture of single-piece IOLs is possible, although 3-piece IOL design is more suitable for the procedure,” he said, “and the patient will require more postoperative anti-inflammatory and intraocular pressure treatment.” Generally speaking, most patients “get used to negative dysphotopsia,” he said, adding he has only done a reverse optic capture in 3 patients to correct negative dysphotopsia. Posterior capsule rent (PCR) risk in cataracts with weakened posterior capsule occurs anywhere form 4% to 36% in people with polar cataracts but is becoming more common in iatrogenic cataracts, said David Lubeck, MD, which he dubbed “the new polar.” Patients who undergo intravitreal injections run a 1.88% to 3% risk of developing PCR. He recommends waiting at least 6 months after a posterior capsule perforation before surgical correction. Among the surgical considerations: no hydrodissection/ hydrodelineation, delaminate the anterior/mid and posterior nucleus, strip the peripheral cortex 50% of the way in for 360°, and viscodissect the central posterior cortex with a dispersive viscoelastic. “If the capsule is open and vitreous is forward of the posterior capsule, perform a complete anterior vitrectomy,” he said. Hungwon Tchah, MD, PhD, said the effect of FLACS on IOL tilt and centration when compared to conventional cataract surgery is unknown. His retrospective study compared a FLACS device (n=110 eyes) to outcomes with conventional surgery (n=78 eyes) about 3 years after surgery. At baseline, there were no statistical differences between the groups. There were no statistical differences between eyes or between treatments in terms of IOL tilt (p=0.171) after 3 years, but there was “wider scatter in the left eye and a wider distribution in the conventional group,” Dr. Tchah said. “This means FLACS provides a more predictable result after surgery.” IOL tilt toward the inferotemporal direction was seen in both eyes regardless of method used. “IOL tilt is also significantly correlated with the crystalline lens tilt,” he said. There were statistical differences in IOL decentration, with FLACS producing a 160±100 mm tilt compared to 240±150 mm with conventional surgery (p=0.002). A statistical difference in decentration was evident in the conventional group that had one-piece haptics (0.21±015 mm) compared to three-piece haptics (0.31±0.14mm) (p=0.027), but there were no differences in the FLACS group (p=0.370). An Explosion of New Lens Implants NEXUS CoNNECtiNg EvEryoNE & EvErythiNg
In the symposium titled The New Black in Presbyopia Correction, surgeons shared their experience with numerous intraocular lens (IOL) implants. Patients may present with various conditions, and there are ways to tackle the challenges. “We need to prepare the surgeon and the mindset of the surgeon to understand the technology and what we know so far,” Robert Ang, MD (Philippines) said. His clinical pearls focused on small aperture IOLs. These small aperture IOLs consist of a non-diffractive EDOF IOL design that filters out unfocused and aberrated light, allowing organized central light rays to focus on the retina. In Dr. Ang’s experience, he found that 100% of his patients achieved uncorrected near visual acuity of 20/25 or better, uncorrected intermediate visual acuity of 20/20 or better, and uncorrected distance visual acuity of 20/20 or better after implanting binocular small aperture IOLs. Aniseikonia, the difference in perceived image size, may be another challenge surgeons encounter, Fam Han Bor, MD, explained. Most patients have a small amount (<1%) of aniseikonia, but in those with clinically significant aniseikonia (≥2%), symptoms present as mild headaches, fatigue, and asthenopia. For these patients, Dr. Fam suggests looking first at eye dominance and avoiding monovision when implanting IOLs. “Look at the biometry and aim for minimum aniseikonia,” he said. For cataract patients with glaucoma, Hiroko Bissen-Miyajima, MD, PhD, explored whether surgeons should consider implanting presbyopia-correcting (PC) IOLs. “A majority of glaucoma specialists and cataract specialists will say no,” Dr. Bissen-Miyajima said. From her research, she found that if patients have well-controlled pressures and a good visual field with non-progressive primary open angle glaucoma (POAG) or if patients have POAG without epiretinal membrane (ERM), she will consider implanting PC IOLs in them. Film Festival Winners A major highlight of every APACRS meeting is the Film Festival, and this year was no exception. This year, the Grand Prize went to Takahiro Shimowake, MD, PhD (Japan) for his film Spiral CTR Injector. Dr. Shimowake previously took home the Grand Prize in 2009. The list of this year’s winners follows: Cataract/Implant Surgery Winner: The Optimal IOP for the Stable Anterior Chamber in Cataract Surgery, Producer: Hisaharu Suzuki, MD, PhD (Japan) Runner Up: A New Miyake- Apple View System Using a Nasal Endoscope, Producer: Takeshi Sugiura, MD (Japan) Cataract Complications/ Challenging Cases Winner: Innovative Extraction Technique for Dislocated Intraocular Lens, Producer: Santaro Noguchi, MD, PhD (Japan) Runner Up: The Polar Bug!, Producer: Tushya Om Parkash, MD (India) Refractive/Corneal Surgery Winner: Tissue Addition for Hyperopia – The Whole Story!, Producer: Sheetal Brar, MD (India) Runner up: Fog Away SLET, Producer: Kyoung Woo Kim, MD (South Korea) General Interest Winner: Future Forward – Artificial Intelligence Assisted Eye Care, Producer: Samaresh Srivastava, MD (India) Runner up: Sew Clever: A Modified Sewing Machine Technique for Iridodialysis Repair, Producer: Elizabeth Aileen Giller, MD (Philippines) IIIC Lectures: The Perfect Save! The 35th APACRS Singapore marked the first time the International Intraocular Implant Club (IIIC) symposium was presented, but it will not be the last. “We will try to bring the IIIC Symposium to every APACRS meeting in the future,”
Ronald Yeoh, MD, chair of the symposium, said. “IIIC is about innovation,” Sri Ganesh, MD, said. The IIIC is a club of committed cataract and anterior segment surgeons founded by Sir Harold Ridley, the inventor of the IOL. At this year’s symposium surgeons presented challenging situations along with their refined tips and tricks for various particular situations. Posterior capsule rupture (PCR) was a hot topic during the symposium and presents as a challenge with IOL placement. Delayed visual rehabilitation and an increase in cost of treatment are some implications of PCR. Dr. Ganesh provided strategies to prevent nucleus and fragment drop, termed the IOL scaffold technique, during phacoemulsification. “Using the IOL scaffold technique provides an elegant surgery,” Dr. Ganesh said, though a 3-piece IOL must be used as the scaffold. Not only are 3-piece IOLs becoming uncommon in today’s surgical world, but the surgeon must also be skilled. “One can damage the haptics when doing phaco,” Dr. Ganesh said. A temporary rescue device, the safety net device, may help. Dr. Ganesh showed two versions of the safety mesh with a net-like structure and one with a circular-like structure. These safety mesh devices allow the surgeon to manage PCR without extending the clear corneal wound and to provide thorough anterior vitrectomy and cortical clean up while minimizing vitreal loss, ultimately preventing devastating complications of nucleus drop. “Despite tremendous technical and technological advancements, PCR can happen during any surgical procedure,” Bryan Hung-Yuan Lin, MD, said. This unexpected occurrence can be managed with a few strategies, including early detection of the rupture, adequately removing residual nucleus fragments and cortical material, and checking the vitreous strands, Dr. Lin suggested. He said these “helpful techniques can lead to a final visual outcome looking similar to an uncomplicated case.” Additionally, he said, “The aspiration rate must be very slow and intraocular pressure should be maintained below 30 mmHg. And be sure to refill dispersive ophthalmic viscoelastic whenever there is not enough tamponade.” Top Gun: Simplifying Cataract Techniques Some surgeons make surgery look so simple or use a shortcut that make others wonder why they hadn’t thought about it first. This year’s Top Gun — Top Cataract Surgery Tips brought together 17 of the world’s leading cataract surgeons to share some of their subtle tips and maneuvers that can make surgery just a bit easier. “This is not about showing complicated surgery,” said symposium co-chair Ronald Yeoh, MD. “It’s about showing how great a teacher you can be.” The grand prize this year was a solid state drive“so you can save all your videos for next year’s submissions,” said symposium co-chair Ronald Yeoh, MD. This year’s grand prize was awarded to Filomena Ribeiro, MD, PhD, for her tips on how to easily insert iris hooks. Iris hooks are often used to expand small pupils and are typically placed via their own small incisions to hold the iris tissue out of the way during surgery. Dr. Ribeiro recommended “painting” with blue dye as one tip. But her primary pearl was to place the hook on the needle itself, thereby eliminating one step to the iris hook insertion. Once the needle/hook combination is inside the eye, simply remove the needle and the hook will already be inserted, she said. This year’s runner-up was Chee Soon-Phaik, MD, for her video on battling Soemmering’s ring. “It’s a complex case with a simple pearl,” she said. She advised surgeons to perform an adequate anterior vitrectomy and then use an IOL cartridge to keep the corneal incision rounded to enable infusion pressure to hydroexpress the entire ring in a controlled manner into the cartridge. “The IOL cartridge is already on your operating table and widely available,” she said. Dr. Chee was previously voted a winner at the ASCRS 2023 Top Gun for the same pearl. Pearls from Surgical Videos Attendees at the industry- sponsored video surgery symposia learned from experts about the safety and efficacy of NEXUS CoNNECtiNg EvEryoNE & EvErythiNg
novel devices. In Johnson & Johnson’s Early Experience with Elita: Next Generation Laser Vision Correction, Rohit Shetty, MD, said the interface “is something that I really enjoy.” Some pearls: When inserting the cone, pinch it so it fits in the suction ring. Mahipal Sachdev, MD, said he began using the Elita to create LASIK flaps before moving to lenticule extraction. The entire flap creation takes about 15 seconds, he said, and “the flap quality is fantastic.” The benefits of microinvasive glaucoma surgery (MIGS) at the time of cataract surgery are numerous, and include the potential to lower intraocular pressure (IOP) without ocular surface disruption or compliance requirements, a reduction in the relative risk of requiring secondary incisional glaucoma surgery, and the potential to reduce the number of ocular hypotensive medications, said Shamira Perera, MD, during the Alcon Vision Suite: Complete, Connected Care. At Alcon’s surgery video symposium, doctors touted Alcon’s Hydrus Microstent, Clareon extended depth of focus IOL, and Ngenuity 3D Visualization System. Meanwhile, in Zeiss’ New Paradigm in Motion, presenters agreed the VisuMax 800 is similar to the VisuMax 500, “but the optic and clarity is much better on the 800,” said Aadithreya Varman, MS (India). “I am much more confident in my dissection technique.” Preparing for Glitches in Cataract Cases Cataract cases at times may present challenges in various different ways, and in the symposium Glitch in the Matrix: Challenging Cataract Cases, surgeons presented top tips they learned from their experience in the operating room. In the case of white cataracts, Yao Ke, MD, described the benefit of performing femtosecond laser-assisted cataract surgery (FLACS). Because it is difficult to differentiate the capsule in white cataracts, there is increased volume and liquefication of the lens material, and it is possible to rupture the posterior capsule and tear the anterior capsule, Dr. Yao recommends FLACS for these cases. “The incidence of capsular tear is extremely low when using FLACS,” he said. Capsular staining is also a good way to avoid this issue, he noted. Mature intumescent cataracts, presenting as swollen and congested with increased intralenticular pressure, is another situation that may create problems while doing cataract surgery. A surgeon may have difficulty visualizing the anterior capsule, may face a stretched capsule, and may even see the Argentinian flag sign. “What I recommend during surgery is to be dexterous. You should be able to perform capsulorhexis in both right and left hands,” Amit Porwal, MD, said. “My top tip, though, is to do intralenticular decompression because it’s very important when you’re handling this type of cataract.” Rock hard cataracts are yet another complicated cataract a surgeon may encounter. These types of cataracts are similar to a piece of granite inside the eye. Mohan Rajan, MD, said that surgeons can perform phacoemulsifcation on rock hard cataracts and still consistently get good results. One tip Dr. Rajan offered: After making a good preoperative assessment, know where the rhexis margin is by staining it with trypan blue. Hydrodissection should be done carefully, not aggressively, and high phaco power at 80% to 100% should be selected to avoid pushing out the nucleus. Changing Patterns in Refractive Surgery Of all the various refractive procedures — lenticule extraction, LASIK, PRK, phakic intraocular lenses (IOLs) — which would be best for a moderate myope (–5 D)? Michael Knorz, MD, attempted to address that question during the Faster Than the Speed of Light symposium. Each of the techniques has its advantages and disadvantages: surface ablation has a slow visual rehabilitation, and femto-LASIK can result in significant dry eye for several months, although both have good safety and customizable treatments. There are several laser lenticule extraction devices on the market, with Zeiss’ SMILE likely the best known, Dr. Knorz said. Each of the platforms allow for fast visual rehabilitation and fewer dry eye symptoms than
LASIK or femto-LASIK but do have some optical side effects and are not reversible. “Corneal laser vision corrections should be limited to moderate myopia because of the loss in quality of vision,” he said, noting the higher the refractive error, the greater the aberrations. Phakic IOLs offer a good safety profile, faster visual recovery, do not create dry eye, boast fewer optical aberrations and are fully reversible, Dr. Knorz said. Further, in his experience with the Visian ICL (Starr Surgical), “I’ve never seen corneal decompensation,” contrary to earlier reports when the technology was first introduced.“Phakic IOLs give patients significantly better night vision than corneal laser surgery and does not interfere with future procedures,” he said, so when the patient needs cataract surgery down the road, “just remove the ICL.” When a –5 D myope wants laser vision correction, Dr. Knorz said the order of surgery he would recommend is phakic IOL (because of the quality of vision and reversibility), followed by laser lenticule extraction (less dry eye than LASIK), then femto-LASIK (higher patient comfort compared to surface ablation), and finally, surface ablation. But only for younger patients. “If that same patient is over 50 years old, I’d recommend refractive lens exchange,” he said. Is Ray-Tracing LASIK More Than a Fad? During the Faster Than the Speed of Light symposium here at the 35th APACRS Singapore conference, Chandra Bala, MD, said the evolution of refractive surgery has moved from PRK to wavefront optimized, to wavefront guided, to topography-guided, and now to ray-tracing LASIK. “I would argue that the purpose of refractive surgery is not to remove a thin lens from the cornea, but to change the angle of incidence of the ray as it strikes the cornea so that the eye may do the rest of the focusing,” he said, “But in order to do that, the ray should strike such that you can predict where it will strike the lens.” Innoveyes’ ray tracing algorithm uses multiple measure surfaces and unmeasurable assumed elements to create a baseline individualized eye model, he said. The all-in-one device does all the steps in one sitting, including refraction, whole eye aberrometry, topography, central corneal thickness, anterior chamber depth, and axial length, among others. In his hands, 8% of eyes achieved 20/10, 50.5% achieved 20/12.5, and 89.3% achieved 20/16; 96% of eyes were within 0.5 D, and 98% had < 15° angle of error. “Ray tracing is a new era in our thinking and ability to correct refractive error,” he said. “We now recognize the need for an individual eye model — an ‘eyevatar’ — for creating a personalized treatment plan.” 10 Years of SMILE With more than a decade of commercialization, “why hasn’t small incision lenticule extraction (SMILE, Zeiss) replaced LASIK?” asked Patrick Versace, MD, during the symposium Faster Than the Speed of Light. Studies show there are no differences between SMILE and femto-LASIK in uncorrected visual acuity or refractive outcomes, but SMILE is significantly better in reducing higher order aberrations and spherical aberrations. While the two techniques produce similar tear film osmolarity and Schirmers’ test results, tear break-up time and Ocular Surface Disease Index outcomes favor SMILE, he said. “Patient acceptance is higher, as there’s no flap, no down time, a rapid return to sports, and less dry eye,” he said. Conversely, LASIK has a much quicker visual recovery. There are five lenticule extraction devices on the market, each of which uses a different amount of energy per pulse. “But what we don’t know is what part of the energy matters (total energy, or energy per pulse, or energy focus, or ease of dissection),” he said. “We only know using less energy is better.” Other upsides are that SMILE can correct myopia up to –10 D, but vertical coma is increased after SMILE, and to date there is no method to digitally register the lenticule cut location, meaning a second lenticule cut would be optimal, but surgically complex to place identical to the first incision. Digital marking is only available on the Zeimer Z8 device, although it may be planned on Johnson & Johson’s Elita. “We can make lenticular surgery greater by introducing auto centration and toric alignment, having easy lenticule removal, improving the precision of the energy delivery, and allowing enhancements with secondary lenticule removal,” he said. EWAP NEXUS CoNNECtiNg EvEryoNE & EvErythiNg
35th APACRS LIM Lecture: Current and Future Development in Intraocular Implants with New Materials by Christina Chintanaphol Singapore – The highly anticipated Lim Lecture of the 35th APACRS Singapore was delivered by Gerd U. Auffarth, MD, during the Opening Ceremony. “Giving the Lim Lecture is something really special. Dr. Lim is iconic in the APAC region, especially in Singapore, and it is a huge honor for me to deliver this lecture,” Dr. Auffarth remarked, whose lecture was “Current and Future Developments in Intraocular Implants with New Materials.” Dr. Auffarth said the basic treatment of cataracts has advanced thanks to the many types of intraocular lenses (IOLs) currently available. Today, in 2023, ophthalmologists are seeing different optical principles being utilized in IOLs such as diffractive optics, refractive optics, and the newer high aspheric optics. “There are so many different types of lenses, and nobody really knows which model is the best, and what model we should use,” Dr. Auffarth said. In fact, “some categories don’t have a true definition.” For example, different types of presbyopia-correcting IOLs overlap in terms of what they can achieve but also differ in terms of their optics. Will we be able to get to the point where we are completely spectacle independent? Dr. Auffarth emphasized “there is no free lunch in optics. You can’t get everything without paying for it.” Different monofocal IOLs have been developed with different characteristics in mind: higher order aspheric components, induced positive spherical aberrations, and hydrophobic properties with 4 diffractive rings, to name a few. Dr. Auffarth warned against going “too far” with these special characteristics, as more problems can crop up such as point spread function, halo, and depth of focus issues. Dr. Auffarth also described new concepts based on current technology. Binocular trifocality and reversible trifocality have been introduced in different complementary IOL systems such as the Artis Symbiose® (Cristalens) and Sulcoflex Trifocal (Rayner). IOLs with phase continuity may provide relief to patients who experience blurred visual quality by way of phase inversion. Neuroadaptation to new optics is yet another patient aspect ophthalmologists may need to consider. One novel IOL material that may be of high interest is crosslinked polyisobutylene (xPIB), which has shown biocompatibility with no glistening nor inflammatory response. Ultimately, “accommodative and adjustable IOL technology will be the future,” Dr. Auffarth said. To name a few, the ophthalmology world has already developed lenses containing macromers that turn into polymers when exposed to ultraviolet light, using a laser beam to change refractive power (two-photon chemistry), pulsing femtosecond lasers to adjust lenses, and using split lens solutions. An abundance of technology promises endless possibilities for patients undergoing cataract and refractive surgery, he said. EWAP
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