eyeworldap.apacrs.org The Asia-Pacific Association of Cataract and Refractive Surgeons ASIA-PACIFIC Vol. 19 No. 1 March 2023 www.eyeworldap.apacrs.org
NEXUS CoNNECtiNg EvEryoNE & EvErythiNg Preliminary Program Overview 8 JUNE 2023 (THU) 9 JUNE 2023 (FRI) 10 JUNE 2023 (SAT) 07:30 – 8:45hrs (S5) THE CATARACT METAVERSE 1 Everything Everywhere All at Once 07:15– 08:15hrs (S11) IIIC LECTURES The Perfect Save! 09:00 – 10:30hrs MASTERCLASSES (MC1) Mastering Toric IOLs (MC2) Mastering Pterygium Surgery (MC3) Mastering Paediatric Cataract Surgery 09:00 – 10:30hrs OPENING CEREMONY & APACRS LIM LECTURE 08:15 – 11:15hrs (S12) SURGICAL VIDEO SYMPOSIA (S1) ANGLE CLOSURE SURGERY New Insights TEA BREAK 11:00 – 12:30hrs MASTERCLASSES (MC4) Mastering Biometry (MC5) Mastering Refractive Surgery Complications (MC6) What They Don’t Teach You in Residency 11:00 – 12:30hrs COMBINED SYMPOSIUM OF CATARACT & REFRACTIVE SOCIETIES (CSCRS) (S6) TRENDING TECHNOLOGIES Highway to the Future 11:15– 12:45hrs (S13) GLITCH IN THE MATRIX Challenging Cataract Cases (S14) FASTER THAN THE SPEED OF LIGHT Changing Patterns in Refractive Surgery NURSING & ALLIED HEALTH (S7) HOLISTIC EYE CARE A Multidisciplinary Approach (Part 1) (S2) UPDATES ON INFECTIOUS KERATITIS FREE PAPERS NURSING & ALLIED HEALTH (S15) HOLISTIC EYE CARE A Multidisciplinary Approach (Part 2) FREE PAPERS INDUSTRY LUNCH SYMPOSIA 14:00 – 15:30hrs MASTERCLASSES (MC7) Mastering Phaco Alternatives (MC8) Mastering Corneal Endothelial Transplantation (MC9) Mastering Phakic IOLs 14:00 – 15:30hrs (S8) THE NETWORK IS DOWN Managing Cataract Complications 14:00 – 15:30hrs (S16) THE CATARACT METAVERSE 2 Everything Everywhere All at Once (S9) THE NEW BLACK IN PRESBYOPIA CORRECTION (S17) ANTERIOR SEGMENT INNOVATIONS (S3) MYOPIA-ASSOCIATED OPTIC NEUROPATHY OR GLAUCOMA FREE PAPERS FREE PAPERS TEA BREAK 16:00 – 17:30hrs MASTERCLASSES (MC10) Mastering IOL Fixation (MC11) Mastering Vitrectomy for Anterior Segment Surgeons (MC12) Mastering MIGS Complications 16:00 – 17:30hrs (S10) FILM FESTIVAL SYMPOSIUM & AWARDS CEREMONY 16:00 – 17:30hrs (S18) TOP GUN Top Cataract Surgery Tips (S4) WHAT’S NEW IN CORNEA 17:30 – 19:00hrs WELCOME RECEPTION MORNING AFTERNOON Visit www.apacrs2023.org for more information
EWAP MARCH 2023 3 EDITORIAL EyeWorld Asia-Pacific • March 2023 • Vol. 19 No. 1 One of the most interesting trends covered in the issue is the increase in interest in modest monovision, in part related to a great opportunity for blended vision when it is used within the context of new extended depth of focus (EDOF) IOLs. I have used monovision for decades and have extolled the virtues of this approach as an alternative to multifocal IOLs. It is important to preserve binocular acuity and reduce asthenopia by limiting the targeted level of myopia in the near eye. An ideal target for modest monovision is –1.25 D as stereoacuity is well preserved and there is less chance of reduced binocular contract sensitivity and asthenopia. However, while this level of targeted myopia will provide excellent intermediate acuity, total spectacle dependence is expected in approximately 30% of patients. And yet despite this limitation, patient satisfaction is extremely high; total spectacle independence in the context of multifocals may not have been the best parameter to address the success of a presbyopic solution from a patients’ perspective. The advent of EDOF IOLs offers a great new opportunity to utilize modest monovision as the extended depth of focus allows overlap of the distance in the near eye resulting in true blended vision and a continuous range of focus without the dysphotopsia typically encountered with trifocal IOLs, particularly those based on a refractive principle. EDOF IOLs can of course be used without monovision and still provide excellent intermediate acuity, but the synergy of utilizing myopic defocus in one eye greatly improves the potential for spectacle independence. A range of myopic defocus can be utilized with a target as low as –0.50 D extending up to –1.50 D, although a target of approximately –1.0 D is considered ideal in this context. The extended depth of focus will better preserve distance vision with the same level of myopia as well as additional reading ability. My personal experience is primarily combining modest monovision with the Rayner EMV lens, which from the outset conceived that the principle of aspherical aberration was ideally suited to combination with a modest level of myopia; the clinical results detailed by Yeo Tun Kuan in this issue confirm the utility of this approach. Modest monovision can of course be utilized with other EDOF IOLs but the impact of myopic defocus will vary depending on the ocular principle as the EDOF group is not homogeneous but includes lenses based on different optical principles. Myopic defocus may impact the contrast as well as the likelihood of dysphotopsia with some other EDOF IOLs. I hope the increasing availability of EDOF IOLs will encourage surgeons to consider the use of this powerful optical mechanism to address presbyopia and experience the magic of modest monovision. Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific • China • Korea • India
4 EWAP MARCH 2023 FEATURE Hot Topics in Ophthalmology 08 New IOLs offer option of ‘blended vision’ by Liz Hillman 12 A discussion on SMILE by Ellen Stodola 15 How vaccines may affect the cornea by Ellen Stodola 17 Procedural classifications of MIGS: How to understand, group the options by Liz Hillman CONTENTS NEWS & OPINION 42 Review of ‘LOCSIII-based artificial intelligence program for automatic cataract grading’ by Tirth J. Shah, MD, Zachary Q. Mortensen, MD, Michael D. Abramoff, MD, and Thomas A. Oetting, MD 45 Review of ‘IOL power calculations after LASIK or PRK: Barrett True-K biometer-only calculation strategy yields equivalent outcomes as a multiple formula approach’ by James Tian, MD, Esteban Peralta, MD, Katherine Peters, MD, Sri Meghana Konda, MD, Cason Robbins, MD, C. Ellis Wisely, MD, and Pratap Challa, MD 47 ASCRS Consensus Statement on VUITY 49 A candid conversation about VUITY by Liz Hillman 03 Editorial MEETING PREVIEW 06 NEXUS – Connecting everyone and everything A preview of the 35th APACRS Annual Meeting in Singapore by Chiles Aedam R. Samaniego CATARACT 21 The importance of ergonomics in the clinic and OR by Ellen Stodola 25 What’s up with NSAIDs? by Liz Hillman REFRACTIVE 27 The EVO ICL: What makes it different and results by Ellen Stodola 31 Word on the street about epithelial mapping 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 IMPORTANT DATES 8 April 2023 1st Tier Early Bird Deadline 8 May 2023 2nd Tier Early Bird Deadline Online registration closes at 23:59hrs, Monday, 22 May 2023 to facilitate preparations for the in-person meeting. Onsite registration commences at 14:00hrs, Wednesday, 7 June 2023 Hall 403, Level 4, Suntec Singapore Exhibition & Convention Centre
TRENDING TECHNOLOGIES highway to the Future Combined Symposium of the Cataract & Refractive Societies (CSCRS) A joint symposium of the APACRS, ASCRS & ESCRS Having successfully embarked on a streamlined version of the in-person APACRS Annual Meeting last year in Seoul, the APACRS returns with a full 3-day scientific program this year for its 35th APACRS Annual Meeting, bringing its members to a NEXUS in Singapore— "connecting everyone and everything.” Here’s a preview of some of what’s in store for attendees at this meeting. 2023 APACRS LIM LECTURE The APACRS LIM Lecture is the highest honor conferred by the APACRS. This year, Prof. Gerd U. Auffarth will deliver the 2023 APACRS LIM Lecture “Current and Future Development in Intraocular Implants with New Materials” at the Opening Ceremony. Dr. Auffarth will present the different categories and lens systems, including trifocals, the heterogenous group of EDOF lenses, and monofocal plus lenses, that are now used in NEXUS – CONNECTING EVERYONE AND EVERYTHING by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer cataract and refractive surgery. Newer approaches include the use of a new material called crosslinked polyisobutylene. Companies are also currently favoring the development of adjustable IOLs such as the Light Adjustable Lens (LAL), femtosecond laser adjustable IOLs, and IOLs with modular optics. Modular optics leads to other options, such as combining accommodative optics with modular base optics to provide toric correction. And while it will be a long time before mechatronic- optoelectronic implants with their own energy supply are available, there are already some concepts here as well. The Opening Ceremony will take place from 09:00 to 10:30 hrs on Friday, 9 June 2023. TRENDING TECHNOLOGIES – Highway to the Future Combined Symposium of Cataract & Refractive Societies (CSCRS)-A joint symposium of the APACRS, ASCRS, and ESCRS This year, experts from the three leading cataract and refractive societies will take a critical look at trending technologies, with the aim of helping attendees decide which technologies to take seriously. The CSCRS will be held from 11:00 to 12:30 hrs on Friday, 9 June 2023. MasterClasses This year’s series of MasterClasses will include familiar courses on the hottest topics in ophthalmic surgery today: Toric IOLs, Pterygium Surgery, Paediatric Cataract Surgery, Biometry, Refractive Surgery Complications, What They Don’t Teach You in Residency, Phaco Alternatives, Corneal Endothelial Transplantation, Phakic IOLs, IOL Fixation, Vitrectomy for Anterior Segment Surgeons, and MIGS Complications. The MasterClasses will be held throughout the first day of the scientific program, on Thursday, 8 June 2023.
APACRS Film Festival The APACRS Film Festival entertains and educates, creatively displaying new innovations and breakthroughs in anterior segment ophthalmic surgery. Don’t miss this exciting session on the evening of Friday, 9 June 2023. Glaucoma Co-hosted by the Singapore National Eye Centre, the 35th APACRS annual meeting’s Glaucoma program consisting of two sessions: The first providing new insights into the management of primary angle closure disease (PACD), and the second engaging with the association between myopia and glaucoma, which has important implications on the global healthcare burden. The two sessions of the Glaucoma program will take place on Friday, 8 June 2023. Cornea Co-hosted by the Singapore National Eye Centre, the 35th APACRS annual meeting’s Cornea program: the first providing essential updates on the treatment of infectious keratitis, the second looking at the latest global trends in the field. The two sessions of the Cornea program will take place on Friday, 8 June 2023. Nursing & Allied Health Program Co-hosted by the Singapore National Eye Centre, the APACRS annual meeting’s nursing and allied health program provides a wonderful opportunity for essential members of ophthalmology practices to network, share experiences, and take home pearls of wisdom to improve their workplaces and the ophthalmic health care they provide. TOP GUN – Top Cataract Surgery Tips Leading Experts present their Top Cataract Surgery Tips— subtle surgical tips and maneuvers that other surgeons can use the next time they are in the operating room. This year’s session features tips from Takayuki Akahoshi, MD, Japan; Bruce Allan, MD, UK; Chandra Bala, MD, Australia; Sheetal Brar, MD, India; Arup Chakrabarti, MD, India; Chee Soon Phaik, MD, Singapore; Oliver Findl, MD, Austria; Sam Garg, MD, USA; M. Nazrul Islam, MD, Bangladesh; Pichit Naripthaphan, MD, Thailand; Pannet Pangputhipong, MD, Thailand; Hadi Prakoso, MD, Indonesia; Chitra Ramamurthy, MD, India; Filomena Ribeiro, MD, Portugal; Sathish Srinivasan, MD, UK; Patrick Versace, MD, Australia; and Elizabeth Yeu, MD, USA. As usual, the APACRS offers a carefully curated scientific program, deliberately designed to minimize concurrent sessions so attendees can make the most of what the meeting offers. The 35th APACRS Annual Meeting will be held at Suntec Singapore from 8 to 10 June 2023. Additional details, information on registration, travel requirements and more can be found on the meeting’s official website at apacrs2023. org. EWAP Editors’ note: All information is correct at the time of publication. Refer to apacrs2023.org for the most up-to-date information on the meeting. TOP GUN Top Cataract Surgery Tips Saturday, 10 June 2023 16:00 - 17:30hrs, Hall A
FEATURE 8 EWAP MARCH 2023 by Liz Hillman Editorial Co-Director New IOLs offer option of ‘blended vision’ W hile the concept of monovision to enhance distance vision in the dominant eye and provide functional near vision in the non-dominant eye — the goal being to reduce dependence on spectacles and contact lenses — is not new, advances in IOL technologies are providing a more coordinated visual experience compared to prior monovision options. In fact, Lance Kugler, MD, said there’s a shift in how the field is talking about monovision produced with IOLs at the time of cataract surgery. “We’re moving toward the term ‘blended vision,’ which seems to be a more inclusive term than monovision,” he said. “With monovision, people think about wearing their contact lenses and a huge difference between the two eyes, and there is a negative connotation to that. Blended vision is more the eyes blending together. With some of these technologies that provide an extended depth of field, whether it’s the IC-8 Apthera IOL [AcuFocus] or different IOLs, you get a completely different experience than what someone might have with monovision contacts.” What does ‘monovision’ look like in your practice? Eric Donnenfeld, MD, said monovision is one of the most common treatments he uses for his cataract patients. “I don’t do a full monovision; I do a micro-monovision of about 0.75–1 D, and that gives patients enough near that they are comfortable without having problems with distance. I like using the extended depth of focus [EDOF] lenses with monovision. I think that’s been the biggest breakthrough that we’ve had in our practice over the last several years, and I think mini-monovision with the added value of an EDOF lens has been a terrific advancement for our patients,” he said. “I like the Eyhance [Johnson & Johnson Vision], the RayOne EMV [Rayner], and Vivity [Alcon].” Dr. Donnenfeld said he’ll usually use an EDOF in both eyes because the biggest risk of monovision is not hitting the distance target. “The significant change in my practice has been that I no longer aim for the first myopic lens because I don’t want to leave anyone myopic in the dominant eye,” he said, explaining that he aims for the first plus lens, knowing that with the EDOF technology, even if the patient is +0.25–0.5, they’ll still see 20/20 at distance. “The IC-8 Apthera IOL is a pinhole IOL that can provide as much as 1.5 D of near vision without splitting light and maintaining 20/20 vision at distance. It’s ideal for post-refractive cornea patients who wish to be spectacle independent but are not good candidates for multifocal IOLs,” he said. Bryan Lee, MD, JD, said he achieves monovision in three ways: with a monofocal or monofocal toric, with the Vivity IOL, or with the Light Adjustable Lens (LAL, RxSight). “I explain to [patients] that with the monofocal, you have This article originally appeared in the December 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Contact information Donnenfeld: ericdonnenfeld@gmail.com Kugler: Ikugler@kuglervision.com Lee: bryan@bryanlee.pro Dr. Lee uses the LAL as one of his options for achieving monovision. Source: Bryan Lee, MD, JD
FEATURE EWAP MARCH 2023 9 two points that are clear, while the Vivity provides more range for each eye. The Light Adjustable Lens is the most accurate both for distance and for near, which is the harder eye to target,” he said. Dr. Kugler said he also uses the LAL as his “go-to option” for monovision in patients who have had previous corneal refractive surgery. He said some of his blended vision patients receive a monofocal lens in the dominant eye and an EDOF or trifocal in the non-dominant eye. “It’s a different kind of blended vision but it has a very high satisfaction rate in the right patients,” he said. Dr. Kugler added that the IC-8 Apthera IOL will be useful in some monovision cases. “If you’ve got a case where you want to avoid multifocality, but you want to give them a nice range of vision, it allows you to do that without the downsides of multifocality and without the limited range of vision that a fixed monofocal has. I think it fills an interesting niche,” Dr. Kugler said. Assessing candidates Dr. Donnenfeld said he employs monovision because any residual dysphotopsias that might occur can be solved with a pair of glasses and because it preserves distance vision. Trifocals, Dr. Donnenfeld continued, come with a little bit of distance vision compromise. “For patients who say they want to reduce their dependence on glasses and wear them infrequently, I want to be able to not have dysphotopsias, or if they’re not a great candidate for a trifocal… they can still be a good The IC-8 Apthera IOL. Source: Eric Donnenfeld, MD Presbyopia eye drops in development The IC-8 Apthera IOL was approved by the FDA in July 2022. When EyeWorld spoke with Dr. Donnenfeld, Dr. Kugler, and Dr. Lee, it was not yet available commercially in the U.S., but they shared their insights on how this IOL would benefit patients with EDOF capabilities as well as some therapeutic uses. Dr. Donnenfeld noted that the IC-8 Apthera was approved as an EDOF IOL. “It was approved on virgin eyes that had good visual potential, and the patients did very well in the FDA trials. The nice part about the lens is it doesn’t split light. It’s a true EDOF lens. It gives dramatically more near than the Vivity, Eyhance, and RayOne EMV, so it gives patients that extra near that they want, and it doesn’t compromise distance. In fact, it very commonly improves distance. I think there is a significant opportunity to add this lens to your portfolio. I think it’s a good consideration for people who want monovision. You will get more reading from this lens than you will from the other EDOF lenses that we generally think about.” The biggest opportunity, however, that he and other physicians consider for the IC-8 Apthera is in irregular corneas. “I think this will be one of the more important new technologies that we add to our armamentarium for the most challenging patients in our practice. This lens is going to solve problems that previously were unsolvable for many patients,” Dr. Donnenfeld said. Dr. Lee, who participated in the clinical trials for the IC-8 Apthera, said that the lens will be helpful for monovision, even when set for –0.75 to –1 D, but he is also looking forward to its use for irregular corneas. “Additionally, the IC-8 Apthera will allow for continued RGP wear for patients, unlike a toric IOL or Light Adjustable Lens. Irregular corneas will be an off-label use because those patients were excluded from the trial, so I expect that surgeons will start using it and see how their patients do, just as with any new technology. However, it will be important for us to have reasonable expectations for the IOL because it would be unfair to expect miraculous results in abnormal, highly aberrated eyes,” Dr. Lee said. Dr. Kugler, also an investigator in the IC-8 Apthera trial, said this lens might be attractive for surgeons who have been hesitant to offer multifocals due to the management or enhancement needed for them. “For cataract surgeons who don’t have access or capability to enhance those patients, multifocals are very difficult to use successfully. You tend to get frustrated with them and stop offering them. I think that’s a huge complexity to multifocal IOLs, whereas the IC-8 Apthera is very forgiving. The enhancement rate is not zero but it’s lower than what you would have with a multifocal,” Dr. Kugler said. He noted that while he doesn’t have experience with post-refractive eyes and the IC-8 Apthera, if you look at the work of international ophthalmologists, the IC-8 Apthera is a common solution for post-refractive eyes. “I do wonder how it’s going to fit into what we’re doing for post-refractive IOLs. The Light Adjustable Lens is great, but it also has its downsides,” Dr. Kugler said, adding that looking at international experience, he thinks it will be an especially good option for post-RK eyes. IC-8 Apthera makes U.S. but
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FEATURE EWAP MARCH 2023 11 candidate for monovision,” Dr. Donnenfeld said. Dr. Lee said he will consider monovision for a patient who has had vision corrected with this technique before and was happy with it. “If a patient likes monovision, I would continue it and never switch to a trifocal. At the same time, the only way I would do monovision in someone with no prior experience but too much cataract for a monovision contact lens trial would be with the Light Adjustable Lens,” he said. In general, Dr. Lee said that monovision can give better reading vision than a presbyopia-correcting IOL in both eyes. He also said that some patients who are not good candidates for a trifocal IOL, due to ocular comorbidities, can still be a candidate for monovision. “Monovision avoids the halos associated with a diffractive IOL, and you can optimize night vision with a pair of glasses,” he said. Some ocular comorbidities rule out monovision/blended vision as a viable option. These, according to Dr. Donnenfeld, include patients with amblyopia, macular degeneration, or other pathology in one eye to the extent where the vision has deteriorated, and the patient thus would not be happy with vision in that eye for near or far. Dr. Donnenfeld said he’ll also steer away from monovision in patients who are athletes and need depth of focus. Golfers, for example, can’t see the greens well with monovision, he said. Dr. Donnenfeld doesn’t specifically trial monovision with contact lenses in patients who are cataract surgery candidates because they won’t get a true experience due to the cataract. Dr. Kugler also cautioned against monovision/blended vision in eyes that are compromised in any way because “each eye has to be able to carry the weight of a certain distance by itself.” Additional examples include eyes with strabismus or keratoconus. “I think you need to be very careful with blended vision because you’re asking each eye to function independently. If the eye is not capable of doing that, it’s probably not going to be a successful result,” he said. Dr. Kugler also said there are patients who simply cannot adapt to monovision. “There are patients who I think aren’t great candidates for blended vision but they are good candidates for bilateral multifocals. That’s absolutely on the list of options.” EWAP Editors’ note: Dr. Donnenfeld practices with the Ophthalmic Consultants of Long Island, Garden City, New York, and has interests with AcuFocus, Alcon, Johnson & Johnson Vision, and Rayner. Dr. Kugler in in practice at Kugler Vision, Omaha, Nebraska, and declared no relevant financial interests. Dr. Lee practices with Altos Eye Physicians, Los Altos, California, and declared no relevant financial interests. In the past decade, social habits have changed from reading printed materials to increased use of electronic reading devices such as tablets and mobile phones. This shift has coincided with the advent of newer intraocular lenses (IOLs) that provide a wider range of vision, such as the IC-8 Apthera (Acufocus), Eyhance (Johnson & Johnson Vision), RayOne EMV (Rayner), and Vivity (Alcon). There is renewed interest in monovision—not full monovision as in the past, but mini or modest monovision to achieve good distance and functional near vision and yet maintain good stereopsis. These new IOLs complement this strategy very well. I frequently employ monovision or blended vision in my practice. It is a useful strategy for patients who want to reduce spectacle dependence but are not suitable candidates for trifocal IOLs. The key factors for successful outcomes are to be able to attain the intended target refraction and correct any existing astigmatism. This can be achieved with newer biometers and modern toric IOL formulas. As many of my patients need to read Chinese characters and have a closer reading distance, I would generally aim for emmetropia and –1.25 D to –1.5 D with monofocal plus IOLs such as the Eyhance and RayOne EMV. The near target would be lower for the EDOF IOLs such as the IC-8 Apthera and Vivity. Results of my current study with the RayOne EMV shows that it provides excellent summation, giving a binocular range of about 2.5 D within LogMAR 0.2. The IC-8 Apthera is another very interesting IOL. Its pinhole technology not only provides an increased depth of focus but is also useful in eyes with irregular corneas. This will benefit patients who are not suitable for toric IOLs due to irregular astigmatism. Many patients are suitable candidates for monovision. I seldom do a contact lens trial in patients due to cataract affecting the quality of vision. Patients with previous laser refractive surgery are good candidates, as many of them may already have experienced monovision in the past. The broader landing zone of monofocal plus IOLs also provides a safety margin in terms of their refractive targets. On the other hand, patients with poor vision in one eye due to ocular pathologies or amblyopia are not suitable candidates for monovision. It will be exciting to see how the addition of these new IOLs to our armamentarium will aid surgeons in achieving their desired outcomes. Editors’ note: Dr. Yeo is a consultant for Alcon and Rayner. Yeo Tun Kuan, MD Senior Consultant, Department of Ophthalmology, Tan Tock Seng Hospital 11 Jalan Tan Tock Seng, Singapore 308433 tun_kuan_yeo@ttsh.com.sg ASIA-PACIFIC PERSPECTIVES
FEATURE 12 EWAP MARCH 2023 by Ellen Stodola Editorial Co-Director A discussion on SMILE W hen any new technology enters the market, physicians spend time determining how it fits into their practice. Lance Kugler, MD, and Audrey Talley Rostov, MD, shared with EyeWorld how they did this with small incision lenticule extraction (SMILE), also called laser-assisted lenticular extraction (LALEX), which was approved for Carl Zeiss Meditec (ReLEx SMILE) in 2016. They discussed how they have incorporated it into practice, what they’ve learned, and issues that may occur. They also addressed advancements and future innovation. ‘Innovation will propel everyone forward’ Dr. Kugler has been using SMILE more in his practice over the past couple of years. “We started with SMILE in 2016 but it was a small percentage of our cases. Some of the upgrades with the VisuMax femtosecond laser [Carl Zeiss Meditec] over the past few years have made it much more appealing as an option for patients,” he said. “I think that refinement of the nomogram has delivered more consistent results for us as well.” Dr. Kugler added that over time, he and his team have been able to improve how they introduce the option of SMILE to patients. Patients may spend years considering the procedure, overcoming fears, costs, and other barriers. “I think we’ve gotten better at introducing SMILE into the discussion.” Dr. Kugler said he likes to use SMILE for low to moderate myopes with a low to moderate amount of cylinder. “I like it for people who may have a reason why an intrastromal procedure is better than having a flap,” he said, adding that this might include someone who doesn’t want to deal with some of the precautions generally taken with LASIK, such as avoiding eye makeup or swimming. There is still some debate on whether the dry eye recovery is any different; in general, people who have had eye surgery may feel dry for a while. This is true for both SMILE and LASIK, but he thinks that SMILE patients recover sooner than LASIK patients. Dr. Kugler said that in the very low myope, LASIK might offer more consistent outcomes compared to SMILE. He thinks the same about those with high amounts of cylinder. Additionally, he may be more likely to use LASIK if he is concerned that there is a higher chance of enhancement for a particular patient. “I may be more likely to use LASIK because it’s a little easier to enhance down the road than SMILE,” he said. “Our understanding and comfort with how to enhance SMILE has improved, but LASIK is still a bit easier to enhance if needed. This enters into the decision process.” Dr. Kugler said that his enhancement rate for SMILE is low, even lower than for Contact information Kugler: lkugler@kuglervision.com Rostov: atalleyrostov@nweyes.com This article originally appeared in the December 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Day 1 postop photo of SMILE. Source: Audrey Talley Rostov, MD
FEATURE EWAP MARCH 2023 13 LASIK. “I think the nomograms, accuracy, and consistency have improved in general,” he said. There are potential complications that can occur during the SMILE procedure that surgeons should be on the lookout for. These include issues with the lenticule. Dr. Kugler said he has experienced a thin lenticule in a low myope that has torn, and he’s had to take it out in a few pieces. This is not a big deal, he said, but the important thing is to recognize when it happens and realize you didn’t get the whole lenticule. When you do remove the lenticule, it’s important to lay it out flat and make sure you’ve gotten it all. “It seems like a waste of time when you don’t find a problem, but occasionally you might find that it’s not a perfect circle, and there’s still a partial fragment that needs to be removed.” As far as other potential complications, “If you’re going in and out of the SMILE pocket/ interface several times in the procedure, either to retrieve part of the lenticule or for some other reason, there is an increased chance of epithelial ingrowth,” Dr. Kugler said. “I’ve seen a few cases of this happen.” He added that this problem is fairly easy to manage if it does occur, and its incidence seems to decrease with experience. “I think the more experienced surgeons become, the less time they’re spending in the pocket. The less in and out there is, the less chance for epithelial ingrowth.” Dr. Kugler offered some advice for surgeons just starting out with SMILE. “I think it’s a little less forgiving than LASIK,” he said. “The lenticule is removed with manual dissection, so there’s definitely more technique involved.” There are more surgeon technique and manual steps compared to LASIK, and LASIK has had a 30-year head start over SMILE, so it is more refined. “If you look at where SMILE is on the timeline, it’s quite remarkable how far along it is,” Dr. Kugler said. “But someone who is used to having a lot of things automated in the LASIK process is going to need to realize that SMILE is more surgeon dependent.” Dr. Kugler said there is currently a gap in what is available overseas for the VisuMax femtosecond laser and what is available in the U.S. “We see a lot of great features that are coming but not here yet,” he said. “I think that’s going to be an important step forward in the technology for U.S. surgeons.” There are also several femtosecond laser companies working on lenticular creation and extraction technologies and software. “We’re going to see a real step forward in innovation and options on other platforms as well,” he said. “I don’t think there’s any question that the lenticular extraction techniques are going to evolve and improve, and a lot of the advantages of that technique that have been theoretical will continue to be refined and become a reality.” Dr. Kugler said that his practice made a conscious decision a couple of years ago to make sure that they were maximizing the SMILE technique because they think it’s going to become more relevant as more options enter the marketplace. “Carl Zeiss Meditec deserves tremendous credit for bringing this to market,” he said. “What’s also great is that we have other companies innovating in the same space, and the innovation will propel everyone forward.” When choosing which procedure to use, it’s a matter of matching the technology to the patient. “One thing I think surgeons should be mindful of is that patients are looking to them to make a recommendation as to the best procedure,” he said. “It’s impossible for patients to understand nuances among SMILE, LASIK, and other options.” Because of this, Dr. Kugler said it’s important for the surgeon to outline the differences and to recommend the most appropriate option for each patient. ‘There are some fallacies with SMILE’ In Dr. Rostov’s refractive practice, anyone who is a candidate for SMILE gets SMILE. She estimated that it’s upward of 80% of patients who come in for a refractive surgical procedure. She said that over the years, outcomes with SMILE, LASIK, and PRK have been shown to be very similar. “There isn’t a significant difference among laser vision correction procedures, and that’s exactly what I tell patients,” she said. “I tell them that when we look at laser vision correction, any of the three procedures will give you a great outcome.” Dr. Rostov said there are a few factors that she particularly likes about SMILE. First, she said it’s less invasive, and she thinks there is less dry eye than with LASIK. There is no flap with SMILE, so you don’t have to worry about late flap dislocation. You also don’t have the concern about haze that you get with PRK or the delay in healing, she added. “I think there’s some fallacies with SMILE, mostly from people who haven’t done it and think you’re not going to get the same results as LASIK and PRK, and that’s just not true,” Dr. Rostov said. “I think that as you refine your technique with SMILE, you can get those nice first-day 20/20 results.”
FEATURE 14 EWAP MARCH 2023 Dr. Rostov said that SMILE has similar criteria as LASIK and PRK. SMILE is approved for up to 3 D of astigmatism. “I find that above 2.0–2.25 D, when it gets to the higher amounts of astigmatism, in my practice LASIK does a better job.” She added that if the patient has a small superficial scar within the SMILE treatment zone, she will choose LASIK because you need a pristine cornea with SMILE. “You can’t have any scars or opacities within the treatment zone, and the reason is that the femtosecond laser is not able to go through opacities.” Dr. Rostov noted that she might choose LASIK instead of SMILE for smaller prescriptions because the lenticule would be very thin in these cases and might be harder to dissect. You could do it, but it depends on the patient. “Especially if it’s a thicker cornea and very low prescription, I might do LASIK instead,” she said. Dr. Rostov agreed that there may be complications that come up, as with any procedure. She had one case where she was unable to get the lenticule out, and she proceeded with PRK. Another potential complication is a suction break. Dr. Rostov said to try to prevent this, she might use medications or “verbal anesthesia.” “I tell patients to listen to my voice. I tell them ahead of time what to expect. I tell them just to listen to what I’m saying and to hold as still and be as quiet as possible,” she said, adding that she’ll let patients know when it’s particularly important to be very still. Dr. Rostov has only had a handful of suction breaks in more than 1,000 cases, and they occurred late in the procedure. With SMILE, there are four cuts that the laser does. The first is the refractive cut. “If you get a suction break during the refractive cut, you cannot do SMILE,” she said. The second cut determines the thickness of the lenticule. The third is the cap, which is the top of the lenticule and is a non-refractive cut. Dr. Rostov has experienced suction breaks during the cap cut. “You can redock and redo it,” she said, and in her cases, the procedure was still successful. There could also be problems during lenticule dissection, Dr. Rostov said. “If the epithelium is irregular or you have too much meibum on the surface, you can get ‘black spots,’ which are places where the laser is not going to be able to go through,” she said. “When you see the laser pattern, you’ll notice these spots where there was meibum or something like that, and if there’s too much, that will make the lenticule dissection too difficult.” Dr. Rostov has not experienced this complication in her SMILE cases Iagree with Dr. Kugler that LASIK performs better than SMILE in patients with very low myopia. I disagree with Dr. Kugler that LASIK is easier to enhance than SMILE. The SMILE circle program is easy to use, and has a much lower incidence of epithelial ingrowth than relifting the flap (Chang et al. 2022). However, creating a LASIK flap with the circle program will cost more than relifting the flap. If I’m concerned that the patient is likely to lose suction, I make my spot separation and line separation wider, which speeds up the laser by a few seconds. A few seconds may not seem to be significant, but it could feel like an eternity especially when the patient appears to be moving. The key is to get the lenticule and the side cut performed as quickly as possible. Giving the patient some oral tranquillizer helps a lot, too! I also warn the patient (preoperatively) that if SMILE fails, we may have to convert to LASIK. For the novice SMILE surgeon, I recommend using closer spot and line separation to make the dissection much easier. The laser will take longer to perform, but there will be fewer lenticule and cap complications. To prevent black spot, we have a suction tube set up in the operation room, and I copiously wash the eye with BSS. I have only had one eye with black spots, and vision was 20/20 on POD 1. I also wash the interface after lenticule extraction and I only had one mild DLK out of the 2,703 SMILE eyes. The biggest advantage of SMILE is obviously the absence of flap and flap trauma. I had one patient who had LASIK surgery over 10 years ago, he came back to me due to traumatic flap dislocation, which will not occur in SMILE patients. However, I repositioned the flap and he did not lose any vision. Regarding suction breaks, I agree with Dr. Rostov that most suction breaks occur late in the procedure. We are currently using the new VM800 (SMILE PRO). The entire laser procedure lasts from 10 to 14 seconds compared to the older laser which takes 22 seconds. A faster laser time leads to a shorter suction time and reduces the risk of suction loss. The new laser is four times faster and it allows closer spot separation and therefore easier separation, reducing the risk of lenticule/cap tear and epithelium ingrowth. Reference 1. Chang JSM, et al. Effect of time since primary laser-assisted in situ keratomileusis on flap relift success and epithelial ingrowth risk. J Cataract and Refractive Surg. 2022;48(6):705–9. Editors’ note: Dr. Chang receives lecture honoraria and research grants from Alcon and Carl Zeiss, and a lecture honorarium from Global Vision HK Ltd. John Chang, MD Hong Kong Sanatorium & Hospital 8/F, Phase II, Li Shu Pui Block, Hong Kong john.sm.chang@hksh.com ASIA-PACIFIC PERSPECTIVES continued on page 20
FEATURE EWAP MARCH 2023 15 by Ellen Stodola Editorial Co-Director How vaccines may affect the cornea T he push for widespread COVID-19 vaccination has renewed the focus on the side effects that vaccines may have. It’s an especially unique situation due to the distinct timeframe for this mass vaccination campaign. Clara Chan, MD, and Bennie H. Jeng, MD, spoke about potential ocular impacts of the vaccine and what physicians should look for. The concept of vaccine- induced corneal graft rejection, or any ocular inflammation, is not new, Dr. Jeng said. “Long ago, people wondered if a flu vaccine or any other vaccination can trigger an immune reaction,” he said. “It makes sense because the vaccination boosts your immune system, and your immune system gets revved up.” Previously, physicians were more likely to see random case reports, but it is appearing more now because of the worldwide push for a higher percentage of people to get COVID-19 vaccinations in a relatively short timeframe. “With a corneal graft, there is something antigenic in the eye, and the vaccination boosts the immune system, potentially causing the immune system to go after the transplant,” Dr. Jeng said. However, he said, “it can be very hard to prove causation in these cases.” Timing wise, if a patient has a graft that’s been doing fine for 6 years, they get the COVID-19 vaccine, and a few weeks later there is a rejection for the first time, that’s suspicious, Dr. Jeng said. While Dr. Jeng said he hasn’t experienced any of these cases in his practice, there have been multiple reports in the literature. “My patients ask me, because I think they have heard about the possibility, ‘Is it OK if I get the COVID-19 vaccination?’ My answer is ‘You should get it, and if it causes graft rejection, we can treat that and usually get you over it.’” There are some doctors who will start upping patients’ steroids for a couple of weeks before the vaccination and continue for a couple of weeks after, then bring them back down to potentially protect against any reaction. There are others like Dr. Jeng who will just have patients call immediately if there are any reactions after the vaccine. These reactions could include red eye, light sensitivity, pain, and decreased vision, among other symptoms. Dr. Jeng prefers the latter approach because adverse reactions are infrequent, so you may be overtreating 500 people to catch one. Additionally, most of the time if you treat after the fact, you can get patients through the episode with successful graft survival, he said. While you can’t always plan for when patients get their vaccine, Dr. Jeng said that if given the choice, he would recommend they get the vaccine before having a corneal transplant. If there is a chance that the vaccine could cause rejection, it’s potentially a lot of This article originally appeared in the December 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Contact information Chan: clarachanmd@gmail.com Jeng: bennie.jeng@pennmedicine.upenn.edu Left eye slit lamp photo of patient with moderate limbal stem cell deficiency (note whorl pattern of “late” fluorescein staining) and best corrected Snellen vision of 20/50.
FEATURE 16 EWAP MARCH 2023 Same patient at 1 month following treatment of HSV immune stromal keratitis and uveitis that flared up 2 weeks after second dose of COVID19 vaccine. resources wasted. Dr. Chan presented on the topic of vaccination and the possibility of graft rejection during the Lindstrom Symposium at the 2022 ASCRS Annual Meeting. In her presentation, titled “Are We Seeing More Inflammatory Corneal Events?” she shared cases she had encountered of corneal complications after COVID-19 vaccination. Because of the pandemic, Dr. Chan said there were a number of variables to consider: A lot of patients missed their follow-up appointments; prescriptions were not being renewed; there was a fear of steroids causing “immune compromise”; there was a fear of coming to the hospital clinic “where COVID patients go;” and there was a push for mass vaccination. The first case Dr. Chan shared was that of a DMEK rejection in a 69-year-old male. The patient had his first DMEK in 2019 for Fuchs dystrophy in the left eye, and it was a routine surgery. However, the patient stopped his steroid drop. Rejection led to DMEK failure, persistent corneal edema, and vision down to 20/200. In 2020, the patient had his second DMEK in the same eye, which was an uneventful surgery. Dr. Chan said he was doing fine postoperatively, but 4 months later came in complaining of a red eye. The patient reported symptom onset about 3 weeks after his first dose of the COVID-19 vaccine. Given his history, Dr. Chan was more aggressive and added oral steroids as well as topical. He was on prednisolone and cyclosporine, and BCVA was 20/40. Dr. Chan increased topical steroids, which resolved the symptoms. Her second case was that of a keratolimbal allograft rejection in a 73-year-old patient who had been stable for the last 6 years. There had been a lot of work done with this patient’s eye to reconstruct it because he had stem cell disease. He had undergone keratolimbal allograft, stem cell transplant from a deceased donor. Then he had a penetrating keratoplasty and cataract surgery. The patient had total limbal stem cell deficiency (LSCD) from a chemical injury before treatment. He had baseline UCVA 20/60 and was on cyclosporine, dorzolamide/timolol, brimonidine, prednisone, and oral tacrolimus. He was doing great, Dr. Chan said, but came in 3 weeks after the first dose of his vaccine and had engorged vessels in each of the keratolimbal segments. Dr. Chan had to be very aggressive and stepped up topical steroids and systemic immunosuppression. The patient refused to take oral prednisone due to a fear of steroids, making him further immunosuppressed. Her third case was that of an 81-year-old female with HSV immune keratitis flare and LSCD progression. She had stable BCVA 20/50 for 5 years. She received dose two of the vaccine 2 weeks prior to complaints of a red eye and decreased vision. She presented with counting fingers, AC 1+ cells, corneal edema, and active haze. Dr. Chan said the cornea was severely inflamed, so she bumped up topical steroid and oral antivirals. A month later, the corneal swelling had cleared, but her LSCD progressed further. Whorl-like late staining passed beyond the pupil, and vision was decreased permanently. But Dr. Chan noted that her other eye was good, so the patient didn’t want anything done. The final case Dr. Chan shared was that of a 54-year-old male who was stable with medically managed Crohn’s disease. He had recent shingles immune stromal keratitis 3 months prior and was on valacyclovir and loteprednol. He was still somewhat immunocompromised but was stable. The patient complained of pain, redness, tearing, and blurry vision OD 2 weeks after getting the vaccine. He had a flare-up of shingles immune corneal keratitis. Dr. Chan stepped up his steroid, and a week later, the corneal edema had unusual dendritic-like epithelial lesions. Given the history of cold sores, she thought it was a herpes simplex complication or zoster. Dr. Chan had to balance the topical steroid with oral antiviral continued on page 39
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