1 EyeWorld Asia-Pacific | June 2025 BUILDING BLOCKS FOR SURGICAL PRACTICE Vol. 21 No. 2 June 2025 The Asia-Pacific Association of Cataract and Refractive Surgeons Scan the QR Code or visit www.eyeworldap.apacrs.org for more information. PLUS Binkhorst Lecture, presented at the 2025 ASCRS Meeting in Los Angeles: Hydro Chronicles Practical Focus: Better Tools, Tough Cases And New Frontiers In Surgical Precision
2 EyeWorld Asia-Pacific | June 2025 SPONSOR AD . ™ IOL, ATTAIN PEACE OF MIND with TECNIS PureSee the new purely refractive presbyopia-correcting EDOF IOL.1 TECNIS PureSee™ IOL with continuous-power technology1 provides better predictable patient outcomes2-5, ensuring high patient satisfaction6 and peace of mind for you Find out more with a J&J representative. References: 1. TECNIS PureSee™ IOL, Model ZEN00V DFU INT, Z311973, current revision. 2. DOF2023CT4011 - Simultions of visual symptoms under defocus for TECNIS PureSee™ IOL. 29 March 2023. 3. DOF2023CT4041 - Clinical investigation of the TECNIS™ IOL, C1V000 and C2V000 Tolerance to Refractive Error. 17 July 2023. 4. Black D. et al. Clinical investigation of tolerance to residual refractive errors following implantation with a refractive extended-depth-of-focus (EDF) IOL. Abstract ESCRS 2023. REF2023CT4129. 5. Bala C, et al. Superior intermediate and uncompromised distance quality of vision with a purely refractive extended depth of focus IOL. Abstract ESCRS Vienna 2023. REF2023CT4128. 6. DOF2023CT4043 - Clinical investigation of the TECNIS™ IOL C1V000 and C2V000. Patient Satisfaction Outcomes 18 July 2023. Australia: AMO Australia Pty Ltd, 1–5 Khartoum Road, North Ryde, NSW 2113, Australia. New Zealand: AMO Australia Pty. Ltd 507 Mount Wellington Hwy, Mount Wellington, Auckland 1060, New Zealand. © Johnson & Johnson Surgical Inc. 2024, 2024PP05503.
3 EyeWorld Asia-Pacific | June 2025 CONTENT GLAUCOMA 37 Identifying And Handling Steroid-Induced Glaucoma 41 Pseudoexfoliation Glaucoma: Management And Considerations For Ocular Procedures CATARACT 10 The Conundrum Of Prolonged Post-Cataract Corneal Edema 14 Digital Tools For Surgical Training 18 The Iris Prolapsed —Don’t Panic EDITORIAL 4Building Blocks For Surgical Practice FEATURE 6Hydro Chronicles Binkhorst Lecture, presented at the 2025 ASCRS Meeting in Los Angeles CORNEA 26 Brightmem Corneal Allograft: A New Treatment For Ocular Surface Disease 30 Handling Opacified Corneas When Cataract Surgery Is Needed 34 Tarsorrhaphy: The Cornea’s Best Friend SURGICAL OUTCOMES 24 Patient-Reported Outcome Measures: A Must-Have For ‘Solid, Consistent Medicine’ 20 Enhancement Rates:What’s Acceptable And Expected?
4 EyeWorld Asia-Pacific | June 2025 Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific • China • Korea • India EDITORIAL BOARD Chief Medical Editor Graham Barrett, MD INDIAN EDITION Regional Managing Editor Abhay Vasavada, MD Deputy Regional Editor S. Natarajan, MD KOREAN EDITION Regional Managing Editor Hungwon Tchah, MD Deputy Regional Editor Chul Young Choi, MD CHINESE EDITION Regional Managing Editor Yao Ke, MD Deputy Regional Editor He Shouzhi, MD Zhao Jialiang, MD Assistant Editors Zhouqi, MD Shentu Xingchao, MD EDITORIAL MEMBERS 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 PUBLISHING TEAM Chief Publisher Ronald Yeoh, MD Executive Director Kathy Chen kathy.chen@apacrs.org Publishing Consultant Donald R Long don@apacrs.org Production Team Gretel Tan Aileen Bian ewap@apacrs.org EDITORIAL Dear Friends, There are many articles of interest in the June issue of our Journal. Refining our surgical technique is a critical “building block,” and understanding the reasons for unexpected findings postoperatively is equally important. In the first category, I would like to highlight “Hydro Chronicles,” a summary of the Binkhorst Lecture, presented by Dr. Ron Yeoh at ASCRS in April this year. This is notable because Ron has carefully analysed hydrodissection—one of the most critical parts of the phaco procedure—and his observations contain insights and tips that should benefit all cataract surgeons. I had the opportunity to attend Ron’s excellent lecture in Los Angeles and, besides its scientific merit, it was a great pleasure to see one of our own leaders in the Asia Pacific region recognized internationally for his teaching and contributions over many years. Building Blocks For Surgical Practice 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: EyeWorld Asia-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. Advertising Office: EyeWorld Asia-Pacific Edition: Asia-Pacific Association of Cataract & Refractive Surgeons (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) MDDI (P) 013/02/2025
5 EyeWorld Asia-Pacific | June 2025 In the second category, unexpected prolonged postoperative corneal edema is always concerning, and a systematic approach—as outlined in the article focusing on prevention, diagnosis, and treatment—is required. It is surprising how a small fragment of nucleus in the angle can result in extensive endothelial loss over a few weeks. Early removal within the first few days can prevent endothelial decompensation and underscores the importance of surgeon review in the immediate postoperative period. TASS can also present as unexplained corneal oedema postoperatively, and its treatment should be limited to medications with proven benefit or those required in specific situations. Although endothelial cell counts pre- and post-op are often not recorded, I routinely perform this in my practice. Monitoring endothelial cell loss is a useful parameter for benchmarking surgical technique. The mean endothelial cell loss, expressed as a percentage in the last 435 eyes I operated on, was 5.4%—which falls at the lower end of the expected range for modern phacoemulsification. I hope you find the “building blocks” discussed in this issue helpful for your own surgical practice. Warmest regards, Graham Barrett LEARNING FROM THE MASTERS IMPORTANT DATES apacrs2025.org Dada Harir Stepwell in Ahmedabad, India 21 JULY 2025 Deadline for 2nd Tier Registration Rates • 22 JULY 2025 ONWARDS On-site Registration Rates Apply • Onsite registration commences on 20 August 2025, Wednesday from 14:00hrs Gate 7, Ground Floor, Registration Area, Mahatma Mandir Convention and Exhibition Centre (MMCEC) Sector 13 C, Gandhinagar 382017, Gujarat India
6 EyeWorld Asia-Pacific | June 2025 FEATURE Binkhorst Lecture, presented at the 2025 ASCRS Meeting in Los Angeles by Ronald Yeoh, MD This article is based on the Binkhorst Medal lecture titled “Hydro Chronicles” which I presented at the April 2025 ASCRS Meeting in Los Angeles, USA. My interest and love affair with hydrodissection started in 1993 when I was a young and inexperienced phaco surgeon. I had been dissatisfied with my hydrodissection technique and thought that hydrodissection through the side port would be more efficient as the anterior chamber would be more watertight. Unfortunately, as I hydrodissected through the side port, the pupil abruptly constricted and this was followed shortly by the nucleus tilting and descending into the vitreous cavity. I managed to retrieve the nucleus using a Vectis and after an anterior vitrectomy was able to implant a three-piece IOL into the sulcus. What I had witnessed was the “pupil snap” sign of hydrorupture of the posterior capsule, and I published this in the BJO in 19951. The “pupil snap” sign occurs when excessive force is used during hydrodissection and the fluid that is injected ruptures the posterior capsule instead of going all the way around the nucleus to the other side. (Fig 1) As the posterior Fig 1: Hydrorupture of the posterior capsule. Source: Ronald Yeoh, MD Fig 2: The nucleus lift sign. Source: Ronald Yeoh, MD Fig 3. Golden rings of hydrodelamination. Source: Ronald Yeoh, MD Hydro Chronicles capsule ruptures, the nucleus abruptly descends away from the iris and this posterior movement triggers the pupil to constrict. Recognition of the “pupil snap” sign is important because steps can be taken to do “slow motion” phaco at lowered parameters which reduces the risk of a nucleus drop or at the very least, the surgeon is prepared with vitreo-retinal backup. If there is one good thing about a hydrorupture of the posterior capsule, it is that the anterior capsular rim is usually unaffected and a three-piece IOL is easily inserted into the sulcus. Tip: Avoid hydrodissection through the side port. This complication stimulated my interest in hydrodissection and hydrodelamination and over the past 30 years, I have studied and analyzed these maneuvers carefully. Standard Hydrodissection Hydrodissection to free the nucleus is the cornerstone of most nuclear removal techniques in phaco. Every cataract surgeon is aware that the occurrence and sighting of the
7 EyeWorld Asia-Pacific | June 2025 FEATURE Fig 4: Lollipopping of small soft nucleus after hydrodelamination. Source: Ronald Yeoh, MD Fig 5: Layer of cortex after failed CCH. Source: Ronald Yeoh, MD fluid wave indicates good hydrodissection. However, we also know that the fluid wave is not seen in every case. So how then are we to know that hydrodissection is adequate? I teach my residents that there are 3 cardinal signs of adequate hydrodissection: 1. Fluid wave 2. Nucleus lift (Fig 2). This is a particularly useful sign! 3. Nucleus prolapse happens if excessive force is used; in this situation, either the posterior capsule ruptures with the snap sign or the nucleus prolapses out of the bag (if you’re lucky)! Whilst the nucleus lifting can often be seen down the microscope, it can be subtle and so three subsidiary signs are useful: 1. Dilation of the capsulorhexis (not so easily seen) and pupil (usually easily seen). 2. Cortical splitting in front of the nucleus. As the nucleus moves forwards, the overlying cortex can be seen to split apart. 3. Push-back sign. When the nucleus is lifted forward, pushing it back into the bag often results in a brisk pop as the nucleus goes back into the bag. This confirms the nucleus lift. The three main and three subsidiary signs of hydrodissection are most reliable and if they are seen, it is almost certain that hydrodissection freeing the nucleus has been achieved. In such cases, I find that rotating the nucleus is unnecessary. Tip: When hydrodissecting, I encourage my residents to hydrodissect to the right and left of the nucleus and avoid the area opposite the main incision. The reason is that when hydrodissecting opposite the main incision, the cannula may rest on top of the nucleus and prevent it from from lifting. Hydrodelamination Hydrodelamination is the perinuclear injection of fluid to isolate and free a small soft nucleus and is well typified by the appearance of a golden ring. (Fig 3) We typically do hydrodelamination in patients with a posterior polar cataract or in those with a soft, ambiguous nucleus. In polar cataracts, hydrodelamination reduces the risk of the fluid bursting through adjacent to the polar opacity. For soft cataracts typically in patients around 50 years old with mild nuclear sclerosis—successful hydrodelamination with golden rings usually means that I can “lollipop” the small nucleus onto my phaco tip, and it is then easily removed. (Fig 4) Care must be taken to remove the epinuclear shell that is left behind. Intraoperative OCT The introduction of intraoperative OCT (iOCT) on the operating microscope was a great help in studying and understanding the mechanics and fluidics of hydro maneuvers during phacoemulsification. It is worth noting that iOCT was initially designed and planned as imaging aids for lamellar corneal and macula surgery; not for phacoemulsification of cataracts. The use of iOCT was a significant development in helping us understand where the hydrodissection fluid planes were. I started exploring the application of iOCT in cataract surgery and scrutinized where the fluid waves went when we were doing hydrodissection and hydrodelamination. In hydrodelamination, it became very clear that the golden rings were caused by fluid in the perinuclear epinucleus, and there could be one or multiple rings present. (Fig 3). In hydrodissection, the dynamic studies showed that despite injecting fluid subcapsularly, the fluid wave was almost always at a level deeper than the lens capsule with a layer of lens cortex between the fluid and the posterior capsule. This finding becomes relevant in the next section.
8 EyeWorld Asia-Pacific | June 2025 FEATURE Cortical Cleaving Hydrodissection 30 years ago, the well known American cataract surgeon Howard Fine proposed the concept of Cortical Cleaving Hydrodissection (CCH) in which precise placement of the hydrodissection cannula under the anterior capsular rim resulted in hydrodissection cleaving a plane under the capsule that completely separates the cortex, epinucleus, and nucleus2. This meant that after removal of the nucleus, an empty bag was left behind, eliminating the need for irrigation/aspiration of the residual cortex! This was a very attractive concept indeed. Unfortunately it was not easy to achieve perfect CCH. Over the years, despite my trying to do so in every case, I was almost always left with a significant amount of residual lens cortex requiring irrigation/aspiration. It puzzled me as to why this was so. My analysis of the fluid wave location after attempted cortical cleaving hydrodissection showed that in almost every case, there was lens cortex left adjacent to the lens capsule; i.e., the CCH had failed (Fig 5). The fluid wave in nearly all cases found a deeper plane than intended. I hypothesize that this is related to corticocapsular adhesions, which prevent the fluid wave from separating the cortex from the capsule and instead direct it into the cortical layer3. These same adhesions also likely contribute to the variable force needed to hydrodissect and hence occasional intraoperative capsular block and hydrorupture. In an effort to determine if the failure was simply due to poor surgical technique on my part, I surveyed 20 internationally renowned cataract surgeons about whether they were able to achieve CCH always, frequently, occasionally, rarely or never. 90% answered “rarely” or “never” (as I found), and only two said they achieved it regularly! Other Complications Of Hydrodissection Another complication of hydrodissection is what I termed the pseudoexpulsive haemorrhage syndrome4. There is a scenario during hydrodissection in which the eyeball becomes rock hard, the anterior chamber shallows and the iris prolapses—simulating an expulsive haemorrhage. It becomes impossible to continue phacoemulsification. In this situation, fluid has loculated and become trapped behind the nucleus, but hydrodissection remains incomplete. This raises intraocular pressure, leading to the above signs. It is important to look for the red reflex as this helps distinguish this syndrome from a true expulsive haemorrhage in which case the red reflex would be lost. The management of this capsular block-related pseudoexpulsive syndrome is to insert a cyclodialysis spatula in front of the nucleus and ballot it several times, or simply press on the nucleus. Merely venting the anterior chamber is inadequate, as the fluid remains trapped. Balloting or pressing on the nucleus helps squeeze the fluid around it, completing hydrodissection and relieving the block. Typically, within a minute or two, the eye softens, the anterior chamber reforms, and surgery can be resumed. Relevance Of Hydrodissection Today As a technique that has been around for more than 30 years, is hydrodissection still relevant to the cataract surgeon today? The answer is… never more so!
9 EyeWorld Asia-Pacific | June 2025 About the Physician Ronald Yeoh, MD | Consultant Eye Surgeon & Medical Director, Eye & Retina Surgeons | Clinical Associate Professor, Duke-NUS Grad Med School, Singapore National Eye Centre | ry@ers.clinic Relevant Disclosures Yeoh: None References 1. Yeoh R. The ‘pupil snap’ sign of posterior capsule rupture with hydrodissection in phacoemulsification. Br J Ophthalmol; 1996 May;80(5):486 2. I Howard Fine. Cortical cleaving hydrodissection. J Cataract Refract Surg. Volume 18, Issue 5, September 1992, Pages 508-512 3. AR Vasavada, D Goyal, L Shastri, R Singh. Corticocapsular adhesions and their effect during cataract surgery. J Cataract Refract Surg. 2003; 29: 309-314 4. R Yeoh, J Theng. Capsular block syndrome and pseudoexpulsive haemorrhage. J Cataract Refract Surg. 2000 Jul;26(7):1082-4 5. Roberts TV, Sutton G, Lawless MA, Shveta JB,Hodge C. Capsular block syndrome associated with femtosecond laser assisted cataract surgery. J Cataract Refract Surg. 2011; 37:2068-2070 6. Yeoh R. Hydrorupture of the posterior capsule in femtolaser cataract surgery. J Cataract Refract Surg. 2012; 38:730 7. Chang, David F.; Campbell, John R. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg; 31(4):664-673, April 2005 8. Ishtiaque A, Rahman Sharah. Sleeve hydrodissection: An innovative hydrodissection technique for IFIS. Submitted to JCRO 9. Osher R. Yeoh R. Riding the hydrodissection wave. J Cataract Refract Surg. 49(7):657-658, July 2023 1. Femtosecond laser assisted cataract surgery (FLACS) In the last decade or so, there have been proponents and detractors of FLACS in cataract surgery. In a very early case report, Roberts et al. described two cases of dropped nuclei during FLACS5. In subsequent correspondence and discussion, it became apparent that the dropped nuclei were related to performing “normal” hydrodissection after the femtosecond laser had been applied6. Gas bubbles produced during laser fragmentation of the nucleus increase intralenticular pressure. It is hypothesized that adding hydrodissection fluid into this pressurized space raises the pressure further, potentially rupturing the posterior capsule. Today, we aim to use less laser energy to reduce gas production and recognize the importance of allowing gas to escape from behind the nucleus before hydrodissecting. Some surgeons omit the hydrodissection step entirely in FLACS cases. 2. Pre-existing posterior capsular weakness or tears The example par excellence is of course the posterior polar cataract in which we have long known that we should not hydrodissect, but should hydrodelaminate instead to avoid the fluid wave bursting through a weaked posterior pole of the lens. Hydrodelamination is of course at a deeper plane, further from the posterior polar element. Today however, there are several other clinical scenarios in which the posterior capsule may already be ruptured pre-operatively. These include patients with: - Needlestick or other injuries - Prior intravitreal injections - Subretinal fluid drainage during scleral buckling - Iatrogenic lens touch during vitrectomy - YAG laser vitreolysis (Fig 5) The common factor in all these conditions is that the patient develops a significant cataract rapidly within hours or days of the offending iatrogenic procedure. This clinical scenario should alert the surgeon to the possibility of a pre-existing capsular defect, in which case hydrodissection should be performed with great caution, if at all. 3. Idiopathic Floppy Iris Syndrome (IFIS) We recognize the triad of iris behaviour in IFIS during cataract surgery: - A billowing, floppy iris - Progressive intraoperative miosis - Significant iris prolapse7. Clearly, hydrodissection in a patient with IFIS may aggravate the tendency to iris prolapse—bearing in mind that even in non-IFIS eyes, inexperienced surgeons may still encounter this complication. Ahmed et al proposed an interesting technique to reduce the risk of intraoperative iris prolapse in IFIS patients: performing hydrodissection with a phaco sleeve placed over the hydrodissection cannula. The sleeve sits in the main incision and tamponades the iris while also providing a venting pathway for hydrodissection fluid accumulating in the eye8. This allows the fluid to bypass the iris. Conclusion So we have come full circle— re-examining hydro maneuvers in a new light, aided by new technology. Today, hydrodissection remains as relevant as ever9. I hope the oft-neglected step of hydrodissection will now be viewed with renewed appreciation.
10 EyeWorld Asia-Pacific | June 2025 CATARACT Some degree of corneal edema following cataract surgery—or any intraocular procedure—is expected. Saba Al-Hashimi, MD, noted that swelling persisting up to 2 weeks postoperatively is typical in the context of cataract surgery. However, when recovery extends to a month or longer, new concerns begin to surface in the surgeon’s mind, prompting a shift in clinical approach: Did I miss Fuchs dystrophy? Is this a Descemet’s separation? Was excessive phacoemulsification energy applied? What should I do next? by Liz Hillman, Editorial Co-Director The Conundrum Of Prolonged Post-Cataract Corneal Edema Preop contributors Several risk factors may predispose patients to prolonged corneal edema following cataract surgery. One example is Fuchs dystrophy—with or without visible guttae. She also noted that a history of herpes simplex virus (HSV) infection could be a contributing factor. “If patients have a known disease, we can counsel them: ‘There is a decrease in the health or number of endothelial cells in your cornea. These are the cells that pump out water from the cornea and help keep it clear. (…) We expect some corneal swelling normally, but you may have more because of this,’” said Himani Goyal, MD. “Without routinely performing specular microscopy preoperatively, low endothelial cell counts—particularly in the absence of guttae—can be easily missed,” added Dr. Al-Hashimi. “However, if the first eye experiences more corneal edema than expected, it may be prudent to perform specular microscopy before proceeding with surgery on the second eye.” Other risk factors, according to Dr. Chan, Dr. Al-Hashimi, and Dr. Goyal, include dense arcus (which may increase the risk of retained nuclear fragments), small pupils (potentially requiring expansion devices and intraocular manipulation), dense cataracts (which often necessitate higher phaco energy), narrow angles, shorter anterior chamber depth (which brings instruments closer to the endothelium during surgery), and advanced age (which may predispose to Descemet’s membrane detachment). Dr. Goyal pointed out that patients with shallow chambers or underlying endothelial disease may be more susceptible to iatrogenic Descemet’s membrane tears. These tears, she said, are common in the area of the main wound. They often flap back up and are of no consequence, but when present, they can contribute to prolonged edema.
11 EyeWorld Asia-Pacific | June 2025 CATARACT Prevention While anatomical factors such as small eyes or dense lenses cannot be altered, Saba Al-Hashimi, MD, emphasized that certain protective strategies can help mitigate postoperative edema. These include the use of a dispersive viscoelastic and maintaining the phaco tip near the iris plane. “Additionally, the use of a femtosecond laser can help fragment the nucleus, and chopping techniques can also be used to reduce the cumulative dissipated energy from the phaco tip, which can also reduce the chances of developing edema,” he said. Dr. Al-Hashimi outlined several practical strategies: • For very dense cataracts, replenish with OVD multiple times during surgery • Aspirate any hyperthermic OVD over the cataract prior to applying high phaco energy during sculpting • Construct wounds carefully to avoid jagged internal main wounds, which elevate the risk of Descemet’s detachment • Ensure adequate fluidics by optimizing phaco machine settings and avoiding crimping of the phaco needle sleeve • Angle the phaco tip downward and keep the eye parallel to the ground • Pause before IOL insertion to confirm lens selection • Avoid posterior capsule rupture (PCR) by refraining from over-hydrating dense lenses • Hydrate wounds gently and maintain physiologic intraocular pressure IOP to reduce Descemet’s detachment risk “Longer operating times are associated with corneal edema.” Dr. Al-Hashimi said. “When a case is complicated or the cataract is particularly challenging, the likelihood of postoperative edema rises. Intraoperatively, using a dispersive viscoelastic—and replenishing it when needed— helps protect the endothelium. If bubbles in the anterior chamber appear mobile rather than fixed, this may indicate that the dispersive viscoelastic is no longer present in adequate quantity—serving as a cue to pause and replenish, especially in high-risk patients.” In smaller chambers, Dr. Goyal said to consider doing a pars plana vitrectomy to help deepen the chamber—if the surgeon is comfortable with the technique—or using preoperative mannitol to reduce vitreous volume. “Part of the reason pseudophakic bullous keratopathy has become less common is that our phaco machines and surgical techniques have become more efficient, making our surgeries shorter and requiring less energy.” Dr. Goyal said. “A key advancement in phaco systems is the ability to adjust intraoperative IOP. Normally, I operate at physiologic eye pressure, but if I need to deepen the chamber, I can raise the IOP. While higher IOP can disturb dispersive viscoelastic, keeping the irrigation ports angled laterally and ensuring the wound is sealed around the phaco sleeve helps minimize this disturbance.” Dr. Goyal said she also thinks there is value in using a smaller than standard speculum for patients with deepset or smaller eyes. Improved patient comfort may reduce surgical duration and the associated risk of postoperative edema. Patient was referred for persistent corneal edema following an uncomplicated cataract surgery; at the initial visit (3 weeks postoperative), vision was count fingers (CF), with a superior, welldemarcated area of corneal edema. Air bubble was placed using a 30-gauge needle at the slit lamp. Slit beam examination revealed a detached Descemet’s membrane. Complete resolution of Descemet’s membrane detachment was observed 1 week later, with visual acuity improving to 20/30. Source (all): Himani Goyal, MD
12 EyeWorld Asia-Pacific | June 2025 CATARACT Diagnosis Dr. Chan said, anterior segment OCT is particularly useful in diagnosing a Descemet’s membrane detachment or retained lens fragment as the cause for prolonged corneal edema. Dr. Al-Hashimi added that pachymetry can confirm the presence of edema, but emphasized the importance of keeping toxic anterior segment syndrome (TASS) in the differential diagnosis, especially when there is significant corneal edema accompanied by marked anterior chamber inflammation early in the postoperative period. Dr. Goyal explained that corneal edema is readily apparent when Descemet’s folds and stromal clouding are present. However, once these folds resolve, reviewing preoperative data and comparing it to postoperative topography or pachymetry can help determine if persistent edema remains. Treatment Once it’s clear the edema is not resolving, Dr. Al-Hashimi offered a simple but reassuring first step: “Don’t panic.” “Corneal edema often resolves with time. Using a more frequent topical steroid regimen may help speed up recovery. It can take several weeks for complete resolution. Serial pachymetry is helpful in monitoring progress, offering objective reassurance to patients—even when their vision seems unchanged initially,” he said. “If no improvement is seen after 4 weeks,there is a high probability the patient will ultimately need an endothelial keratoplasty. Sodium chloride ophthalmic solution drops or ointment may help, but this typically is only useful when there is epithelial edema.” Dr. Chan said treatment of the edema depends on its etiology and whether there was any pre-existing endothelial compromise or disease present. “If a retained nuclear cataract piece is removed within a week to a month, the cornea, if otherwise healthy, can typically clear up in 1–4 weeks,” she said. “If a Descemet’s membrane detachment is rebubbled within 1 to 3 weeks, corneal clarity can usually be restored. However, beyond 1 month, the membrane may fibrose and lose the ability to conform to the stroma, necessitating DMEK. A history of HSV endothelial disease and/or iritis may also cause the endothelial cells to be dysfunctional or deficient, leading to a greater risk of prolonged corneal edema after cataract surgery, especially if other intraoperative risk factors are not mitigated.” Dr. Goyal said intervention becomes necessary when edema persists beyond 1 month. She starts treatment with sodium chloride drops or ointment. If this does not help, she would consider a rho-kinase (ROCK) inhibitor, which she said “can help our endothelial cells function at their best and are low risk.” If a ROCK inhibitor is going to help, it would improve within a few days to weeks. If improvement does not occur within a few days to weeks, she then considers endothelial keratoplasty (DMEK), though she hopes future options will include endothelial cell therapy. Dr. Al-Hashimi warned that long-standing edema, especially with bullae and microcystic changes, can result in subepithelial scarring that limits vision—even after a successful endothelial keratoplasty. “It is best to address unresolved edema surgically within a few months to prevent permanent scarring,” he said. Dr. Chan added that patients may experience significant discomfort from ruptured bullae or a persistent foreign body sensation due to microcystic edema. She emphasized the importance of a thorough postoperative evaluation for corneal edema following cataract surgery. “Always assess for Descemet’s membrane detachment or retained nucleus piece as well because managing these problems as soon as possible can successfully reverse postoperative corneal edema.” About the Physicians Saba Al-Hashimi, MD | Associate Professor of Ophthalmology, University of California, Los Angeles, Los Angeles, California | alhashimi@jsei.ucla.edu Clara Chan, MD | Associate Professor of Ophthalmology, University of Toronto, Toronto, Canada | clarachanmd@gmail.com Himani Goyal, MD | Clinical Associate Professor, NYU Langone Health New York, New York | himani.goyal.md@gmail.com Relevant Disclosures Al-Hashimi: None Chan: Théa Goyal: Alcon This article originally appeared in the March 2025 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
13 EyeWorld Asia-Pacific | June 2025 CATARACT OCULUS KERATOGRAPH 5M Optimize Cataract & Refractive Outcomes with Targeted Pre-op Dry Eye Treatments Ensure the best results for your patients with the OCULUS Keratograph 5M Ocular surface disease – such as dry eye – is a leading cause of refractive surprises and IOL exchanges. So, tear film analysis is essential prior to surgery. Use the OCULUS Keratograph 5M‘s comprehensive tool set to make the best possible decision for your patients. Find out more on our website Fast Screening within a few minutes, performed by your staff Safe Make a reliable surgical decision Simple Easy to understand results with traffic light colors The availability of products and features may vary by country. OCULUS reserves the right to change product specifications and design. OCULUS Asia Ltd. Hong Kong www.pentacam.com • info@oculus.hk
14 EyeWorld Asia-Pacific | June 2025 CATARACT The landscape of surgical training is evolving at an unprecedented pace. While in-person residency remains a critical foundation for skill development, the rise of digital tools has expanded the way ophthalmologists learn and refine surgical techniques. Social media and online platforms have broadened access to education, bringing world-class instruction within reach for surgeons everywhere. Advanced simulation tools, virtual reality operating rooms, and artificial intelligence (AI) are redefining how trainees gain experience and confidence. With a blend of traditional and virtual methods, the next generation of ophthalmologists can now access comprehensive, immersive training opportunities that were once beyond reach. As a surgeon, I rely heavily on the foundation I obtained during my residency and fellowship training. Yet, I continue to grow and evolve by learning from other skilled surgeons online, exploring innovative techniques, and staying current with the latest advancements in our field. —Ashraf Ahmad, MD, YES Connect Guest Editor by Ellen Stodola, Editorial Co-Director Digital Tools For Surgical Training New tools in surgical training are continually enhancing teaching methods. In this YES Connect column, several physicians discussed digital tools for surgical training and how these integrate with more traditional training approaches. “Surgical training is experiencing a transformation,” said Omar Krad, MD. “While residency remains the cornerstone, the landscape is expanding beyond traditional programs to publicly accessible platforms like YouTube and Instagram. The internet has democratized higher education, making specialized surgical skills more accessible than ever before,” he said. “Previously, aspiring surgeons often had to travel long distances, even internationally, for advanced training. Today, the internet has effectively placed the world’s expertise into a single, global classroom, transforming how surgeons learn and develop their craft.” A porcine eye prepared for cataract surgery simulation. Source: Anthony Chung, MD Simulated placement of a capsular tension hook in a Kitaro artificial eye. Source: Anthony Chung, MD
15 EyeWorld Asia-Pacific | June 2025 CATARACT He added that although the necessary technology has been available for years, its impact on surgical training was initially limited by a scarcity of online content. “Fortunately, this landscape is shifting dramatically,” he said. “An increasing number of surgeons are now using online platforms to share educational materials, enriching the learning experience for their peers.” Anthony Chung, MD, said there are a number of simulation tools available in ophthalmology. He noted the Eyesi (Haag-Streit). “We’ve integrated these types of technologies thoroughly in the field,” he said. Since Dr. Chung has been in practice, he said that the recent trend has been to increase immersion by using virtual reality headsets to create a 3D world that you’re sitting in virtually. “I trained at a time when this had become commonplace for residents to have virtual reality,” Dr. Chung said. He noted that the extent to which these tools are integrated varies widely between programs, but he added that many programs have these simulators as part of the curriculum to gain experience. Jaclyn Haugsdal, MD, also noted some of the available virtual simulators. She mentioned that the Eyesi has been around the longest, and there are newer simulators being developed, such as those from HelpMeSee, Fidelis (Alcon), and FundamentalVR. Some of these are manual small incision cataract simulators, such as HelpMeSee and FundamentalVR, whereas Eyesi and the Fidelis are more focused on phacoemulsification simulation. One of the best features of virtual simulators is their capacity for repetition, Dr. Haugsdal said. “They usually are easy to set up and clean up, and it’s easy to get in many repetitions in a short timeframe without using additional resources or supplies. For beginners, the simulators provide realistic enough feel to help develop the basics of surgical techniques. With the benefit of easy repetition, they can be an excellent resource.” Simulators are also great at teaching hand positioning, moving in the eye, and maintaining centration. Dr. Krad said that in-person residency training is essential for establishing a strong foundation in ophthalmology. “However, my attendings emphasized the importance of lifelong learning, noting that many procedures they currently perform weren’t part of their own residency training,” he said. “While a solid foundation is crucial, digital tools can be incredibly effective for skill development postresidency. Without that strong initial foundation, though, there’s an increased risk of misinterpreting online content, potentially hindering one’s growth.” Dr. Krad said the journey to becoming a proficient surgeon involves building procedural familiarity, developing muscle memory, and gaining confidence. Each repetition, whether in a wet lab, online, or in a virtual environment, helps to reduce a trainee’s anxiety and bolster their confidence, ultimately leading to improved performance under pressure, he said. “A well-rounded training strategy that incorporates multiple modalities is essential for supporting the growth of future surgeons.” Dr. Chung said that digital tools like this are more of a self-directed learning option. “Because it’s self-directed, it can be like a video game,” he said. “You learn on your own and learn how to play the system, but whether or not that system is creating good habits for surgery is another thing.” He said that using these simulators also requires proper guidance when you’re first learning to ensure you’re using the right techniques. Speaking about the pros and cons of virtual simulators vs. traditional simulation, Dr. Haugsdal again mentioned that virtual simulators are easy to set up and clean and allow for repetition. They are also good at teaching hand positioning, moving in the eye, and maintaining centration. But they may come with cost or space limitations and could be missing a more realistic feel. A more traditional simulation approach (like with pig/cow eyes or with artificial eye models) could be more realistic and could use actual surgical equipment and instrumentation. But resources could be limited, making repetition difficult, and the use of biological material requires proper handling and cleaning. Many surgical simulators focus on cataracts, but Dr. Chung added that some have vitreoretinal modules on them, too. While these are unique ways to learn, Dr. Chung also believes in the combination of both virtual and traditional learning methods working together. “You need to be in front of patients and learning from the patients while doing your due diligence and practicing outside the OR,” he said. “I think all of these simulation techniques out there are supplemental to the traditional method of operating with the attending.” Anecdotally, Dr. Chung said he will often tell residents that the motion they use when performing the procedure is not terribly different from what he uses, but the difference he notices is in the pacing between each movement. Dr. Chung added that the wet lab is a passion of his, and he hopes there comes a time when wet lab curriculum is more standardized among programs. This will help define
16 EyeWorld Asia-Pacific | June 2025 CATARACT the progression and integration of these tools within the broader training framework, he said. When commenting on whether virtual training options could grow to replace traditional ophthalmic training, Dr. Krad again stressed that traditional in-person training is crucial for establishing a solid foundation in surgery. “Without this foundational training, the effectiveness of virtual learning is significantly diminished. Only with a strong foundation can one fully leverage the benefits of virtual training resources,” he said. The rapid growth in virtual and augmented reality technologies holds immense potential for surgical training and collaboration, Dr. Krad continued. “These advancements could enable trainees and practicing physicians worldwide to participate remotely in training sessions, experiencing them as if they were physically present. Imagine being able to virtually assist in any surgery from your home office. During a lunch break, for instance, one could virtually scrub in and observe a retina, cataract, or cornea specialist through the assistant scope. Interactive features, such as live Q&A with the surgeon, could further enhance the learning experience. This technology has the potential to dramatically improve access to specialized surgical training, benefiting both ophthalmologists and patients worldwide.” Training programs equipped to provide top-tier surgical education have a unique opportunity to elevate the standard of care within their communities, Dr. Krad said. “By extending their educational resources virtually to practicing ophthalmologists, they can foster a culture of continuous learning and collaboration. The technology to livestream or post recordings of grand rounds and notable cases is readily available. Embracing this opportunity to share knowledge will ultimately translate to improved patient outcomes.” Dr. Haugsdal finds that these newer simulation options complement the more traditional training approach. “The virtual simulators and traditional simulation models each have their benefits,” she said. “The simulators may be better for introductory-level level education of a technique, whereas traditional approaches could be more helpful for advanced techniques.” She added that some newer technology that is in development is the use of AI to analyze recorded surgical videos to assist with surgical education. “This could be used to determine inefficiencies in surgery or track trends in surgical time of individual steps or whole surgeries, or even to compare trainee videos to expert videos to determine areas that deviate from expert level,” she said. “This technology could be used as an additional surgical teacher or mentor to help provide feedback to the trainee on their actual surgical videos.” In terms of new and future technologies and applications, Dr. Chung noted the quest to try to get more objective data from surgery itself. This will help to show the steps and where there’s room for improvement, he said, adding that AI and machine learning could play a role in evaluating such data going forward.
17 EyeWorld Asia-Pacific | June 2025 CATARACT About the Physicians Anthony Chung, MD | Assistant Professor, University of Washington School of Medicine, Seattle, Washington | atchung5@uw.edu Jaclyn Haugsdal, MD | Clinical Assistant Professor, University of Iowa, Coralville, Iowa | jaclyn-haugsdal@uiowa.edu Omar Krad, MD | Eye Associates of Orange County, Mission Viejo, California | omarkrad@gmail.com Relevant Disclosures Chung: None Haugsdal: None Krad: None This article originally appeared in the March 2025 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. ASIA-PACIFIC PERSPECTIVES This article by Drs Chung, Haugsdal, and Krad provides insightful perspectives on the dynamic evolution of ophthalmic surgical education, particularly over the last decade. I especially appreciated Dr Haugsdal’s emphasis on the complementary nature of simulation, be it virtual, dry lab, or otherwise, to traditional live surgical training. Access to modern simulation tools is important, but it is how these tools are integrated into structured, supervised learning that determines their true educational value. At the beginner level especially, supervision significantly enhances outcomes, although independent learning also has a place in well-designed programs. Since the work of Dr John Ferris and colleagues demonstrated a clear reduction in surgical complications through access to virtual reality training, there has been a global shift towards more systematic simulation-based learning. In Victoria, Australia, supervised and unsupervised virtual reality training has been mandated since 2018, with a national rollout following in 2023. Residents are now required to achieve proficiency in both virtual and wet lab environments before undertaking live surgery. This shift has demonstrably improved surgical preparedness. Importantly, simulation fidelity—how realistic a simulator is—has been shown to be less critical than the transferability of learned skills to live surgery. The focus must remain on attitude, mindset, core skill development and performance improvement, rather than fidelity. I was especially encouraged by the discussion around incorporating simulation into ongoing professional development. Simulation has proven valuable not only for Jacqueline BELTZ, BMedSci, MBBS, MSurgEd, FRANZCO Ophthalmologist, Melbourne, Australia 2/232 Victoria Parade East Melbourne jacquelinebeltz@mac.com beginners but also for practicing surgeons refining new techniques, preparing for complications, participating in complex procedural simulations or returning to surgery after a break. Dr Krad’s points on confidence building were especially resonant; these skills are closely tied to decisionmaking and performance under pressure—both of which benefit from targeted simulation. At our centre, the shift to structured simulation has changed our entire approach to early surgical training. Rather than working backwards from the end of the procedure, we now confidently start with capsulorhexis, enabling junior surgeons to safely complete more steps and build their skills faster and safely. This has led to more cases being allocated to early trainees, boosting surgical throughout and reducing wait times. Supervision remains essential, both in the lab and in theatre, but efficiencies have emerged. 1:4 supervision in the lab, compared to 1:1 in theatre, has allowed for more effective faculty resource allocation. I share the authors’ optimism. This is an exciting time for surgical education. More and more ophthalmologists are taking specific interest and/or higher degrees in surgical education. This is undoubtedly advancing the field at a much more rapid rate than we have previously seen. We should continue to encourage this and I look forward to seeing where this progress leads. Editors’ note: Dr. Jacqueline Beltz is a consultant for Alcon, and Johnson and Johnson, but has no financial interests related to the comments.
18 EyeWorld Asia-Pacific | June 2025 CATARACT by Ellen Stodola, Editorial Co-Director The Iris Prolapsed —Don’t Panic Regardless of surgical experience level, Richard Tipperman, MD, said iris prolapse is something that can occur to any surgeon occasionally. As such, knowledge of the risk factors that predispose a patient to iris prolapse, how to handle the event should it occur, and postop considerations are worth revisiting periodically. “There are a lot of different ways to manage it and mitigate it, but it is something that everyone will see on occasion, and one certainly needs to know how to manage,” Dr. Tipperman said. Predisposition And Prevention Both Dr. Tipperman and Beeran Meghpara, MD, cited intraoperative floppy iris syndrome (IFIS) as the most common risk factor for iris prolapse during cataract surgery. There are a number of medications that can cause IFIS, they both said, and other contributing factors include ocular anatomy and wound construction. Medications include most notably tamsulosin/alpha blockers, though Dr. Meghpara said other medications can contribute to IFIS. “The list keeps growing and growing,” Dr. Meghpara said of medications that can cause IFIS. “There are certain antipsychotic medications that do it, certain blood pressure medications that have been reported, certain blood thinners. When you’re in a busy cataract practice, it’s often hard to keep track of what the different medications are that a patient is taking that fall on this ever-expanding list.” Dr. Tipperman said that even if a patient is not currently on tamsulosin but had taken it in the past, it could still affect their iris. “Some patients could have been on tamsulosin 15 years ago for a month then stopped it. They forget that they were on it, but their iris will still act like they’ve been on it the entire time,” Dr. Tipperman said. “Some patients come in for cataract surgery and they’ve been on tamsulosin for some time, and they say, ‘Should I stop it for my surgery?’ but there is no benefit in stopping it. Some irises on tamsulosin behave completely normally, while others are very abnormal and prone to prolapse.” Dr. Tipperman said too shallow or too posterior of a phaco entry could entice iris prolapse, as could eyes with a smaller axial length or anterior chamber depth, according to Dr. Meghpara. “Even something as simple as a thin blue iris … if I see a thin or pale blue iris, that makes me worry a little bit,” he said. Dr. Meghpara said poor dilation can be an indicator for IFIS. “If they don’t dilate well, that is also something that will get your radar up,” he said. If you have a known IFIS case that could be at risk for iris prolapse, Dr. Meghpara said it’s important to dilate the patient as much as you can ahead of time. He said if he’s worried about proper dilation, he’ll increase the phenylephrine dose to as high as 10%. He also said the patient could be started on an atropine drop 1–3 days preoperatively to improve dilation. “There have been reports of using a topical NSAID 1–3 days before surgery that also suggest improved dilation. Just [try to] get as much dilation as you can ahead of time,” he advised. Maintaining that dilation intraoperatively can be achieved with intracameral injections of epinephrine or phenylephrine/ketorolac (Omidria, Rayner) in the irrigating solution. The latter, he said, is helpful if you have access to it from an insurance standpoint. Dr. Meghpara said it’s important with some of these cases to place incisions a little more anterior and make them a bit longer to position them farther from the limbus, reducing the risk of iris prolapse. Intraoperatively, Dr. Tipperman said overfilling with viscoelastic, overly aggressive hydrodissection, or even a speculum that’s putting too much pressure on the globe can lead to iris prolapse.
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