EyeWorld India March 2013 Issue

March 2013 58 EWAP NEWS & OPINION would follow the morphology of normal corneal tissue—with most media, cultivated cells grow chaotic and spindle shaped. M5 appears to be just the medium needed for the procedure, and now what’s needed is a carrier—a RAFT (real architecture for 3D tissue), made of plastic compressed collagen. Using cultivated endothelial cells for treating endothelial disease remains some years down the road, but with Dr. Mehta and his colleagues working on it, the future of endothelial keratoplasty is just over the horizon. Dr. Mehta delivered this year’s Nakajima Award Lecture in a symposium on “Current trends in posterior lamellar cornea surgery: A revolution in evolution.” Perspectives on difficult glaucoma The International Academy of Ophthalmology includes the world’s senior members of ophthalmologic academia and was established to promote academic ophthalmology and education. One of the strengths of the Academy is its ability to draw on experts from a variety of different subspecialties to offer their perspectives on issues on which the discourse might otherwise be confined to experts within a single specialization. This was exemplified by the Academy symposium on the management of difficult glaucoma. Glaucoma is an epidemiologically significant condition in the Asia-Pacific region, one that has wide-reaching effects on and associations with a variety of other ophthalmic conditions. One significant cause of secondary glaucoma is iridocorneal endothelial (ICE) syndrome. In this condition, secondary glaucoma develops when abnormal cells proliferate, crossing the Schwalbe’s line and covering the trabecular meshwork and obstructing the anterior chamber angles, said Dennis S.C. Lam, MD , Hong Kong, secretary-general of APAO. In addition, peripheral anterior synechiae can form. “On one hand, you have an open angle component,” he said. “On the other hand, you can actually have anatomical changes, making this a closed angle situation.” The treatment options are the same as for ordinary glaucoma, although because the ICE syndrome is progressive, most are only useful at the beginning. Trabeculectomy, for instance, is usually successful only initially, with failure occurring as early as six months after the first procedure, said Dr. Lam. Trabeculectomy fails not only because of the progressive nature of ICE, but because of the extensive fibrosis seen in these relatively young patients; there can be aggressive PAS. “Trabeculectomy will fail eventually,” said Dr. Lam. While medical management and other procedures are successful in the beginning, Dr. Lam said that some doctors “want to use drainage devices as their first line.” However, the tube is at risk for tip lumen obstruction by proliferating abnormal cells, and tube migration caused by this same proliferation or PAS formation can also occur. “If you are using this procedure, I think it is a good idea to communicate to your patient that this may occur and require further surgery,” said Dr. Lam. As a way of minimizing or circumventing this risk, Dr. Lam suggested using a longer tube shunt. In pseudophakes, the tube could be placed initially in the sulcus or pars plana—the latter case requiring full vitrectomy. Indian physician sees evolution of ophthalmology in India over long career When R. B. Jain, MD , Delhi, India, was 10 years old, he visited his maternal grandfather on holiday. His grandfather needed building materials for a house, so he asked Dr. Jain to go with him. His grandfather, a prominent, well-educated postmaster in his town in India, was 90% blind from glaucoma. He had to hold Dr. Jain’s hand, and Dr. Jain led him to the shop. Dr. Jain selected the best wood for his grandfather. He signed forms to ensure the wood was delivered. He was, in essence, his grandfather’s eyes, and the difficulty of the situation, and the unfairness of it—why anyone would go blind and be so helpless that they could not be independent in such every day activities as walking or shopping—struck him hard that day. He made his grandfather a promise. “I told him, ‘I’ll be an eye surgeon,’” said Dr. Jain. That was 1956. In 1972, Dr. Jain became qualified as an ophthalmologist, and he went on to an illustrious career as a retina specialist and past president of the Delhi Ophthalmological Society and the All India Ophthalmological Society. Dr. Jain said he has never forgotten that day when he pledged his future career to his grandfather. “I felt very sad,” he said. “I thought, why should he be blind? Why should anyone be blind? Why should an educated person be blind?” He discussed his 40-year career, and the innovations and experiences that he has seen as an ophthalmologist in India in an award lecture at the Prevalence of Visual Impairment, Training and Education in the Asia-Pacific Area symposium. “It is fascinating to look back at some of the radical changes during my career of 40 years,” he said. #1 pearls Cataract surgery, said Hungwon Tchah, MD , Seoul, is essentially nucleus removal—the rate limiting step, the phase of the surgery that takes the most time and effort. The hardness of cataract is thus the main factor to determine the technique to be used during cataract surgery. Soft cataracts, said Dr. Tchah, can be managed by simple debulking and prechopping. For harder cataracts, there’s the divide and conquer technique, and the phaco chop. The hardest cataracts, grade 5+, pose a challenge for even experienced surgeons, but grooving and chopping work for these cataracts. However, for such hard cataracts, even using these techniques, the increased phaco energies necessary to emulsify the nucleus pose a risk to the endothelium. For these cases, Dr. Tchah prefers his own “multichop” technique. The principle, he said, is similar to eating a pizza—it’s difficult to eat a whole pizza until you cut it into radial slices. The steps are simple: engage the nucleus, create the first chop, rotate and chop, rotate and chop, etc. Once the nucleus has been “multichopped” into manageably sized pieces, the pieces can be emulsified and removed one at a time. This decreases the phaco power significantly and reduces the risk of heat damage to the incision, as well as the potential for damage to the corneal endothelium. Dr. Tchah shared his pearl with attendees at a symposium titled “My number one pearl in cataract surgery.” Also on hand to share their pearls were session chairs Shamik Bafna, MD , Cleveland, who described ways to improve refractive outcomes in cataract surgery, including using the ORA system (WaveTec Vision, Aliso Viejo, Calif., USA); Tetsuro Oshika, MD , Tsukuba, Japan, who described his technique for transconjunctival single-plane sclerocorneal cataract surgery; and Boris Malyugin, MD , Moscow, who described his approach to small pupils, highlighting a stepwise approach including but not exclusive to the use of the Malyugin ring (MicroSurgical Technology, Redmond, Wash., USA). Dr. Malyugin also described his technique for performing 1.8-mm C-MICS in a vitrectomized eye. EWAP Editors’ note: Dr. Mehta is part of the team that developed the EndoGlide, but has no financial interests related to his lecture. Dr. Malyugin is the co- inventor of the Malyugin ring, which he described in one of his pearls. None of the other doctors named in this article have financial interests related to their talks. Live - from page 56