EyeWorld India June 2017 Issue

3 EWAP EDITORIAL June 2017 T he most common refractive error that impacts on almost everyone as they enter middle age is presbyopia. There is a long history of attempts to address presbyopia with surgery, including limbal radial incisions and scleral implants, most of which have proved to be ineffective. Not surprisingly, the potential for a procedure to address the gradual loss of our ability to change focus from distance to near vision has attracted the attention of potential candidates and industry. Monovision with pseudophakia correction is an effective procedure and intraocular lens replacement with multifocals or extended depth of focus IOLs offer additional lens-based solutions. As an alternative, procedures to alter the power of the cornea have attracted the attention of many innovators. Monovision LASIK/PRK is widely practiced and a variety of laser refractive procedures that create a multifocal cornea have had modest success. More recently, there has been interest in corneal inlays to create a multifocal cornea. The attraction of the latter concept is that inlays are potentially reversible. Corneal inlays can alter the corneal curvature or produce their effect purely by altering the refractive index in the corneal stroma. Polysulfone inlays based on the latter concept were first considered by Peter Choyce to address high myopia. The polysulfone implants produced the desired correction but problems occurred due to disruption of corneal metabolism with scarring and corneal melts. My own interest in corneal inlays began in the 1990s when I developed a small diameter hydrophilic corneal inlay of approximately 2 mm. The concept was to address the limitations of biocompatibility by using a semipermeable hydrogel and a small diameter so as not to interfere with corneal metabolism. A small diameter inlay could create a bifocal cornea based on the refractive index of the material and I first implanted corneal inlays in 1996 to correct presbyopia. These inlays were well tolerated and patients achieved excellent unaided near vision. A multicenter study was begun with Chiron Ophthalmics with Richard Lindstrom as the medical monitor but the invention was not commercialized. Some 20 years later, interest in similar presbyopic inlays has rekindled and several devices including the Rainbow and Flexi-View micro lens are now available and discussed in depth in this issue. In addition, inlays based on the extended depth of focus created with a small aperture (Kamra) have been introduced. The limitations of current corneal implants relate to the compromise in quality of vision due to the multifocal nature of the correction or small aperture. In addition, the intracorneal location of inlays may react with inflammatory changes resulting in fibrosis. These inlays therefore require careful monitoring to allow removal before irreversible changes and impairment of vision occur. Modest monovision, either with presbyLASIK or with extended depth of focus IOLs offer viable alternatives and whether corneal inlays will become the dominant method to address presbyopia remains to be seen. Regardless, I am sure you will find the detailed coverage in this issue interesting. The “Age of Inlays” has indeed begun and it is fascinating to watch this field develop after my earlier work in developing corneal inlays to correct presbyopia in the 1990s. EWAP I t gives me immense pleasure to invite you to read this edition of EyeWorld Asia-Pacific . Our feature for this issue is “advances in corneal inlays”. Discussion on what is available now and what’s coming down the pipeline with these presbyopia-correcting implants is extensively described. It was also suggested that in addition to serving a previously untapped market, corneal inlays are also revitalizing other refractive surgeries. This issue also discusses whether it is time to move to intracameral antibiotics. Although evidence of the benefits of intracameral antibiotics continues to mount, some say additional steps are needed before widespread adoption. Benefits and risks of NSAID use during cataract surgery in high- risk patients such as diabetics have also been illustrated. This issue also highlights vancomycin-associated HORV. Timing cataract surgery around anti-VEGF injections is described and it has been shown that better visual outcomes are noted in wet AMD patients with more frequent injections and longer exudation-free periods. We also get insight into the ocular surface for cataract surgery, such as what to look for, how to treat it, and how to counsel these patients. This issue also deals with amniotic membrane products, their use in optimizing the ocular surface before cataract surgery and to improve outcomes with advanced IOL techniques. We also discuss some of the methods to diagnose and address corneal lumps and bumps prior to cataract surgery. This issue also adds to our knowledge about minimally invasive glaucoma surgery (MIGS). Hope you all have a thoughtful experience reading this issue along with it being helpful to you practically. EWAP As always, I would like to end with a few lines from Thirukkural no. 431: Great indeed is the wealth of those men Who aren’t proud, angry and mean. The Age of Inlays Graham Barrett Chief Medical Editorial EyeWorld Asia-Paci c S. Natarajan, MD Regional Managing Editor EyeWorld Asia-Paci c