eyeworldap.apacrs.org The Asia-Pacific Association of Cataract and Refractive Surgeons INDIA Vol. 18 No. 3 September 2022 Licensed Publication Highlights of the 34th APACRS–2022 KSCRS Joint Meeting
EWAP SEPTEMBER 2022 3 EDITORIAL EyeWorld Asia-Pacific • September 2022 • Vol. 18 No. 3 Graham Barrett Chief Medical Editor EyeWorld Ƃsia*acific • China • Korea • India T he past few years have been challenging with restricted travel and the inability to hold an in-person APACRS meeting for the past 2 years. Although we have held very successful virtual meetings and have provided comprehensive online seminars, nothing can replace the atmosphere and intense learning experience of getting together as friends and colleagues in the same venue. So it was with some trepidation that we committed to our in-person 34th APACRS meeting held in conjunction with the KSCRS in June this year in Seoul. Despite the inability of some countries to join us, we had over 1,000 attendees in Seoul and a vibrant enjoyable meeting. The standard of presentations was excellent. The MasterClasses were full of enthusiastic attendees who were able to hear the latest from leading eÝperts in their respective fields. The CSCRS symposium on extended depth of focus IOLs was particularly valuable. The term extended depth of focus is applied to many different technologies; different optical technologies are grouped within this family but each lens has its own unique characteristics. There is always a trade-off on the amount of additional reading offered by these lenses, while maintaining quality of vision. Generally, these lenses are enhanced by combining a modest level of myopia if the patient requires additional spectacle independence. Although diffractive trifocals still provide a greater likelihood of total spectacle independence, the reduced unwanted dysphotopsia such as halos and glare offered by all the technologies make this category a welcome addition for ophthalmic surgeons in their endeavor to provide greater spectacle independence while maintaining quality of vision. It appears that extended depth of focus and monofocal plus lenses will become increasingly popular as they provide excellent intermediate vision as well as some functional reading ability compared to monofocal lenses. The recent annual meeting in Korea truly has marked a new dawn for APACRS, its attendees, and the ophthalmologists who attend from all around our region. Hopeful that as the COVID-19 pandemic wanes, our enthusiasm for travel is renewed. We have begun planning for and look forward to your participation in next year’s annual meeting to be held in Singapore from 8 to 10 June 2023. Abhay Vasavada Deputy Regional Editor EyeWorld Ƃsia*acific T his issue highlights excerpts from the annual meeting of the APACRS held in conjunction with the Korean Society of Cataract and Refractive Surgeons. This year’s meeting was the first physical conference since the pandemic. In incoming APACRS President Yao Ke’s APACRS LIM lecture, there was more than one lesson to be learned\ first and foremost, keep changing with times. We need to understand the science behind technologies, and what patientÉeye profile they will work best for. As surgeons, we all need to evaluate any new technology in a clinical setting, as they will fail to have a widespread impact if they do not translate to tangible gains or clear-cut improvement in practice. Therefore, every clinician should incorporate some degree of clinical research to evaluate new technology, to pave the way for future developments. Another important take away from the lecture is that care models need to be customized to the needs of the patient and the demographics. Our primary goal is to help the patient, and this may mean delivering services across the spectrum. As highlighted in one of this year’s MasterClass series, refractive surgery is one area where patients can be at two extremes— eÝtremely satisfied, or terribly dissatisfied in case they encounter an adverse event. When managing these complications, it is a combination of applying the right scientific principles, eÝperience, as well as how the patient is dealt with that will define success. Keeping in line with the philosophy of the APACRS to always be at the helm of advancing techniques and technology, newer IOLs were discussed. It is heartening to know that there are several innovations and advances coming our way that will enhance patient’s visual performance. While we strive toward surgical and technological excellence, it remains of paramount importance that we now direct our efforts more than ever before to minimizing wastage and developing alternative solutions that will be less damaging to the environment, which we and generations to come need in order to thrive.
4 EWAP SEPTEMBER 2022 GLAUCOMA 50 Insights on adopting new technologies by Liz Hillman 53 Non-valved tube implants: Comparison of different devices and size options by Ellen Stodola CONTENTS FEATURE Highlights of the 34th APACRS–2022 KSCRS Joint Meeting 07 APACRS Lim Lecture recap: Cataract in China by Chiles Aedam R. Samaniego 08 CSCRS highlights: ZEN – A balance of quality and depth of focus by Chiles Aedam R. Samaniego 10 A New Dawn: Highlights of the 34th APACRS–2022 KSCRS Joint Meeting Reportage by Christina Chintanaphol and Chiles Aedam R. Samaniego The New Dawn: Highlights of the 07 – 14 34th APACRS–2022 KSCRS Joint Meeting 03 Editorial NEWS & OPINION 56 Review of ‘Risk factors for posterior capsule rupture in cataract surgery as reyected in the European Registry of Quality Outcomes for Cataract and Refractive Surgery’ by Jasdeep Sabharwal, MD, PhD, and Fasika Woreta, MD 58 Review of ‘Comparison of contact lens-assisted and transepithelial corneal crosslinking with standard epithelium-off crosslinking for progressive keratoconus: 24-month clinic results’ by Neal Patel, MD, and Nandini Venkateswaran, MD 61 Multisociety OICS Task Force issues recommendations on reducing topical drug waste in ophthalmic surgery by David F. Chang, MD 35 A holistic approach to presbyopia correcting IOLs by Liz Hillman 42 Incorporating presbyopia drops into practice: Early experience with Vuity by Ellen Stodola CATARACT 22 Spontaneous lens dislocation: Why it occurs, when, management, and other insights by Liz Hillman 25 Anterior segment OCT for cataract surgery: Preop, intraop, and postop applications by Liz Hillman REFRACTIVE 33 Optometrists share how their practices are using comanagement by Ellen Stodola 29 Posterior capsule rupture: How to proceed and lens options by Ellen Stodola CORNEA 44 Scleral lenses for dry eye by Ellen Stodola 47 Corneal sweep test for recurrent corneal erosion by Ellen Stodola
References: 1. Rangarajan R, Kraybill B, Ogundele A, Ketelson H. Effects of a hyaluronic acid/hydroxypropyl guar artificial tear solution on protection, recovery, and lubricity in models of corneal epithelium. J Ocul Pharmacol Ther. 2015;31(8):491-497. 2. Davitt WF, Bloomenstein M, Christensen M, Martin AE. Efficacy in patients with dry eye after treatment with a new lubricant eye drop formulation. J Ocul Pharmacol Ther.2010;26(4):347-353. 3. Rolando M, Autori S, Badino F, Barabino S. Protecting the ocular surface and improving the quality of life of dry eye patients: a study of the efficacy of an HP-guar containing ocular lubricant in a population of dry eye patients. J Ocul Pharmacol Ther. 2009;25(3):271-278. 4. Ogundele A, Kao W, Carlson E. Impact of Hyaluronic Acid Containing Artificial Tear Products on Re-epithelialization in an In Vivo Corneal Wound Model. Poster presented at: 8th International Conference on the Tear Film & Ocular Surface; September 7-10, 2016; Montpellier, France. See instructions for use, precautions, warnings and contraindications © 2021 Alcon Inc. ASIA-SYH-2100002
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 Huang Weitian 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
FEATURE EWAP SEPTEMBER 2022 7 by Chiles Aedam R. Samaniego APACRS LIM Lecture recap: Cataract in China In his 2022 APACRS LIM Lecture, “Cataract in China: My Cataract Surgery Journey from Couching to FLACS,” Yao Ke, MD, Eye Center, Second Affiliated ospital of <heiang 1niversity School of Medicine, Zhejiang University Eye ospital, compared cataract surgery to the Chinese myth of Kuafu, running after the sun: “Our pursuit of light has never stopped, and cataract surgery in hina has always been on the road of swift development.” Dr. Yao conteÝtualiâed his own eÝperience and practicep which has culminated in efforts to eliminate cataract blindness across hinapin the history of cataract surgery in the country, from couching, the earliest form practiced in the country and introduced from India through the Silk Road in Ó0È B , to femtosecond laser-assisted cataract surgery FLA S®. ouching, he said, was the pride of hina for thousands of years before reaching its peak when hairman Mao <edong himself received couching to treat cataract in £Çx. Dr. Yao himself performed couching early in his career, during his residency in the £Ç0s. owever, as an “ancient procedure,” he said, the procedure had “many defects” and so gradually faded from the stage of history in China in the £0s. Dr. Yao also subseµuently practiced intracapsular cataract eÝtraction I E® from £ÇÇ Watch Dr. Yao’s 2022 APACRS LIM Lecture in full at [https://apacrs.org/34thapacrs.asp.]. to £nx. Later, following the mainstreaming of IOLs which reµuire the preservation of the posterior capsule, he switched to eÝtracapsular cataract eÝtraction E E® and, more recently, conventional phacoemulsification surgery P S®. In the interest of keeping cataract surgery in China at the cutting edge, Dr. Yao’s practice is currently very interested in FLACS; in addition to having performed more than 4,000 cases by Ó0Ó£, Dr. Yao and his colleagues have been deeply involved in studying the procedure’s efficacy and safety since Ó0£4. e brieyy went through the 15 studies they have published to date on the procedure. But perhaps the crowning achievement of Dr. Yao’s career thus far is the establishment of “Automobile Eye ospitals” in £È. Dr. Yao’s mobile eye hospitals have “traveled to snow-covered plateaus and vast deserts” to provide thousands of free cataract surgeries to the poor. In addition to providing completely free cataract surgery, they have established £x eye clinics in remote parts of hina, training local surgeonspsimultaneously “feeding them with fish and teaching them to fish at the same time,” Dr. Yao said. The automobile hospital, he said, has been running for Óx yearspand will continue to run for as long as patients need it. Dr. Yao and his team are committed to eliminating cataract blindness and, to achieve this, promoting the development of cataract surgery on into the future, together with their colleagues across the region, and the world. EWAP
FEATURE 8 EWAP SEPTEMBER 2022 by Chiles Aedam R. Samaniego CSCRS highlights: ZEN – A balance of quality and depth of focus T he ombined Symposium of Cataract and Refractive Societies S RS® is the APA RS annual meeting’s primary symposium, a oint symposium through which maor regional specialty societies share their eÝpertise and eÝperiences with the techniµues and technologies available to them, offering the opportunity for a truly comprehensive, global view of the modern cataract and refractive surgery landscape. This year’s S RS was held with eÝperts from APA RS, ASCRS, and ESCRS, and focused on IOL technologies that “bridge the gap” between monofocals and multifocalsp the IOLs that, according to the program description, “offer more than mere monofocals and fewer image µuality issues than multifocals”. Oliver Findl, MBA, FEBO, Austria, tasked with discussing monofocal plus IOLs, focused his discussion on the TECNIS Eyhance IOL (Johnson & ohnson Vision E Vision®®. These lenses, he said, address the needs of cataract patients today that are unmet by standard monofocal and multifocal IOLs\ an increased demand for intermediate distance activities along with a worry over visual disturbances such as glare and halo. Watch “ZEN-A balance of quality and depth of focus” online at https://apacrs. org/34th-apacrs.asp. The Eyhance design is based on a continuous higher order aspheric surface with no âones, reducing spherical aberration to almost âero. The patented aspherical optics feature smooth, continuous increase in refractive power from the periphery to the center, providing better distance and intermediate visual acuity than other aspheric, monofocal IOLs. The IOL, he said, provides “something for nothing”, with its monofocal IOL photicphenomena profile and better spectacle independence for intermediate distance. It has been Dr. Findl’s standard IOL for Î ¤ years now. Francis S. Mah, MD, 1SA, followed with a discussion of the TECNIS Symfony (J&J Vision), an IOL that eÝpands or stretches a patient’s range of vision through the combination of an aspheric anterior surface with an achromatic diffractive posterior surface. In his eÝperience, the Symfony IOL eÝpands the scope
FEATURE EWAP SEPTEMBER 2022 9 of patients and makes it easier for surgeon to achieve good results with eÝpanded range of vision. Graham Barrett, MD, Australia, who said he coined the term “eÝtended depth of focus” (EDOF) over a decade ago, emphasiâed that the lenses under discussion are neither a homogenous group of IOLs, nor completely, distinctly, heterogenous, with the distinctions between terms such as “monofocal plus” and “EDOF” often actually µuite artificial and arbitrary. hoosing an optical solution to address presbyopia, Dr. Barrett said, is always a compromise between spectacle independence and unwanted symptoms. In his practice, an EDOF IOL based on positive spherical aberration together with mini or modest monovision best offers a balance of µuality and depth of focus. e suspects that many surgeons would select this optical solution for themselves, and encouraged them to bear in mind the ethic of reciprocityp“If it’s worth it for ourselves, it’s worth it for our patients as well,” he said. In his talk, Thomas ohnen, MD, PhD, FEBO, Germany, who consults for <eiss, homed in on “bridging the gap” with the company’s AT LARA, which eÝtends depth of focus with a trifocal diffractive optic in a plate haptic design. 1nlike non-diffractive EDOF IOLs, the AT LARA does, Dr. ohnen conceded, still has some photic phenomenaÆ however, this particular lens offers a wider diopter range than other IOLsp from q£0.0 to ³ÎÓ D. Flipping over to the nondiffractive options for eÝtending depth of focus, Robert Ang, MD, Philippines, discussed pinhole or small aperture IOLs in his talk “The Smaller the Better.” e focused in particular in data gathered regarding the I -n, manufactured by AcuFocus for which Dr. Ang consults. The I -n IOL, he reported, “has been evaluated in hundreds of eyes in both controlled studies and commercial retrospective analysis.” In those studies, the small aperture IOL\ provided a continuous range of visionÆ comparable distance vision and superior intermediate and near vision compared to monofocal controlsÆ good binocular contrast sensitivity, with low level of visual symptomsÆ “promising results” when implanted bilaterallyÆ performed consistently in eyes with £.x D or less astigmatismÆ can be implanted using the same surgical techniµue as any other IOLÆ allowed posterior segment visualiâation and other similar diagnosticsÆ had a mechanism of action beneficial for compleÝ cornea patients. losing out the combined symposium, Terry im, MD, 1SA, summed up his clinical eÝperience with the AcrySof I+ Vivity EÝtended Vision IOL. In his eÝperience, he said, the IOL\ had an outstanding reception among patients who ended up “Ó0É appy”Æ eÝpanded his candidate pool for presbyopiacorrecting IOLsÆ provided a more forgiving platform in terms of biometry, visual disturbances, and other factors; demonstrated a visual disturbance profile similar to an aspheric monofocal IOL. atch-up on or revisit the full ombined Symposium online at apacrs.org. EWAP Pentacam® AXL Wave Essential to refractive practice for 20 years Thanks to the streamlined measurement workflow and application-oriented overview screens you further improve your time efficiency. Plus, with tons of studies and a huge user community to support data validity, you are always on the safe side. Optimized workflows, satisfied patients and best possible clinical results are all achieved quickly and reliably and without long training periods. No risk, just fun – the Pentacam® AXL Wave I T ʼ S T I M E T O C H A N G E The Gamechanger for ophthalmic surgeons Don‘t miss the Satellite Symposium at ESCRS! Saturday, 17th September 16:00 h, room Brown 2 Gerd U. Auffarth and Michael W. Belin OCULUS Asia Ltd. Hong Kong pentacam.com/axl-wave • info@oculus.hk KLB Instruments Co. Pvt. Ltd KLB
Unhappy patients after cataract surgery: Reasons for dissatisfaction and how to help Reportage by Christina Chintanaphol and Chiles Aedam R. Samaniego Day 1 On Saturday, 11 June 2022, the APACRS returned for its first in-person annual meeting since the beginning of the COVID-19 pandemic, jointly holding its 34th annual meeting with the 2022 annual meeting of the Korean Society of Cataract and Refractive Surgeons (KSCRS). The first day featured a packed instructional scientific program centered on the Society’s signature series of MasterClasses, included a “Squid Game” of challenging cases, and culminated in the 2022 APACRS Film Festival Symposium and Awards Ceremony. A NEW DAWN: Highlights of the 34th APACRS-2022 KSCRS Joint Meeting MasterClass: Mastering Refractive Surgery Complications In the MasterClass on “Refractive Surgery Complications,” Cordelia Chan, MD, Singapore, summed up “Handling Unexpected Scenarios and the Unhappy Refractive Patient.” Intraoperative refractive surgery complications, Dr. Chan said, do not occur frequently; when they do, even the most experienced surgeons may be caught off guard. Reacting to this challenge well, she added, comes with experience. Much consideration in her talk was given to the subjective experience of the patient. While surgeons themselves should stay calm, it is important for them to help keep the patient calm and choose their words and what is conveyed to the patient very carefully. In addition to identifying risk factors and detailing management strategies including sharing cases of suction break, flap tear, and gas bubbles, Dr. Chan noted how patients who have had “complicated” refractive surgery may be psychologically impacted and dissatisfied with their visual outcome and attribute every symptom they experience to the intraoperative event—even if the complication was visually inconsequential. Thus, she said, surgeons need to spend more time with these patients postop, empathizing, comforting, and reassuring them, while treating coexisting issues such as dry eye more aggressively. In the same MasterClass, Sri Ganesh, MD, India, discussed “Dealing with the Frowning Patient after SMILE,” describe some complications they’ve found unique to SMILE and how they dealt with them. In the first case Dr. Ganesh presented, they were referred a post-SMILE patient who complained of blurred vision in both eyes that did not improve with glasses, so bad that the patient could not drive. While the topography, aberrations, and anterior segment OCT were unremarkable, retroillumination revealed an irregular interface with “crop circle” patterns in both eyes, resulting in an abnormal scatter further quantified using an HD Analyzer. Reviewing the case, Dr. Ganesh noted that the surgeon, who had only begun to perform SMILE, used an unusually high energy setting, resulting in the irregular interface. Energy optimization, he concluded, is a crucial factor for visual recovery and quality of vision. Dr. Ganesh corrected the problem using the Circle software and phototherapeutic keratectomy (PTK). In the second case, despite an apparently intact SMILE lenticule extracted, retroillumination revealed a black patch which they interpreted as a surface irregularity but turned out to be a retained lenticule fragment. They corrected using the Circle software with removal of the fragment and PTK. MasterClass: Mastering Biometry The MasterClass on “Mastering Biometry” covered the EWAP meeting reporter banner.indd 1 27/07/2022 10:22 AM
complexities of intraocular lens (IOL) power calculations while approaching and overcoming a variety of challenging patient situations. Oliver Findl, MBA, FEBO, Austria, began the MasterClass by presenting on cornea topography in IOL power selection. In patients with significant higher-order aberration (HOA), Dr. Findl suggested avoiding trifocal, extended depth of focus, and toric intraocular lens. Furthermore, if applicable, the practitioner should remove any superficial corneal pathology (pterygium, Salzmann nodules, or map-dot-finger dystrophy, for example) before operation. In dry eye patients, practitioners should use artificial tears before keratometry. “Ideally, you should put the eye drops in, wait for five minutes, and then take the keratometry measurement,” Dr. Findl said. With this technique, measurements are more accurate compared to taking a measurement 30 seconds after instilling lubricating eye drops. Yeo Tun Kuan, MBBS, MMed, Singapore, continued the discussion by providing recommendations on toric IOL power calculations. By utilizing three different machine astigmatism measurements, one can achieve more accurate outcomes while machine selection is less of an issue. The three readings may come from two optical biometers (IOLMaster and Lenstar) and one topographer, providing an integrated K value for toric IOLs. IOL power calculations can be even more complex when thinking about the sources of error. Youngsub Eom, MD, PhD, South Korea, provided the audience with four main reasons why calculated IOL power may not be as accurate as practitioners hope. Contributing factors include an inaccurate measurement area of the keratometer, the assumption that the posterior and/or anterior corneal curvature radii ratio is constant when calculating corneal power, an inaccurate estimation of effective lens position, and an inaccurate measurement of axial length. “How you want to treat the patient depends on how well the patient wants to see, whether that is near vision or distance vision,” said Fam Han Bor, MBBS, MMed, Singapore. In his presentation, Dr. Fam noted that it is important to distinguish whether patients desire sharp vision or comfortable vision. When practitioners target refraction in surgery, they must consider acuity needs, the target refraction, and the comfort of monovision. “All of this hinges on IOL power calculation,” says Dr. Fam. In fact, the field of calculating the power of IOLs is the perfect subject of study to apply the scientific method in medicine. The performance of measurements, the construction of anatomical and predictive models, predictions, and error measurements must be taken into consideration. Damien Gatinel, MD, PhD, France, with the help of his colleagues, created the PEARL-DGS formula (available at www.iolsolver.com) by taking into account multiple paradigms for predicting IOL power. The PEARL-DGS formula has been utilized by Dr. Gatinel to improve postoperative refractive outcomes in many patients. With keratoconus, IOL power calculation becomes a bit more complicated as well. Graham Barrett, MB BCh, FRACO, FRACS, Australia, described how keratoconus can present with steep K values. In addition, abnormalities of the cornea in patients with keratoconus disrupt the relationship of the posterior and anterior corneal radii, resulting in unexpected spherical outcomes. Through case presentations, Dr. Barrett suggested that the idea in solving the issue of keratoconus in calculating a correct power value is to provide a solution in which one formula will allow you to choose, among many, a piggy-back IOL prediction, a lens exchange prediction, a way to rotate the existing lens, and an effective lens position (ELP) option for prediction of IOL power. MasterClass: Mastering Toric IOLs In the 2022 APACRS MasterClass on “Mastering Toric IOLs,” Tetsuro Oshika, MD, PhD, Japan, discussed “Preoperative Consideration and Postoperative Management.” Dr. Oshika said that of all their patients undergoing cataract surgery, they found that 53% had greater than 0.75 D and 38% had greater than 1.0 D of astigmatism, indicating that many are good candidates for toric lens implantation. Residual astigmatism, he said, significantly deteriorates postoperative uncorrected distance visual acuity (UDVA). Reviewing the definitions of with-the-rule (WTR), against-the-rule (ATR), and oblique astigmatism, he said they’ve found that in terms of impact on vision, ATR had the greatest and WTR the least. In addition, the effect of toric IOLs reduced significantly over time in cases with preop ATR astigmatism but not in cases with preop WTR. Furthermore, he noted the importance of complete CCC-edge coverage of the optic; should rotation occur, repositioning should be delayed until rotation has stabilized at about 1 week. Using a yellow and blue color EWAP meeting reporter banner.indd 1 27/07/2022 10:22 AM
chart to describe age-related changes in astigmatism, Dr. Oshika took the opportunity to express support for Ukraine, especially the doctors, healthcare workers, and patients in that area. “We stand for them,” he said. In the same symposium, Graham Barrett, MB BCh, FRACO, FRACS, Australia, discussed “Mastering the Barrett Toric Calculator.” Dr. Barrett created the calculator based on a theoretical model he conceived to explain why the cornea behaves the way it does; unlike other calculators that use a population-based model, it predicts a unique posterior corneal astigmatism for each eye. The calculator recognizes that not all residual is due to the posterior cornea because the visual axis is not aligned with the optical axis of the eye; there is an angle alpha and this produces an apparent tilt. “If you don’t take account of this, you won’t get an accurate result,” he said. Dr. Barrett’s formula is a Gaussian formula—for each individual lens, it calculates the location of principal planes; the thickness of the lens and principal planes impact toric IOL prediction. At the end of his talk, Dr. Barrett was asked whether he performs a toric IOL calculation in every case. “Getting rid of astigmatism is as important as getting a great spherical outcome,” he said. “There’s no point in getting a great spherical outcome if you’re leaving residual astigmatism. That means every patient really is a candidate for toric IOL, which means I do a toric IOL prediction in every case.” He decides whether to proceed with a toric IOL depending on the results. MasterClass: Mastering IOL Fixation The MasterClass on “Mastering IOL Fixation” presented a variety of patient case surgical videos, allowing attendees to visually learn IOL fixation techniques from different complex surgeries. Even before surgery takes place, Chee Soon Phaik, MD, Singapore, emphasized the importance of the pre-surgical examination. “You need to examine the patient from the front to the back of the eye,” she said, to make sure there are no abnormalities. Additionally, the surgeon should perform an endothelial count, observe the macula, and look for viral infections before performing biometry. In an iris suture fixation video, Dr. Chee showed how to bring the intraocular lens (IOL) to the plane of the iris root by using IOL-grasping forceps. By stretching the iris away from the iris root, miosing the pupil, taking only a 1-clock hour bite of the iris as peripheral as possible, and using a Siepser sliding knot and McCanel suture, Dr. Chee is able to perform successful iris suture fixation. “It is important to ensure you can retrieve the IOL and clear vitreous safely,” reminds Dr. Chee. The next few videos shown by Seong Jae Kim, MD, PhD, South Korea, demonstrated captured optic fixation using trans-scleral sutures. By utilizing an Artificial Bag with optic Capture (ABC) technique, Dr. Kim showed the ease of performing this procedure. In this technique, the artificial bag helps the haptics position in the sulcus during IOL insertion. Additionally, optic capture occurs between two sutures: the posterior suture is located 0.5 mm in front of the anterior suture at the limbus. Finally, the posterior suture prevents dislocation of the IOL into the vitreous. Dr. Kim’s visual examples through his video showed how simple the ABC technique is, how easily accessible the technique is to anterior segment surgeons, and how stable and achievable the results are without IOL tilt and conjunctival issues. Another prominent technique in IOL fixation is the Yamane technique. As Hiroyuki Matsushima, MD, PhD, Japan, described in his presentation, he frequently utilizes a modified version of the technique for flanged fixation, in which the main incision is performed on the right side with a lower 30-G incision more than 90 degrees from the main incision. Dr. Matsushima pointed out that polyvinylidene fluoride (PVDF) haptics and ultra-thin wall needles are most suitable for flanged fixation. When making a flange, it is important that the ends of the haptics are cut 1 to 2 mm and cauterized using an ophthalmic cautery device. Dr. Matsushima advised not to touch the haptics directly using the cautery and instead use heat to make the flange. Additionally, the flange must be small enough to be buried into the sclera. Managing a decentrated IOL is possible, too, by correcting the IOL position. The surgeon should pull out and shorten the haptic. Since it is difficult to pull out the flange after it being buried into the sclera, the surgeon must expose the head of the flange using a needle and then use a capsule forceps to EWAP meeting reporter banner.indd 1 27/07/2022 10:22 AM
pull out the haptic. Mohan Rajan, MBBS, DO, FACS, FRCS, India, closed the session by discussing glued IOLs and iris fixated lenses. Glued IOLs are a new concept aimed at fixing a posterior chamber IOL (PCIOL) in eyes with no capsule. The glue used during surgery is a quick-acting surgical fibrin glue sealant derived from human blood plasma; this glue may be used to assist sutureless PCIOL implantation and can be easily performed with the available IOL designs with minimal surgical time. The advantages of glued IOLs, Dr. Rajan shared, is that there is an easy learning curve, no occurrence of pseudophakodonesis nor secondary glaucoma, and good dilation is possible post-surgery for retina evaluation. With many case presentation videos in this masterclass session, audience members were able to follow along the various techniques our surgeons shared during more complex surgeries. On the Horizon-What’s New in IOLs? A variety of presenters during the afternoon session, “On the Horizon-What’s New in IOLs?”, explored new IOL designs in form and function. Chul Young Choi, MD, South Korea, began the session by presenting a variety of new features in intraocular lens (IOLs) including violet light-filtering IOLs. These IOLs allow full transmission of healthy blue light and provide better contrast especially during night time. Another feature of IOLs that may improve outcomes is utilizing smoother and more regular surface design in reducing surface scattering to a greater degree. One other feature of IOLs discussed was high-water content trifocal IOLs, presented by Young Sik Yoo, MD, South Korea, which provides better visual outcomes especially at a near distance. “It is the specific optic design related to reducing chromatic aberrations that might improve near vision with these relatively high-water content trifocal IOLs,” said Dr. Yoo. With the many different IOL choices that are present, it may be difficult to decide which one is right for your patient. Ji Eun Lee, MD, PhD, South Korea, offered that patients suitable for the Synergy IOL (a presbyopia-correcting IOL) are those who expect good uncorrected distance visual acuity (VA) and understand the limitations of this IOL. On the other hand, patients suitable for the Symfony IOL (extended depth of focus IOL) are those who desire both distance and intermediate VA and have no problem with wearing glasses for near vision. With the Artis Symbiose, a multifocal hydrophobic IOL, Dr. Gerd Auffarth, MD, FEBO, Germany, explains that it provides good functional distance, near, and intermediate vision with low glare sensitivity and photoptic phenomena. Ultimately, Dr. Auffarth said that 80% of the lenses he implants are some type of monofocal option, even though a multitude of IOL options exist in today’s IOL world. In a hybrid monovision approach, Kimiya Shimizu, MD, PhD, Japan, aims to use a monofocal IOL in the dominant eye and a multifocal IOL in the nondominant eye. This technique is a rescue approach for those dissatisfied after bilateral multifocal IOL implantations and is also effective for correcting presbyopia in cataract surgery. Squid Game-Challenging Cases Cataract surgery may be challenging, just like partaking in Squid Game, in many different ways, and the key to its success is to be aware of the many issues that can arise. Being prepared for all situations will allow surgeons to successfully manage their patients. In the late afternoon session, “Squid Game-Challenging Cases”, capsular tension rings (CTR) were discussed as a preferred instrument in treating weak zonules. Though iris retractors, modified capsular tension rings (MCTR), or capsular tension segments (CTS) may also be appropriate instruments for managing zonular issues, CTRs support localized zonular dehiscence and generalized zonular weakness. They prevent optic decentration and tilt of the IOL while minimizing fibrosis and collapse of the capsular bag. CTRs may be inserted, either with an injector or manually, before the removal of the nucleus as it provides safer surgery and equatorial support to the bag. However, complications may, at times, arise such as inadvertent threading of a CTR through a capsule retractor loop. Solving this issue involves opening or EWAP meeting reporter banner.indd 1 27/07/2022 10:22 AM
amputating the distal loop to facilitate hook removal. Terry Kim, MD, USA, explained that prevention strategies for avoiding this complication include holding and/or lifting the retractor(s) during CTR insertion, aiming the CTR posteriorly, and loosening the retractor(s) before CTR insertion. Another challenging situation surgeons may face is the management of small pupils in cataract surgery. Sang Mok Lee, MD, South Korea, explained that diverse strategies may be used to enlarge the small pupil in surgery, though the strategies may depend on the availability of instruments and/or devices, patient abnormalities such as possible zonular weaknesses, and, of course, the surgeon’s skill and preferences. With the recent development of diverse pupil expansion devices, surgery on small pupils can be made easier. Posterior polar cataracts (PPC), may also present itself as a challenging case. Though PPCs can be a congenital effect, Pannet Pangputhipong, MD, Thailand, explained that it can also occur as a result of localized absence or thinning of the posterior capsule. Strategies to manage PPCs include avoiding hydrodissection and minimizing hydrodelineation, triangular cracking for medium to hard cataracts, half bowl and rim aspiration techniques for soft cataracts, maintaining anterior chamber depth, and avoiding polishing the capsule. The various challenging situations that present in cataract surgery provided ample opportunity for surgeons to explore and share their management techniques through many different patient case videos in today’s session. Just as there are many rules and high stakes in Squid Game, one misstep in a challenging cataract case may lead to undesired outcomes. Unhappy after Successful Presbyopia Cataract Surgery… What are We Missing? As patients are top priority to all surgeons, patient satisfaction after cataract surgery is one aspect to consider in terms of successful surgery. Many patients may set high expectations for their vision after presbyopic cataract surgery. They may desire high contrast at all distances or great near and distance vision, but Hiroko Bissen-Miyajima, MD, Japan, explained that this high expectation may result in patients being unhappy with their postoperative vision. In fact, a patient’s visual acuity will be different than the level of contrast in their vision. This idea must be explained to patients in order to manage their expectations. Visual cues and simulated images may be used to explain the quality of vision patients will experience after surgery. One interesting aspect of managing patient expectations is neural adaptation of vision. Because optical quality does not necessarily equal visual quality, neural receiving of images (retinal sampling and neural processing) affect how one perceives an optical image. In short term neural adaptation, the human brain can enhance an image. If an image is perceived as too sharp, the brain will want to make it softer. Subjective image quality, then, does depend on neural adaptation. In his practice in South Korea, Myoung Joon Kim, MD, instructs his patients to avoid and ignore sources of distraction and to keep focusing on the lines and contours of objects. This technique of removing noises is one way to train a patient’s brain to improve their perception and vision. Such vision training can help patients become adapted to their new vision after surgery. How quickly can neural adaptation take place? Dr. Kim said that the neural adaptation period may last about 3 months and can even take 6 months to one year. Age plays a role, and the older a patient is, the longer it may take to adapt. Old age is also a factor in decreasing contrast sensitivity. Ronald Yeoh, MBBS, FRCS, Singapore, as part of the discussion panel, stated that one of his cases took one year to finally adapt to her new vision after IOL implantation. In the end, if patients are not able to adapt, the patient may just be incompatible with the IOL. One prevailing point that all surgeons can take to their practice in managing patients is being empathetic and being able to talk to patients. “We need to take patients seriously. Then, they will feel trusted and understand that you’re caring for them,” said Michael Knorz, MD, Germany. 2022 APACRS Film Festival Symposium and Awards “A Whole New World,” produced by Viraj Vasavada, MD, India, took home this year’s grand prize at the 2022 APACRS Film Festival Symposium and Awards Ceremony. The film tells the touching story of how Dr. Vasavada’s experience EWAP meeting reporter banner.indd 1 27/07/2022 10:22 AM
with postpartum intracranial hemorrhage changed her career, her life, her entire world, and the hopeful way becoming both a doctor and a patient has taught her to view not only her own struggles, but also those of her patients. Other winners: Cataract/Implant Surgery Winner: Looking into the Shadows: Airflow dynamics in ophthalmic practice, Producer: Vaishali VASAVADA, India Runner Up: Development of a new irrigation/aspiration tip with a variable aspiration port, Producer: Oki TETSUTARO, Japan Cataract Complications/ Challenging Cases Winner: Microinvasive Surgery to Solve a Rare Ophthalmic Disease, Producer: Karl BRASSE, Netherlands Runner Up: New Surgical Technique for Secondary Intraocular Lens Implantation using Artificial Bag with Optic Capture, Producer: Seong Jae KIM, South Korea Refractive/Corneal Surgery Winner: Help Me I Am Stuck! Techniques and tips for managing retained lenticules in SMILE, Producer: Sheetal BRAR, India Runner up: Next Generation Crosslinking Calculator for Titration of Ultraviolet Energy (NXT-UVA) in Thin Keratoconic Cornea, Producer: Pooja KHAMAR, India General Interest Winner: Dark Side of the Lens, Producer: Ronald YEOH, Singapore Runner up: CSI Heidelberg: A view from inside, Producer: Gerd AUFFARTH, Germany Day 2 On Sunday, 12 June 2022, the program began with industry-led video symposiums and proceeded to the meeting’s Opening Ceremony, featuring this year’s APACRS LIM Lecture (see recap). The day’s program also featured the year’s Combined Symposium of Cataract and Refractive Societies (CSCRS, see recap), several other scientific symposia, and as usual ended with the APACRS annual meeting’s signature Top Cataract Surgery Tips competition, this year called “Taekwondo Masters.” Opening Ceremony The 34th APACRS Annual Meeting Opening Ceremony buzzed with eagerness and enthusiasm as the delegates of this year’s meeting finally came together for the first in-person meeting after three long years. The session began with a welcoming statement by Joon Young Hyon, South Korea, the KSCRS organizing committee president. “I would like to give a special thanks to the delegates who traveled to Seoul with all the restrictions of COVID-19. In this first ever in-person meeting since 2019, we have over 900 delegates who registered from over 50 countries.” Regarding the advancements in cataract and refractive surgery and being the most common procedure in Korea and worldwide, Prof. Hyon stated, “It would not be possible to figure out how many patients have benefited from these modern revolutionary procedures. So, the significance of this meeting keeps growing.” Abhay Vasavada, MS, FRCS, India, APACRS President, provided the opening address. “A new dawn is so appropriate now that we are entering a new dawn post COVID-19. We are going to see an exhibition of the skills, teaching, and academics. It’s really an extravaganza for that.” Seoul has been the capital city of many kingdoms and countries on the Korean peninsula for many thousands of years. Nowadays, Seoul is a place for tradition and modernity, and the EWAP meeting reporter banner.indd 1 27/07/2022 10:22 AM
organizing committee hopes that all delegates will enjoy the charm of Seoul. The 2022 APACRS Certified Educator (A.C.E.) award was presented to three surgeons: Con Moshegov, MD, Australia (posthumous), Tae-Young Chung, MD, South Korea, and Yeo Tun Kuan, MD, Singapore. Finally, the 2022 APACRS Gold Medal award was presented to Hungwon Tchah, MD, South Korea. “I joined APACRS about 20 years ago and since then, APACRS and KSCRS have worked very hard to build a good relationship. It is a great honor to receive this gold medal, especially in Seoul. It’s a joint meeting and a joint medal.” Crash Landing [On You] - Cataract Complications “If you say you don’t have many complications [in your surgeries], it means you don’t perform many surgeries. If you do a lot of surgeries, you will encounter a lot of complications,” said Pannet Pangputhipong, MD, Thailand. In this afternoon session, speakers shared some of their tips for ensuring safe surgeries and techniques for minimizing complications in the surgical setting. One obstacle surgeons may face in cataract surgery is vitreous loss. Once vitreous loss occurs, it must be treated immediately. To facilitate cataract surgeons in handling vitreous loss, phaco machines have a built-in device for anterior vitrectomy (A-vit). Yoshihiko Ninomiya, MD, Japan, explained some advantages of practicing three-port vitrectomy in vitreous loss situations. These advantages include freeing both hands by fixing the infusion cannula, cutting the vitreous from the vitreous base, and simultaneously taking care of the fundus pathology. Surgeons must also pay careful attention during cataract surgery to prevent serious corneal complications. One serious corneal complication is corneal edema: swelling of the corneal stroma due to damage to the corneal endothelium. Corneal edema, which may resolve within a few days or weeks after surgery, results in decreased visual acuity. Young Joo Shin, MD, PhD, South Korea stated that treating corneal edema consists of four important points. Surgeons must eliminate the cause of the edema by lowering intraocular pressure (IOP) and treating inflammation, enhance surface dehydration, treat patients’ pain with lubricants, and restore anatomy (DSAEK, DMEK, or PKP). Situations of IOL explantation may also pose challenges during cataract surgery. Reasons for IOL explantation may include IOL power miscalculation, IOL calcification, and IOL subluxation from the capsular bag, said Hadi Prakoso, SpM(K), Indonesia. It is important to preserve the capsular bag during explantation. Dr. Prakoso provided his tips on how to successfully explant an IOL from the capsular bag. “The first challenge is to release the IOL from its attachment to the capsular bag. Another challenge is taking the IOL out of the bag and finally preserving the capsular bag from rupture or zonular loss,” said Dr. Prakoso. Many of these cataract challenges and complications were shown to be managed successfully through careful observation and treatment, as seen in the various case presentations during this session. Cutting Edge of Corneal & Refractive Surgery In the symposium “Cutting Edge of Corneal & Refractive Surgery,” John Chang, MD, Hong Kong SAR, shared his early experience with the Visumax 800 (Carl Zeiss Meditec). This laser, he said, is four times faster than the previous version and allows closer spot sizes for easier separation and lower risk of lenticule or cap tear. It can be used for lower myopia since it is easier and so safer to separate even thin lenticules. It has better centration, better astigmatism treatment which can be matched to cornea markings after suction, and better ergonomics. Dr. Chang said that he has completely switched to the Visumax 800 for flap making since he does 80-micron flaps for high myopes or thin corneas. The laser allows him to leave a 280- to 300-micron bed even in –10-D myopes. In almost 500 cases, he has had no haze, gas bubbles, anterior chamber bubbles, opaque bubble layer, or canthotomy. Dr. Chang said they have found a significant improvement in SMILE complications. Out of 419 eyes, only one had an incision tear, one had incomplete bubble separation, and one a lenticule adherent to the cap. One thing that does happen more often with the new laser is going deep first—it is easier to go to the deeper layer, but very easy to find and separate the cap layer. However, this, Dr. Chang noted, is no longer a complication as the ease with which the cap can be separated EWAP meeting reporter banner.indd 1 27/07/2022 10:22 AM
decreases or even eliminates the risk of false track creation. For their early, 3-month results, including 90 eyes, 100% had 20/20 or better best-corrected visual acuity and 98% 20/20 or better uncorrected distance visual acuity. At the same session, Jodhbir S. Mehta, BSc(Hons.), MBBS, PhD, FRCOphth, FRCS(Ed), FAMS, Singapore, talked about “Cornea Nerve Regeneration Following Lenticule Extraction.” Dr. Mehta said that in both animal and clinical studies, postop re-innervation has been shown to be superior in terms of corneal nerve fiber area, length, density, and branch density in SMILE compared to LASIK from 6 to 12 months. But what happens after that time period? Dr. Mehta and his colleagues performed a contralateral RCT with each patient having one eye undergoing LASIK, the other undergoing SMILE—essentially providing a matched patient cohort. At a mean average follow-up of 4.1 years, they found that all mean fiber parameters, there was a significant advantage in the SMILE group. Qualitatively, the SMILE group also had significantly less beading response to nerve damage. Note however that these postop eyes still have lower parameters than age-matched, unoperated eyes even after 5.5 years of follow-up. Also, these did not translate to significant differences in clinical parameters between SMILE and LASIK; the differences were seen via in-vivo confocal microscopy. Taekwondo Masters–Top Cataract Surgery Tips Fifteen cataract surgeons shared their top cataract surgery tips through a series of patient case videos in the last session of the 34th APACRS Annual Meeting. At the end of the session, audience members voted on the best surgery tip and winners were presented directly at the end of the session. Highlights from this session included Jong Suk Song, MD, PhD, South Korea, who demonstrated the advantage of intracameral triamcinolone (TA) injections in reaching the macula sufficiently in pseudophakic eyes to treat macular edema. “It is easier to irrigate TA powder when IOP is increased,” said Dr. Song. Chee Soon Phaik, MD, Singapore, presented her tip to surgeons who have struggled with rotating a nucleus despite cortical cleaving hydrodissection. In viscocleaving the cortical adhesion site, surgeons inject viscoelastic in the subcapsular plane to reach the equator in order to avoid rotational issues. Doing this can preserve zonules while enabling consistent nucleus rotation. Francis Mah, MD, USA shared his tip on reducing IOP as much as possible when faced with iris prolapse, a difficult situation. “The key is to get the viscoat out and decrease pressure,” he said. Hyun Seung Kim, MD, South Korea, provided tips for small pupil cataract surgery without using pupil expansion devices. Dr. Kim demonstrated the hidden capsulorhexis technique as well as a procedure using a 2nd instrument in performing successful surgery on small pupils. Thomas Kohnen, MD, PhD, FEBO, Germany, explained that a posterior capsule rupture with premium IOL implantation is not the end of the world. By utilizing proper cortex aspiration, vitrectomy, and implanting the IOL in the capsular bag on the remaining posterior leaflet, one can still be quite successful in the procedure. Chopping is one technique in which cataract surgeons may benefit from advice. In a minimal power chop, Joon Young Hyon, MD, South Korea, explained that less energy can be delivered to the anterior chamber with this technique, and it can even be used in small pupils. Angling the chopper in the direction towards the phaco tip will allow for surgeons to succeed in splitting the nucleus. Many other surgeons provided useful tips and tricks during this session to demonstrate how to perform cataract surgeries with ease while managing any arising challenges. As for the winning tip? Dr. Joon Young Hyon took the win for his tip on chopper alignment. The runner-up was awarded to Dr. Chee Soon Phaik for her tip on viscocleaving. Congratulations to the winners! “Taekwondo Masters” was an incredibly instructive and knowledgeable session, providing delegates with useful tips to bring to their surgery room. EWAP EWAP meeting reporter banner.indd 1 27/07/2022 10:22 AM
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