EyeWorld Asia-Pacific September 2024 Issue

The Asia-Pacific Association of Cataract and Refractive Surgeons

Vol. 20 No. 3 September 2024

PLUS Meeting Round Up:

What went on at the 36 th APACRS and 24 th CSCRS joint meeting in Chengdu, China In Trend And In Sight: An appreciation for trends influencing refractive surgery

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EyeWorld Asia-Pacific | September 2024 Scan the QR Code or visit www.eyeworldap.apacrs.org for more information.

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EyeWorld Asia-Pacific | September 2024

CONTENT

EDITORIAL 4 Precision & Perfection

CORNEA 44 Wish Granted: More Ocular Surface Options 48 Antiviral Treatment For HSV

CATARACT 20 Comparing Bimanual And Coaxial I/A 24

FEATURE 6 Tales Of The Flanging Technique 2024 APACRS LIM Lecture at the 36 th APACRS-24 th CSCRS Joint Meeting, Chengdu, 2024 7 Pathways To Precision And Perfection Combined Symposium of the Cataract & Refractive Societies (CSCRS) — a joint symposium of the APACRS, ASCRS, and ESCRS coverage at the 36 th APACRS-24 th CSCRS Joint Meeting, Chengdu, 2024 9 The Perfect Save! IIIC Lectures coverage for the 36 th APACRS-24 th CSCRS Joint Meeting, Chengdu, 2024 11

I Wish I Identified And Treated ABMD Before Cataract Surgery

NEWS & OPINION 52

REFRACTIVE SURGERY 36 A Decline In LASIK Procedures: What This Means For Refractive Surgery As A Whole 28 Tips For IOL Exchange

Sustainability In The Asia-Pacific

Top Cataract Surgery Tips From The Wisdom Of The Kung Fu Masters

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EyeWorld Asia-Pacific | September 2024

EDITORIAL

EDITORIAL BOARD Chief Medical Editor Graham Barrett, MD

CHINESE EDITION Regional Managing Editor Yao Ke, MD Deputy Regional Editor He Shouzhi, 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 Hiroko Bissen-Miyajima, MD Japan Kimiya Shimizu, MD Japan Sri Ganesh, MD India Chee Soon Phaik, MD Singapore Johan Hutauruk, MD Indonesia

Zhao Jialiang, MD Assistant Editors Zhouqi, MD Shentu Xingchao, MD

Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific • China • Korea • India

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 PUBLISHING TEAM Chief Publisher Ronald Yeoh, MD Executive Director Kathy Chen kathy.chen@apacrs.org

Precision & Perfection

“ Precision and Perfection ” are the themes of our recent annual APACRS meeting in Chengdu, and for the current issue of EyeWorld Asia Pacific. These words neatly summarize our lives as cataract and refractive surgeons, and aptly ran through as a common point during the meeting. The publication also provides a summary of some of our unique sessions that have become the Hallmark of our annual meeting. Highlighted in this issue are the Combined Symposium of Cataract and Refractive Societies (CSCRS) and the “ Top Cataract Surgery Tips ,” which in Chengdu was aptly titled “F rom the Wisdom of the Kung Fu Masters .” The latter session is typically the finale of the meeting, where invited surgeons present the top tips they have found, which result in safer and more efficient cataract

Publishing Consultant Donald R Long don@apacrs.org Production Team Gretel Tan Aileen Bian ewap@apacrs.org

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-Pacifi c 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-Pacifi c 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) 038/02/2024

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EyeWorld Asia-Pacific | September 2024

surgery. The format is a competition in which the best tip is judged by the audience and presented with a prize. The tips are always practical and can be implemented in your own surgeries on your next list. I have chaired this session every year, together with Ron Yeoh, and we have always remarked how useful we have found the suggestions by the top tier surgeons in the Asia Pacific region. So, this year I have selected the most interesting tips for our news journal so that all readers can benefit from the wisdom of the presenters. Ishtiaque Anwar from Bangladesh, who also won an award in the film festival, presented his innovative idea of preventing iris prolapse when performing hydro dissection in cases with floppy iris syndrome. I would recommend you read this as well as the other selected tips as you may find something valuable that could be helpful when you perform the next list! The other bookend to our meeting is the CSCRS, which followed after the Lim Lecture - delivered outstandingly by Shin Yamane. The CSCRS format this year was a debate which tackled three of the more controversial topics in our field. Speakers from the 3 major regional societies of APACRS, ASCRS and ESCRS provided the point and counterpoint views on LAL vs Formulae, Phaco vs FLACS and SMILE vs LASIK. This style of presentation presents the pros and cons of each approach so surgeons can evaluate their own preferences. Beyond the excellent scientific content, the session is unique in that it represents an opportunity for the international societies to share a podium and highlights some of the different preferences of surgeons from different regions. I am proud that APACRS initiated the CSCRS concept 19 years ago in Beijing. Since then, the CSCRS symposium is held during the annual meeting of each society and continues to provide an opportunity for our societies to cooperate as we share deep common interests in this field. I am sure that the contents of this issue will be of interest to our readers and provide a sample of our annual meeting in Chengdu.

Dada Harir Stepwell in Ahmedabad, India

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IMPORTANT DATES

21 SEPTEMBER 2024 Abstract Submission Open • 21 NOVEMBER 2024 Registration Open • 21 FEBRUARY 2025 Deadline for Abstract Submission • 21 MAY 2025 Deadline for 1 st Tier Early Bird Registration Rates

Warmest regards, Graham Barrett

Deadline for Submission of ePosters & Videos for Film Festival

apacrs2025.org

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EyeWorld Asia-Pacific | September 2024

FEATURE Highlights from the 36 th APACRS - 24 th CSCRS Joint Meeting Chengdu, 2024

Tales Of The Flanging Technique

by Christina Chintanaphol and Michelle Dalton

Shin Yamane, MD (Japan) presented at the Lim Lecture this year, with the promise to “reveal everything about the flanging technique: how the flanging technique was developed; what other techniques exist besides the original flanged intraocular lens (IOL) fixation technique; and problems associated with the flanging technique and how to overcome them.” Although a trained vitreoretinal surgeon, Dr. Yamane won both the ASCRS Film Festival and APACRS Film Festival in 2016. Dr. Yamane was “so honored to be selected as a speaker of the Lim Lecture,” but humbly and professionally noted how his technique was the result of collaboration. He “noticed intrascleral IOL fixation techniques were not perfect,” and so modified them. His first-generation attempt used two 27-gauge needles to insert both haptics. Admittedly, it was not as successful as he’d hoped. Soon, he found that both 31- and 30-gauge needles could insert haptics of 3-piece IOLs, but the haptics may end up under the conjunctiva. “It’s not a big problem,” he explained. Shortly after this discovery, he continued reading about flanging techniques that were first used in glaucoma surgery. “Flanging techniques are not my own idea. I modified it from other applications. My fixated intrascleral IOL fixation with the double-needle technique only takes about 5-6 minutes, but it took many tries to make it successful,” he said. Dr. Yamane offered several steps for mastering his technique. Among these steps included bending the needles to 45 degrees with bevel side

up and inserting the haptic into the needle on the table before the first case (and to use non-human eyes as the test case). “The direction of the needle hole is important,” he said. Scleral tunnels should be 2.3-2.5 mm from the limbus to avoid iris capture. Over the years, his flange size has decreased from 1 mm to about 0.25-0.5 mm, but Dr. Yamane noted how he still uses a 30-gauge needle. He also developed a needle stabilizer to ensure the insertion angle is perfect so surgeons have better control of IOL tilt. His first iteration “didn’t work,” and his second idea was to create a spiral groove, “but it was too difficult to make.” After he won the Film Festival in 2016, however, “many companies came to me to develop the instrument.” The device has two wings to hold the loops 20 degrees inward and 10 degrees downward, he said. Finally, he commended others for modifying his flanging technique as well. “My take-home message is to learn from the past,” he said. “Ideas don’t come from one person alone.” The Lim Lecture was named after APACRS founder Professor Arthur S.M. Lim, a pioneer who recruited and worked with expert ophthalmic microsurgeons from around the world, to introduce microsurgical techniques and IOL implant technology to the region. “If you use a 27-gauge, you’ll need a larger flange,” he added. “This is especially effective for beginner surgeons,” he said.

Shin Yamane

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EyeWorld Asia-Pacific | September 2024

FEATURE Highlights from the 36 th APACRS - 24 th CSCRS Joint Meeting Chengdu, 2024

Pathways To Precision And Perfection

by Christina Chintanaphol and Michelle Dalton

This year’s Combined Symposium of the Cataract & Refractive Societies (CSCRS) — a joint symposium of the APACRS, ASCRS, and ESCRS — explored three areas of contention in cataract and refractive surgery. Top surgeons argued their case for either Light Adjustable Lens (LAL) or IOL formulae, manual phacoemulsification or Femtosecond Laser-Assisted Cataract Surgery (FLACS), and Small Incision Lenticule Extraction (SMILE) or LASIK. LAL vs. IOL Formulae In the USA, ASCRS representative David F. Chang, MD (USA) has performed many surgeries using the LAL and noted its rapid adoption in the United States. Although LALs cannot guarantee perfect vision, they can be customized as close to the patient’s needs as possible rather than with selecting a non-adjustable IOL. “I like multifocal IOLs, but their use can come with a whole host of problems,” Dr. Chang said. For example, patients with non-adjustable IOLs could experience night time halos or reduced contrast sensitivity while maintaining high expectations for a high-performing lens. “LALs let patients try out the options,” he said. There is also no need for patients to comprehend preoperative counseling, and they can decide their vision goals after surgery, reducing overall anxiety. Results have been positive with 97% of patients in one study presenting with 20/25 or better uncorrected binocular distance vision after LAL implantation.

On the other hand, APACRS representative Graham Barrett, AM, MBBch, FRANZCO (Australia) argued for sticking to the precision of using IOL formulae. Even though LAL has excellent outcomes, “I find that with my predictions using formulae, I come close to 90% accuracy for both sphere and cylinder,” he said. Other disadvantages of LAL that Prof. Barrett described included the high cost of LAL surgery, concerns with ultraviolet light, anecdotal reports with unusual adverse events, and the need to avoid photosensitizing medications after LAL implantation. “I like precision,” Prof. Barrett said. “Measure twice, cut once. It is better to get things right the first time than fixing after the fact. This is the reason I would suggest predicting with biometry as the pathway to better outcomes.” Phaco vs. FLACS Nic Reus, MD, PhD (Netherlands), representing ESCRS, presented his stance on sticking with conventional cataract surgery rather than performing FLACS, primarily because both procedures have similar, if not the same, clinical results and phacoemulsification requires less operating time and is less expensive. If both phaco and FLACS both result in similar surgically-induced astigmatism, postoperative refractive error, and endothelial cell loss, he asked, why not stick with phaco?

David Chang

Graham Barrett

Nic Reus

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EyeWorld Asia-Pacific | September 2024

FEATURE Highlights from the 36 th APACRS - 24 th CSCRS Joint Meeting Chengdu, 2024

In China, however, Prof. Yao Ke from APACRS argued (with evidence from studies) that, while remaining a safe and effective technique, FLACS has the ability to reduce phaco power and involves the risk of posterior capsule rupture. Furthermore, Prof. Yao argued against the claim made by Dr. Reus that in one of his studies, he found an endothelial cell loss rate of 7.85% after FLACS compared to 19.96% after phaco. SMILE vs. LASIK Even though LASIK has come a long way in the 22 years since it obtained US FDA approval, it still possesses shortcomings with its procedure, William F. Wiley, MD (USA) from ASCRS explained. Problems with dry eye, long-term enhancement options, biomechanics, and flap safety are a few to name. “This is where SMILE has stepped in,” Dr. Wiley said. 6 years after its US FDA approval, the data on SMILE showed that 95% of patients achieved 20/20 vision after 1 month while 98% of patients achieved 20/20 after half a year. “SMILE eliminates the ‘what-ifs’ in refractive surgery,” Dr. Wiley said. From not achieving attempted outcomes, to mitigating risk for dry eye, among other considerations like biomechanical strength issues and need for enhancement, Dr. Wiley professed a slew of different ‘what-ifs’ for contemplation.

“Not everyone achieves the refractive target in the long-term,” Dr. Wiley explained. “With LASIK, it is relatively easy to enhance the eyes in the first year or two. But after 4-5 years, you have a higher risk of epithelial ingrowth.” With the additional benefit of the minimally-invasive nature of SMILE allowing patients to quickly return to regular activities, there are good reasons why SMILE is the fastest-growing corneal refractive procedure. “I’m always an advocate for saying all refractive procedures are great, so it is really difficult to argue for one,” ESCRS representative Thomas Kohnen, MD, PhD, FEBO (Germany) said. But there are clear advantages, with LASIK procedures including faster rehabilitation time, high safety outcomes, and good astigmatism correction, he said. In fact, Dr. Kohnen shared that a lack of cyclotorsion control and centration during SMILE has been shown to contribute to axis alignment inaccuracy, which negatively affects astigmatism correction outcomes. Even patient satisfaction is quite high with LASIK. A 2016 LASIK update review article analyzing 97 articles reported that 1.2% of patients were dissatisfied with their LASIK procedure. “Tell me one procedure in medicine that can give a 99% satisfaction rate,” Dr. Kohnen challenged.

Yao Ke

William F. Wiley

Thomas Kohnen

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EyeWorld Asia-Pacific | September 2024

FEATURE Highlights from the 36 th APACRS - 24 th CSCRS Joint Meeting Chengdu, 2024

The Perfect Save!

by Christina Chintanaphol and Michelle Dalton

The Perfect Save Teaches Techniques for Difficult Cataract Cases For its second year running at APACRS, the International Intraocular Implant Club (IIIC), a club of committed cataract and anterior segment surgeons founded by the inventor of the IOL Sir Harold Ridley, discussed challenging situations for cataract surgeons with emphasis on the idea of ‘The Perfect Save.’ World-renowned surgeons discussed challenges that ranged from techniques for avoiding posterior capsule rupture, to using IOL scaffold techniques during an IOL lens exchange, and also, one surgeon’s own experience with a Posterior Chamber (PC) IOL post-LASIK. Hiroko Bissen-Miyajima, MD, PhD (Japan) spoke about her own monocular cataract surgery in her post-LASIK eye. Although most ophthalmologists when polled say they would prefer a monofocal IOL, she opted for a diffractive IOL. “I am enjoying daily life without spectacles,” she said, while expressing her appreciation for being able to continue consulting and performing surgery without the use of spectacles. She can enjoy driving and “has a better understanding of how patients see.” But she said the surgery was not without some lessons learned. First, she had low astigmatism so did not opt for a toric lens. “Posterior corneal astigmatism should not be underestimated,” she said. “A toric model should have been considered.” Second, surgeons should consider the impact of the dominant eye. In her implanted eye, glare and halo are noticeable, but the effects of the dominant eye

make the bilateral vision acceptable. Third, near vision should be assessed binocularly. Her implanted eye can read letters but is “somewhat weak in contrast.” Binocularly, however, letters are more easily read. Overall, she said her quality of vision is “better than expected,” and she would likely opt for another diffractive IOL in her other eye when the time comes. Paul G. Ursell, MBBS, MD, FRCOphth (UK) described the case of a dissatisfied patient with a toric IOL who was seeing 6/6 unaided shortly after surgery but noted slight disorientation which Prof. Ursell attributed to anisometropia. However, after the second eye surgery, visual acuity readings were still good and the toric lenses were on axis, but the patient remained unhappy. Opting to perform a lens exchange, Prof. Ursell discussed using an IOL scaffold to support small pupils and implanting the replacement lens underneath the scaffold before removing the initial lens. “Small pupils leave no room for instruments like iris hooks or rings,” he said. Using a scaffold alleviates potential issues and allows surgeons to remove the initial lens without concerns about iris prolapse. In post-radial keratotomy (RK) eyes, toric lenses can be considered, said Boris Malyugin, MD, PhD (Russia), but surgeons should be wary if IOL recommendations vary widely. “That should be a red flag for you to think about potential subsequent surgeries, although surgical outcomes can still be good.”

Hiroko Bissen-Miyajima

Paul G. Ursell

Boris Malyugin

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EyeWorld Asia-Pacific | September 2024

FEATURE Highlights from the 36 th APACRS - 24 th CSCRS Joint Meeting Chengdu, 2024

Morganian cataracts can be challenging even for the most experienced of surgeons, said Arup Chakrabarti, MD (India). He recommends using a direct chop after creating a 5-5.5 mm rhexis, using dispersive ophthalmic viscosurgical devices (OVDs) to support the capsular fornix. “Before the surgery, though, a B-scan is a must. Be prepared to use trypan blue dye, microforceps and scissors, and a reliable phaco device,” he said. Concerns in these cases include rhexis issues and potentially poor surgical views. “If you have femtosecond lasers, use it for white cataracts. It’s very safe,” Prof. Yao said during the discussion.

Raising the issue of sustainable practice through the reduction of disposable use items in surgery, Dr. Chang joked about having “no financial interest in climate change.” Dr. Chang said that if the global medical community was a country, it would be the fifth largest in terms of CO 2 emissions. A newer organization, eyesustain.org, aims to reduce the amount of disposable items ophthalmic clinics use by opting for more reusable goods in and out of the surgery suites. “Cross contamination is a minimal risk,” he said. “Numerous papers show that. We’re advocating for electronic Instructions for Use and advocating for the industry to make all-day cassettes.”

Arup Chakrabarti

David Chang

Application opens for the APACRS Travel Grant 2025 to participate in the 37 th APACRS Annual Meeting in Ahmedabad, India. 21 October 2024

Submission Deadline: 20 December 2024

Scan the QR Code or visit www.apacrs2025.org/travel-grant for application criteria and submission.

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EyeWorld Asia-Pacific | September 2024

EDITOR’S PICKS Selected cataract surgical tips presented at the Wisdom of the Kung Fu Masters symposium

One of the most anticipated session of any APACRS annual meeting is the session about top cataract surgery tips. Some surgeons make surgery look so simple, despite others finding it challenging to emulate them. The Top Cataract Surgery Tips session however, provides an opportunity for other surgeons to follow along to learn their genius. This year, attendees heard from 17 surgeons from around the world, each of whom presented a short, 4-minute video featuring their best tips for cataract surgery. Top Cataract Surgery Tips From The Wisdom Of The Kung Fu Masters

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EDITOR’S PICKS Selected cataract surgical tips presented at the Wisdom of the Kung Fu Masters symposium

Taming The Floppy Iris – Sleeve Hydrodissection!

capsular rupture, loss of vitreous, nuclear drop, cystoid macular edema and exaggerated and prolonged postoperative inflammation (Kumar & Raj, 2021). Most of the time, using iris hooks to dilate these poorly dilated pupils in IFIS patients can help to prevent iris prolapse. However, there are instances when an iris prolapses even after using iris hooks or pupil dilating devices during hydrodissection (Figure 1). Iris prolapse in IFIS occurs because irrigating fluid is entrapped below the poorly dilated iris (pupil), with only main incision and side port openings as places for fluid to escape. At this time, the trapped fluid pushes the flaccid iris above the incisions, causing iris prolapse (Figure 2). If we could tamponade the iris near the main wound during hydro dissection, this prevents fluid accumulation and creates a passage for the hydro fluid to escape, preventing iris prolapse and decreasing the chance of further prolapse, so as to allow a completed surgery without grave complications and consequences. Hence, I propose sleeve hydro dissection, which passes the hydro dissection cannula in the commercially available phaco sleeve (Figure 3). The sleeve is then introduced with canula in the eye through the main incision (Figure 4) to tamponade the iris before hydro dissection (single or multi quadrant) (Figure 5). This prevents iris prolapse as 1) the wound is sealed by the sleeve 2) the sleeve tamponades the iris near the wound and 3) the hydro fluid comes out through an alternative channel between the sleeve and cannula continuously (Figure 6-7). When in place, the sleeve prevents the chance of fluid accumulation in the eye during hydro dissection. I have measured the pupil size with a digital callisto system from Zeiss Meditec, Germany before and after the sleeve hydro procedure and there was no reduction of pupil size after this procedure (Figure 8). With over a hundred cases of IFIS performed over the last three years that I have been doing Sleeve Hydrodissection, I have not seen any iris prolapse issues since. The introduction of sleeve hydrodissection offers a promising technique for safe phaco surgery in IFIS cases, alleviating one of the significant challenges surgeons face in managing these complex scenarios. Reference: 1. Chang, D. F., & Campbell, J. R. (2005). Intraoperative floppy iris syndrome associated with tamsulosin. Journal of Cataract and Refractive Surgery , 31(4), 664–673. https://doi.org/10.1016/j.jcrs.2005.02.027 2. Kumar, A., & Raj, A. (2021). Intraoperative floppy iris syndrome: an updated review of literature. In International Ophthalmology (Vol. 41, Issue 10, pp. 3539–3546). Springer Science and Business Media B.V. https://doi.org/10.1007/s10792-021 01936

by Ishtiaque Anwar, MD

Intraoperative Floppy Iris Syndrome (IFIS) was first described by David F Chang and John R. Campbell in 2005. IFIS poses unique challenges for cataract surgeons, characterized by a triad of flaccid iris stroma, propensity for iris to prolapse towards surgical wounds and progressive intraoperative pupillary constriction. (Chang & Campbell, 2005) Iris dilator pupillae muscles contain α 1-adrenergic receptors which contract with dilating drugs facilitating safe and smooth cataract surgery. α 1-adrenergic receptor-blocking drugs such as Tamsulosin block dilator muscle contraction, which causes poor pupillary dilation and sometimes severe loss of pupillary tone. David F Chang identified Tamsulosin as the drug related to IFIS but over the years IFIS has been correlated with several risk factors including: age, gender, hypertension, diabetes, other α 1- adrenergic receptor antagonists ( α 1-ARAs), 5- α reductase inhibitor such as finasteride, angiotensin II receptor inhibitors, benzodiazepines, antipsychotics, antidepressants, anti hypertensive drugs, preoperatively decreased dilated pupil diameter, acute primary angle closure, which are thought to cause loss of iris tone, and iris prolapse during cataract surgery (Kumar & Raj, 2021). Iris prolapse can occur at any stage and is sometimes encountered even after creating a well-constructed multiplanar clear corneal incision. Hydrodissection is the most common step when iris prolapse occurs. But hydrodissection is a crucial step for rotating the nucleus effectively and safely, and is particularly pivotal in IFIS cases where visualization is compromised due to poor pupil dilatation. Once an iris is prolapsed, its tissue becomes more flaccid, which can lead to further prolapse. Extensive prolapse can lead to complications such as iris dialysis, tissue loss, and bleeding. Iris prolapse may lead to complications secondary to miosis such as iris trauma/chafing, posterior

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EyeWorld Asia-Pacific | September 2024

EDITOR’S PICKS Selected cataract surgical tips presented at the Wisdom of the Kung Fu Masters symposium

Figure 1: Even after using iris hooks, the iris prolapsed after hydro dissection.

Figure 2: Trapped fluid underneath the iris near wound causes iris prolapse during hydro dissection.

Figure 3: Hydro dissection cannula is introduced into the phaco sleeve.

Figure 4: Hydro cannula and phaco sleeve introduced in the eye through the main clear corneal incision.

Figure 5: Multi quadrant sleeve hydro dissection being performed in a IFIS case with poor pupil dilation without iris prolapse.

Figure 6: Phaco Sleeve oar locks the wound, tamponades the iris near the wound.

Figure 7: Hydro fluid escapes through the space around the cannula and sleeve wall without collecting in the anterior chamber.

Figure 8: Pupil size remains unaltered after sleeve hydro dissection.

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EDITOR’S PICKS Selected cataract surgical tips presented at the Wisdom of the Kung Fu Masters symposium

Naren’s Fluid Pillar: Improving the performance and safety of phacoemulsification machines

Additionally, the active force exerted by the fluid deepens the chamber, especially when there are few or no pieces in the capsular bag. Intraoperative OCT imaging has demonstrated this deepening effect when the ports are oriented anteriorposteriorly. Furthermore, pressure sensor data indicates reduced chamber IOP fluctuation with this orientation compared to when the holes are directed towards the angles.

by Naren Shetty, MD

Chamber fluctuation or surge is a challenge that every phacoemulsification (phaco) machine aims to overcome. Surge, or collapse in the chamber, reduces the distance between the cornea and the posterior capsule, drawing them closer to the center and potentially leading to complications such as posterior capsular rupture or damage to the endothelium. However, a straightforward technique, termed “Naren’s Fluid Pillar,” promises to revolutionize the performance and safety of current phaco machines.

By implementing this simple technique, we can create Naren’s Fluid Pillar and enhance the performance and safety of our current phaco machines.

DUCK

by Thanapong Somkijrungroj, MD

DUCK , or D own U nder and C ountercloc K wise is a novel surgical technique designed to rotate and refine the position of a 1-piece C-loop toric IOL. A 1-piece C-loop toric IOL is a standard treatment for regular corneal astigmatism in patients undergoing cataract surgery. Thus, the design of the IOL generally requires positioning in the capsular bag with clockwise rotation intraoperatively. DUCK is a safe, easy, and efficient technique designed for counterclockwise rotation, used to refine the final position of the toric IOL.

The creation of Naren’s Fluid Pillar involves orienting the irrigation holes of the phaco probe towards the cornea and posterior capsule (anteriorposteriorly). This orientation generates a strong fluid force (fluid pillar) that pushes the cornea and posterior capsule apart. Consequently, when there is a break in the occlusion, the time for the fluid to exit the irrigation holes and reach the cornea or posterior capsule is drastically reduced.

With the standard IOL implantation technique via a temporal clear corneal incision, the IOL typically lands in

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EDITOR’S PICKS Selected cataract surgical tips presented at the Wisdom of the Kung Fu Masters symposium

the superotemporal/inferonasal axis in the right eye and the superonasal/inferotemporal axis in the left eye. The toric IOL generally needs to be rotated to the designed axis clockwise and refined into the final position after removing the viscoelastic in the anterior chamber, especially beneath the IOL, to prevent postoperative IOL rotation from the planned axis.

Step 3: Use the tip of the I/A handpiece to rotate the IOL counterclockwise (with continuous irrigation) at the peripheral one-third of the IOL optic to the designed axis.

DUCK Step 1, with irrigation directed upward/downward, allows the surgeon to stretch the capsular bag, push the IOL up to create a slight tilt, and push the posterior capsule backward, creating space for counterclockwise rotation. Step 2 ensures that all viscoelastic underneath the IOL is completely removed, and Step 3 safely and gently performs the counterclockwise rotation with adequate space between the IOL and posterior capsule, created by the irrigation of the I/A handpiece. Step 3 must be performed gently without creating too much tilt of the IOL, safely creating the rotation force counterclockwise by lifting the IOL at the peripheral one-third of the optic and gently moving sideways from right to left. This step can be done repetitively using either a one-hand technique with the I/A handpiece only (the author’s preference) or bimanually, together with a second instrument via a clear corneal incision. Thus, DUCK should be performed when the IOL is misplaced beyond the design axis by less than 30 to 45 degrees; otherwise, standard clockwise rotation is recommended. In summary, DUCK is a novel, safe, easy, and effective surgical technique for performing counterclockwise IOL rotation in the bag, used to refine the final intraoperative position of a 1-piece C-loop toric IOL.

In some cases, especially after the viscoelastic is removed from beneath the IOL, the position of the IOL may be over the planned axis. The surgeon generally needs to rotate the IOL clockwise almost 180 degrees to the preoperative design position. Rotating the IOL in the bag without viscoelastic, using either a one-hand or two hands technique, while employing a second instrument, can exert force on the zonules and possibly cause zonular injury, affecting the IOL’s position intraoperatively and postoperatively. Zonular damage can create decentration, tilt, and/or anterior/posterior movement of the IOL, which directly affects the effective lens position (ELP) postoperatively and causes undesired residual refractive error that impacts patient vision. DUCK is a technique to rotate the IOL counterclockwise with minimal force applied to the zonule, consisting of three simple steps:

Step 1: With the I/A handpiece, go underneath the toric IOL with irrigation in an upward/downward or oblique position.

Step 2: Gently tilt the IOL in the capsular bag and remove all viscoelastic from underneath the IOL.

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EyeWorld Asia-Pacific | September 2024

EDITOR’S PICKS Selected cataract surgical tips presented at the Wisdom of the Kung Fu Masters symposium

by Tim Roberts, MD How To Improve The Effectiveness Of Intracameral Anaesthetic During Cataract Surgery Under Topical Anaesthesia Topical Anesthesia (TA) is a common, safe and effective method for clear corneal phacoemulsification. It eliminates the risks associated with orbital needle injection and minimizes patient discomfort during the procedure, allowing for minimal sedation. Visual recovery is rapid, and patients do not require an eye pad after surgery. This allows for early (same-day) instillation of antibiotic and anti-inflammatory eye drops postoperatively, reducing complications and improving surgical outcomes. Benefits of Topical Anaesthesia • Eliminates complications of orbital injections • Minimises risk with anticoagulants • Minimises IV sedation • Easier to administer and manage • More efficient theater time • Allows earlier (same-day) administration of antibiotic/ anti-inflammatory drops • Quicker visual recovery post-surgery

Supplementing TA with IntraCameral Anesthesia (ICA) may further reduce discomfort which can occur particularly during stages involving manipulation of intraocular structures or rapid changes in eye pressure. 1,2,3 At the recent 36 th APACRS-24 th CSCRS Joint meeting in Chengdu, I shared a simple technique which has greatly improved patient comfort with ICA and is a practical tip that all cataract surgeons can use immediately on their next surgical list. SURGICAL TIP – TO MAINTAIN THE ANTERIOR CHAMBER, DON’T WASH OUT THE INTRACAMERAL ANAESTHETIC WHEN INJECTING OVD How OVD is injected into the AC immediately after the ICA can have a significant impact on the anaesthetic effect. Over the last year I observed that most of my patients were comfortable and pain free, but a small and vocal minority complained of discomfort during surgery. I reviewed the surgical videos and initially couldn’t see any difference in phacoemulsification or IOL insertion techniques that could explain why some patients complained of discomfort while others didn’t. It was, however, a case of “looking but not perceiving.” After many hours looking at videos I finally “saw the light” and discovered a direct correlation between how the OVD is injected into the AC and the effect of ICA. Avoid This Technique The OVD cannula tip is passed through the corneal incision and across the anterior chamber and OVD is injected, filling the anterior chamber toward the corneal incision. Whilst this does flush out any air bubbles (especially with FLACS), it ‘flushes’ the intracameral anesthetic out of the eye, reducing the anesthetic effect and increasing a patient’s likelihood of being aware of discomfort.

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EyeWorld Asia-Pacific | September 2024

EDITOR’S PICKS Selected cataract surgical tips presented at the Wisdom of the Kung Fu Masters symposium

The Recommended Technique The OVD cannula tip is placed just inside the lip of the corneal incision and OVD is injected away from the incision filling the anterior chamber, ‘trapping’ the intracameral anesthetic in the anterior chamber, significantly enhancing patient comfort.

Surgical Technique Reasonable surgical speed is required as patient comfort and cooperation decrease exponentially, the longer the process of surgery carries on. Other tips: avoid excessive light by initially dimming the illumination of the operating microscope, so that the patient is not startled by the bright light at the beginning of the procedure. Use a Lieberman style speculum to avoid excess eyelid pressure; minimize instrumentation and frequent inflation of the Anterior Chamber (AC) as pressure fluctuation is a common cause of patient discomfort. Also, develop a conjunctival ‘no touch’ technique (avoid forceps or fixation rings). It is helpful to avoid talking to your patient too much during surgery, as this avoids sudden re-fixation movements when the patient responds. The eye assumes a neutral position when the patient is in a relaxed ‘dreamy’ state. Occasional updates on the surgery, e.g. “I’ve safely removed the cataract and I’m polishing the capsule before implanting the intraocular lens” and reassuring comments that “all is going well’ and “not long to go” are sufficient, and provide the most comfort. Reference: 1. Roberts TV et al (2008). Adverse medical events associated with cataract surgery performed under topical anaesthesia. Clin Exp Ophthalmol . 2008 Dec;36(9):842 6. doi: 10.1111/j.1442-9071.2009.01924.x. PMID: 19278479. 2. Minakaran N et al (2020). Topical anaesthesia plus intracameral lidocaine versus topical anaesthesia alone for phacoemulsification cataract surgery in adults. Cochrane Database of Systematic Reviews 2020 , Issue 7. Art. No.: CD005276. DOI: 10.1002/14651858.CD005276.pub4. Accessed 13 July 2024 3. Roberts TV et al (2002). A comparison of cataract surgery under topical anesthesia with and without intracameral lignocaine. C linical and Experimental Ophthalmology 2002 ;30(1):19-22. [PMID: 11885789]

Patient Selection Not all patients are suitable for TA. If you are considering transitioning, topical anesthesia works best with clear corneal incisions. It is best to avoid challenging or difficult cases which are likely to require a longer operating time. I’d recommend in the early stages avoiding eyes with dense cataract, weakened zonules, a poorly dilating pupil, or shallow anterior chamber. Patients with anxiety/claustrophobia, nystagmus, severe dementia or developmental delay and language barriers need to be carefully assessed to determine the most appropriate anesthetic technique.

Editors’ note: This article focuses on cataract surgical tips selected by the EyeWorld Asia-Pacific Editors, and it is not intended to be a full report on all the tips presented at the Wisdom of the Kung Fu Masters symposium.

About the Physicians Ishtiaque Anwar, MD | Consultant (Cataract & Refractive Surgery), Bangladesh Eye Hospital & Institute | ishtiaqueanwar1976@gmail.com

Naren Shetty, MD | MS Ophthalmology, H.O.D Cataract & Refractive Narayana Nethralaya | Narayana Nethralaya, Bangalore, India | narenshetty.27@gmail.com Thanapong Somkijrungroj, MD | Vitreoretinal Research Unit, Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand | thanapongmd@gmail.com Tim Roberts, MD | Clinical Associate Professor of Ophthalmology, The University of Sydney School of Medicine, Faculty of Medicine and Health, Consultant Ophthalmic Surgeon, Royal North Shore Hospital, Vision Eye Institute, Sydney | tim.roberts@vei.com.au

Relevant Disclosures Anwar: Zeiss Meditec Shetty: Alcon, Zeiss, Johnson & Johnson, Bausch and Lomb, Casulaser Somkijrungroj: ALCON, Zeiss Roberts: None

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EyeWorld Asia-Pacific | September 2024

Alcon at APACRS 2024: Formal Introduction of the WaveLight Plus

Supplement to EyeWorld Asia-Pacific September 2024

He added his real-world outcomes are “not that surprisingly different from the multicenter trial. In our study, 89% of our patients achieved 20/16; “Analysis of lines of change from preoperative CDVA to month 3 CDVA showed that 46.5% eyes had no change, 40.3% eyes gained 1 line, and 8.0% eyes gained 2 lines of visual acuity. None of the eyes lost 2 or more lines of CDVA compared with preoperative CDVA.” With more than half the patients seeing 20/16 or better, “my touch-up rate has gone down,” Prof. Bala said, adding that most of those are in eyes with higher cylinder. Preoperative higher-order aberrations (HOAs) were 0.308±0.102, and post LASIK they were 0.371±0.135; these increases were not clini cally signi cant.. Additionally, spherical aberration decreased. “This is the rst time we are seeing a systematic reduction in spherical aberration from, and that is an achievement for engineering technology at a 6mm zone. Remember, this is not at the 4mm zone,” he said. Using one device to redefine refractive surgery Accurate refraction is the most important parameter for a successful laser vision correction (LVC) surgery, and refraction is based on the cycloplegic and the manifest or subjective refraction, with manifest refraction being the gold standard for LVC, co-moderator Prof. Yueguo Chen, MD (China) said. Errors introduced in the subjective refraction (inadvertently from tech nicians or optometrists and/or patients) can lead to clinically signi cant refractive surprises. The question becomes, How accurate is the wavefront-based objective refraction and can it replace manifest refraction or be used with a nomogram adjustment? The WaveLight Plus creates the ablation pro le by creating a 3D eye model (Innov Eyes) and an ablation pro le incorporating 2,000 rays of light from the corneal anterior surface to the retina. It then takes into account the geometrical and optical properties of the entire cornea and intraocular segments, he said. In unpublished data on the consistency between the subjec tive refraction and the objective wavefront refraction in 500 eyes (average age was under 30 years), Dr. Chen found both the wavefront refractive sphere and cylinder (-6.18D and -1D,

CHENGDU, China — This year’s APACRS served as the formal launch in Asia of Alcon’s latest refractive device, the WaveLight Plus. Several experts spoke about the device’s attributes, among them its ability to create a 3D eye, which allows sur geons to truly personalize each patient’s treatment. Introducing the WaveLight Plus Co-moderator Chandra Bala, PhD, BSc(Med), MBBS, FRANZ CO (Australia) has performed more than 2,000 surgeries with the WaveLight Plus; he recently completed a study (N=400) that showed more than 80% of the patients achieved 20/16 vision or better. An advantage of the WaveLight Plus is its InnovEyes Sight map, a single, non-contact-ophthalmic diagnostic device designed to capture images of the anterior segment of the eye, which includes the cornea, pupil, anterior chamber and lens. Furthermore, it provides the axial dimensions and is indicated to analyze the optical aberrations of the eye by use of wave front technology.” “The patient doesn’t get up and move anywhere,” Prof. Bala said. “Everything — refraction, aberrometry, topography — all these metrics are measured in one sitting and they’re aligned to the patient’s corneal vertex.” Error rates are diminished as a result; treatment occurs along the corneal vertex, he said. “No longer do we need to treat their glasses; we’re treating each and every dot on their cornea as an individual dot. It’s truly personalized to their eye,” he said.

In his experience, Prof. Bala has only encountered three instances where he could not get the pupil to dilate enough to

take a measurement. Real-world results

In his real-world study 1 of 400 myopic eyes (range ≤ -8.25D; astigmatism 0 to -4.25D) that were treated with the WaveLight Plus and having a 3D eye model generated with a customized LASIK ablation pro le, Prof. Bala said “in more than half the cases, we were able to achieve 20/12.5. In fact, we were able to get 20/10 in 8% of cases.”

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EyeWorld Asia-Pacific | September 2024 In a 400-eye cohort, 89.3% of eyes achieved 20/16 or better uncorrected distance visual acuity after myopic LASIK with the WaveLight Plus.

No longer do we need to treat their glasses; we’re treating each and every dot on their cornea as an individual dot. It’s truly personalized to their eye. Chandra Bala, PhD, BSc(Med) “ ”

respectively) to be higher than the subjective refractive sphere and cylinder (-5.59D and -0.90D, respectively). There were also different gaps in the type of astigmatism between the two refractions. “Use of wavefront-based objective refraction and whole eye ray-tracing customized ablation can further improve uncorrect ed VA (UCVA) and visual quality,” he said. A. John Kanellopoulos, MD (Greece) told attendees that pre vious refractive surgery techniques negatively impacted the cornea as an optical surface even when providing spectacle independence. “Ray-tracing is a different story. This device uses data from epithelial remodeling according to the spherical equivalent you’re treating,” he said. “WaveLight Plus has its own algo rithm through the Eyevatar to calculate the low-order myopia and astigmatism as well as the higher order aberrations (HOAs) automatically.” Surgeons do not need to make any nomogram adjustments as a result, and the device recommends the opti mal treatment. Plus, the WaveLight Plus technology “takes into account the tilt between the cornea’s elliptical system and the lens’ elliptical system,” Prof. Kanellopoulos said. A multicenter, multinational published study 2 found “a sig ni cant reduction of the astigmatism to essentially nil,” Prof. Kanellopoulos said. Some eyes even gained 2 lines of vision, he added. For eyes that cannot have LASIK. Another pa per 3 showcased Prof. Kanellopoulos’ own ray-tracing cohort outcomes postoperatively and “established that the data are stable even 2 years out,” he said. “Postop contrast sensitivity is better than the preop.” In short, he said, “we have the opportunity to improve the visu al optics of the eye for the rest of the patient’s life.” Personalized plans improve visual outcomes Fengju Zhang, MD, PhD (China) showed results from her real-world clinical study (51 patients, 99 eyes). She included patients with a pupil size >4.5 mm, and used the Sightmap to evaluate anterior chamber depth, central corneal thickness, wavefront refraction, and topography. She used the WaveLight FS200 to make the customized aps on her patients, with a thickness of 110 µm and a diameter ranging from 8.6 mm to 8.8 mm (depending on the customized ablation pro le). She used the WaveLight EX500 to create optical zones of 6.0 mm to 6.7 mm. “If the difference between the subjective refraction and the wavefront-measurement was more than 0.5 D to 0.75 diopters, I will make a little bit of adjustment,” she said. At postop Month 1 (n=44 patients/87 eyes), 56% of the eyes gained ≥ 1 line of CDVA, she said, adding that UDVA was better than 20/20 in 99% of eyes, was 20/16 in 66% of eyes, and 20/12.5 in 15% of eyes. Further, UDVA was within 1 line of preop CDVA in all eyes. Spherical equivalence was within ±0.5 D of target in 77% of eyes and was within ±1.00 D of target in 98% of eyes. At post op Month 1, 75% of eyes were within ±0.25 D of cylinder. The mean difference vector was 0.05D, and the correction index was 0.98, she said.

At postop Month 3 (n=30 patients/59 eyes), “the refraction remained quite stable,” she said; UDVA was ≥ 20/20 in 98% of eyes, ≥ 20/16 in 64% of eyes, and ≥ 20/12.5 in 15% of eyes. When the InnovEyes manifest refraction is “a bit high com pared to the cycloplegic refraction, I will reduce the spherical correction,” she said. In younger eyes that may have postop regression, “I keep the cycloplegic refraction the same in the dominant eye.” WaveLight Plus is “truly an incredible driver for personalized myopia correction,” said Pierce Lin, MD, PhD (Taiwan), and the InnovEyes Sightmap leverages the unique ray-tracing technol ogy by iteratively tracing 2,000 rays of light. “This allows us to measure from the cornea to the crystalline lens, then to the retina, creating a personalized 3D eye model to help identify the best ablation pro le for our patients,” Dr. Lin explained in a video. Dr. Lin presented unpublished data comparing outcomes with the WaveLight Plus (n=58) and Alcon’s Contoura (n=106). Gen der and age distribution was similar between the two groups, but the Contoura group had much higher spherical equivalent (-6.83±1.89 D) than the WaveLight Plus group (-4.66±1.55 D). At postop month 1 there was “excellent ef cacy” in UCVA, with 41% of eyes in the WaveLight Plus group and 10% of eyes in the Contoura group achieving 20/12.5. The predictability was also excellent in both groups, with “a majority of patients within 0.5 D,” Dr. Lin said: 96.6% of pa tients in the WaveLight Plus group were within ±0.5 D, com pared to 89.4% of patients in the Contoura group. Dr. Lin said surgeons should think of traditional lenticular ex traction as buying a suit “off the rack,” whereas the WaveLight Plus is more like “having a suit custom-made for the buyer.” Reference: 1. He G and Bala C. Ray-tracing-guided myopic LASIK: real-world clinical outcomes. J Cataract Refract Surg. 2023;49:1140-1146. doi.org/10.1097/j.jcrs.0000000000001286 2. Kanellopoulos AJ, Maus M, Bala C, Hamilton C, Lemonis S, Jockovich ME, Khoramnia R. International Multicenter, Myopic and Myopic Astigmatism Femto LASIK, Customized by Automat ed Ray-Tracing Ablation Pro le Calculation: A Postmarket Study. Clin Ophthalmol. 2024 Feb 20;18:525-536. doi: 10.2147/OPTH. S435581. 3. Kanellopoulos AJ. Ray-Tracing Customization in Myopic and Myopic Astigmatism LASIK Treatments for Low and High Order Aberrations Treatment: 2-Year Visual Function and Psychometric Value Outcomes of a Consecutive Case Series. Clin Ophthalmol. 2024 Feb 22;18:565-574. doi: 10.2147/OPTH.S444174. 4. InnovEyes™ Sightmap Diagnostic Device User Manual 5. RFP911-P001 Postmarket Study of Outcomes from WaveLight EX500 InnovEyes

Media placement sponsored by ALCON Carl Zeiss Meditec AG

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EyeWorld Asia-Pacific | September 2024

Copyright 2024 APACRS. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or publisher, and in no way imply endorsement by EyeWorld, Asia-Pacific or APACRS. All other trademarks are the intellectual property of their respective owners. © Alcon 2024 08/24 ASIA-WL5-2400001