Dynamic leaders essential to APAO’s success, growth

Biennial conference will become yearly starting with next year's meeting in Singapore.

KUALA LUMPUR, Malaysia — New ruling members of the Asia Pacific Academy of Ophthalmology were welcomed during a ceremony at the APAO meeting here, as attendees bade farewell to the outgoing leaders.

Prof. Arthur S.M. Lim, MD (Hon) FRCS, of Singapore, the outgoing secretary general of the APAO, welcomed new secretary general Prof. Dennis S.C. Lam, FRCS, FRCOphth, of Hong Kong, and new president Prof. Yasuo Tano, MD, of Osaka, Japan.

“I wish to announce that we have two wonderful leaders for the coming years, Prof. Tano, of Japan, and for APAO to succeed, it’s important to recognize younger, dynamic leaders for APAO, and for this we have Prof. Dennis Lam,” Prof. Lim said.

According to APAO tradition, the new secretary general officially began to conduct the activities of APAO immediately following the ceremony.

Dr. Tano congratulated the council for conducting “the most successful meeting in the APAO history.”

“I am now very happy to take over the presidency of the APAO, which has a good and long history,” Prof. Tano said. “This is a time where everything is really changing. Asian ophthalmology is growing so very rapidly numerically, economically and scientifically. ... I am more than happy to take this responsibility at this exciting time. I am very confident with new secretary general Dennis Lam and all of the wise council members. I will [work very hard] in the next 2 years to make this APAO stronger, and more fruitful with lots of prosperity.”

In his remarks, Prof. Lam said, “With regard to APAO, we have come a long way. We have developed from scratch to a position of strength. So the charge I have is to develop from strength to strength.

“Asia-Pacific is a large region, in which we have a lot of diversity and a lot of different needs,” he continued. “Let us be united, so that we can have unity in diversity. With the able leadership of Prof. Tano and also the advice and guidance of our very capable senior leaders, I am fully confident that APAO will develop from strength to strength, and in a short period of time we hope that we will be able to get to new heights.”

Prof. Lam said medical work is a “commitment to serve humanity,” and that when it is done correctly physicians have the ability to make a difference.

“We want to make the best use of the resources available to help the greatest number of patients at the best possible level. So let’s all work together to treat treatable blindness and to prevent the preventable blindness,” Prof. Lam said.

The APAO meeting, attended by 2,990 delegates from around the world, included 22 symposia, 67 instruction courses, and many free paper sessions and presentations. Beginning with next year’s APAO/Asia-Pacific Association of Cataract and Refractive Surgeons joint meeting in Singapore, June 10-15, 2006, the meeting’s frequency will change from biennial to annual, according to the meeting organizers.

Two new programs were incorporated into the meeting this year: a symposium on holistic remedies and a medical ophthalmology program.

Switch to customized LASIK

A surgeon who has been using wavefront-customized LASIK for more than 2 years reviewed some of his clinical results and patient selection criteria at the APAO meeting. Michael Lawless, MD, spoke to Ocular Surgery News about his clinic’s experience with customized LASIK.

Dr. Lawless’ clinic in Sydney, Australia, began using Alcon’s LADARVision platform about 4 years ago, he said, and began using the company’s wavefront customization options in January 2003. From May to December 2003, the clinic treated about 2,500 eyes, and about 29% of those received customized wavefront surgery, Dr. Lawless said. He discussed some of the clinical results in the custom-treated eyes.

The Asia Pacific Acadamy of Ophthalmology congress was held at the Sunway Lagoon Resort and Hotel in Kuala Lampur, Malaysia. Image: Mullin DW

“We were getting low to moderate uncorrected visual acuity in the range of 90% to 95% with 20/20, and about half of those were 20/15,” he said.

Dr. Lawless also observed that “contrast sensitivity could improve under low light and photopic conditions” for patients undergoing customized treatments. And psychometric testing showed that patients treated with wavefront-guided correction “came up with results that were better than we could get with conventional LASIK,” he said.

Dr. Lawless also spoke about his patient selection criteria for customized LASIK and for corneal refractive surgery in general.

“The people who didn’t get custom were those outside the treatment range and people with hyperopia,” he said. In addition, patients with thin corneas were at first not selected for the custom program because early algorithms removed more tissue than current algorithms, he said.

Each new algorithm has been “always better than the previous version,” he said. “They’re better at saving tissue, better at targeting spherical aberration and remain a very good treatment for coma and other higher-order aberrations.”

Not all patients should be candidates for corneal refractive surgery, Dr. Lawless said.

“Somewhere around –8 D is my limit for corneal refractive surgery,” he said. “Beyond that I don’t want to operate on the cornea because you’re doing too much to it.”

Dr. Lawless says he prefers to leave a stromal bed at least 300 µm thick. With new algorithms, he said, Alcon’s CustomCornea treatment regimen is “relatively tissue sparing, but it still has constraints.” Faced with a patient whose cornea is too thin, he will opt to perform another procedure rather than risk thinning the residual stromal bed to less than 300 µm, he said.

Ideally, Dr. Lawless said, he would like to see the CustomCornea treatment range expanded, “not on the myopia or astigmatism side, because they are maxed out, but on the hyperopic side.”

A more complete version of the interview with Dr. Lawless will appear in an upcoming issue of Ocular Surgery News.

Custom LASIK vs. conventional

Postoperative refraction and improvement in best corrected visual acuity were better with customized LASIK than with conventional LASIK in a study presented here.

Anun Vongthongsri, MD, presented the results of a clinical study he performed using several software options available on the Nidek excimer laser. The strategies used, in addition to conventional ablation, were the Navex optimized aspheric treatment zone (OATz), the customized aspheric treatment zone (CATz) and the optimized path difference customized aspheric treatment (OPDCAT).

The nonrandomized prospective study included 382 eyes of 216 patients, 99 of whom were men. Dr. Anun used the Nidek OPD scan, the Nidek CX2 excimer laser and the Nidek MK2000 microkeratome. Patients ranged in age from 19 to 62 years old. The mean follow-up was 3.6 months, ranging from 3 to 8 months, Dr. Anun said. Conventional LASIK was performed in 112 eyes, OATz in 137 eyes, CATz in 27 and OPDCAT in 106.

Preoperatively, BCVA was 20/20 or better in 83.9% of patients in the conventional group, in 81% of patients in the OATz group, in 57% in the CATz group and in 85% in the OPDCAT group, Dr. Anun said. Mean preop refractive error ranged from –4.11 D in the conventional group to –5.45 D in the OATz group. Patients treated with CATz had a mean preop refractive error of –4.69 D, and those treated with OPDCAT had a mean preop refractive error of –4.5 D

Postoperatively, BCVA was 20/20 or better in 86.5% of the conventional LASIK treatment group, 92.7% in the OATz group, 85.7% in the CATz group and 97.1% in the OPDCAT group.

Postop refraction was with within 0.5 D of emmetropia in 86% of the patients in the conventional group, in 95% in the OATz group, in 97% in the CATz group and 100% in the OPDCAT group.

“All groups had good results; all groups had 100% postoperative uncorrected visual acuity equal to or greater than 20/40; all groups had a gain in BCVA of 7% to 43%, with conventional LASIK gaining less than the other groups,” Dr. Anun said.

“Customized LASIK seems to be better than conventional ablation,” he said.

‘Light touch’ CK

Patients who underwent conductive keratoplasty with a modified “light touch” technique reported a higher level of satisfaction than patients who underwent conventional CK, according to Low Cze Hong, MD, FACS, FRCS, FRCOphth.

Dr. Low performed “light touch” CK in 85 eyes of 65 patients under local anesthesia using the Refractec ViewPoint CK system. He compared the results with that procedure against the results of the clinical study submitted to the Food and Drug Administration for approval of conventional CK.

Dr. Low performed the modified technique in one eye of 45 patients and bilaterally in 20 patients. All patients were between 43 and 59 years old, he said. There was no loss of best corrected visual acuity in any of his patients, and 99% achieved N6 or better near vision, he said.

“Patients who undergo [light touch] CK find the response is greater because it’s less invasive and results are enhanced,” Dr. Low said.

He said he sees CK as an additional tool for presbyopia correction because “it’s suitable to those averse to cutting a corneal flap and its associated risks.” Counseling to ensure than patients have reasonable expectations is a necessary first step before surgery, he told attendees.

“We’re not promising the sky, and it’s very important in presbyopia,” Dr. Low said. “As an initial start, anyone who embarks on a refractive procedure needs to lower expectations. The important thing is realistic expectations. Aim for J1, but tell your patients they’ll achieve J3,” and you will have a happy patient, he said.

SLT in different populations

Selective laser trabeculoplasty (SLT) safely lowered IOP in trials conducted in Australia and China, according to two speakers here. The two physicians said the laser procedure could become a first-line treatment for glaucoma, either in combination with or in lieu of medical treatment.

The studies were conducted by Jimmy S.M. Lai, MD, MBBS, FRCSEd, FRCOphth, and colleagues in Hong Kong and by Ivan Goldberg, MBBS, FRANZCO, FRACS, and colleagues in Sydney, Australia.

In SLT, a non-thermal laser beam is used to “selectively target pigmented trabecular meshwork cells without causing structural damage,” Dr. Goldberg said.

“SLT appears to cause no structural damage to the trabecular meshwork,” he said.

Dr. Goldberg retrospectively studied 324 eyes of 324 patients followed for a mean of 21 months after SLT treatment.

The minimally invasive procedure “could well be considered an alternative to argon laser trabeculoplasty and medical therapy for patients who want it,” Dr. Goldberg said. “It is a useful option for patients on maximum medical therapy.” He said he began using SLT instead of ALT more than 3 years ago.

In the study Dr. Goldberg presented, 226 of 324 eyes (70%) achieved their targeted pressures at 6 months. Of the 98 eyes that did not reach their target IOPs, 37 showed an IOP reduction of more than 25% from baseline IOP, 35 had an IOP reduction of less than 25% and 26 showed no change from baseline, he said.

The study also found that, following SLT, 87 patients (26.9%) used fewer medications, 217 patients (67.0%) used the same number of medications and 20 patients (6.2%) needed an increase in their medications.

Dr. Lai’s study, conducted in Hong Kong, included 58 eyes of 29 Chinese patients. In this prospective randomized trial, one eye of each patient underwent SLT and the fellow eye received medical treatment. All patients had dark brown irides and a pigmented trabecular meshwork, he said.

Patients received 1% apraclonidine 1 hour prior to the laser treatment. They were also treated with 1% apraclonidine after treatment. Topical steroids (1% prednisolone acetate) were administered four times per day for 1 week. Following SLT, IOP was measured hourly for 2 hours, and hourly measurements continued if IOP was greater than 5 mm Hg. Slit-lamp examination was also performed.

In the medically treated eyes, topical glaucoma medications were commenced 2 hours after SLT. Follow-up was performed at 1 day; 1 and 2 weeks; 1, 3 and 6 months; and then yearly.

“With fewer medications, SLT gives IOP reduction similar to medical therapy alone in Chinese patients with primary open-angle glaucoma or ocular hypertension,” Dr. Lai said.

Blue-light filtering lens

Patients implanted with a clear IOL in one eye and a blue-light filtering IOL in the other reported no significant differences in color perception between the two eyes, said Khiun Tjia, MD.

Dr. Tjia of Zwolle, Switzerland, reported results of a study in 96 patients who had an Alcon AcrySof SA 60 clear lens implanted in one eye and an AcrySof Natural SN 60 yellow-tinted, blue-light filtering IOL in the other. A control group of 82 patients had clear IOLs implanted in both eyes.

“For both groups there was no significant difference in follow-up, best corrected visual acuity or refraction preop and postop,” Dr. Tjia said in his presentation here.

Telephone interviews were conducted asking all patients if they noted any differences in color perception, disturbance by bright light or preference in regard to color and brightness between their two eyes.

Dr. Tjia said three patients in the clear/Natural group reported a color difference with both eyes open. None of the patients in the clear/clear group reported any color difference with both eyes open. With eyes alternatively opened and closed, 12 additional patients reported a color difference in the clear/Natural group and eight reported a color difference in the clear/clear group.

Two patients reported being mildly bothered by the color difference in the clear/Natural group, and three were mildly bothered by the difference in the clear/clear group.

No differences between the two eyes in response to bright light were reported in either group.

“There were no significant complaints of color vision discrepancy with the SN 60, no difference in brightness of light and no preference for SN 60,” Dr. Tjia said. “Patients with a [clear] lens in their first eye can have a yellow implant in the second eye to benefit from the blue filtering protective effect in at least one of their eyes.”

Manual fragmentation results

A higher level of intraoperative pain may be experienced by patients undergoing manual phacofragmentation than by those undergoing phaco, said Pipat Kongsap, MD. However, no significant differences were found in patient cooperation, ease of surgery or surgical complications, in a study he conducted to compare the two procedures.

Dr. Kongsap found that 70% of patients undergoing prechop manual phacofragmentation and 80% undergoing standard phacoemulsification reported either no pain or a slight discomfort.

He said 92 patients undergoing phaco or prechop manual phacofragmentation were asked to rate their pain level on a scale of 1 to 10 during surgery. All patients were given topical anesthesia.

Dr. Kongsap said the mean pain score was 1.62 in the prechop group and 1 and in the standard phaco group.

He said this difference was statistically significant (P = .01), but there was no significant difference in patient cooperation, ease of surgery or complications between the groups.

Dispersive-cohesive viscoelastic

A viscoelastic material that combines the qualities of cohesive and dispersive viscoelastics has “just the right balance” of each for cataract surgery, said Abhay Vasavada, MS, FRCS.

Dr. Vasavada said DisCoVisc (chondroitin sulfate, sodium hyaluronate, Alcon) is cohesive enough during cataract surgery to maintain anterior chamber depth and to be removed easily after IOL insertion, and it is dispersive enough to protect intraocular structures.

Dr. Vasavada subjectively evaluated the viscoelastic during capsulorrhexis, phacoemulsification, IOL insertion and when removing the viscoelastic from the anterior chamber. He said DisCoVisc is superior in all aspects of surgery compared to Viscoat (chondroitin sulfate, sodium hyaluronate, Alcon).

“DisCoVisc retains all positive aspects of both cohesive and dispersive viscoelastics. It’s an excellent space maintainer, it’s easy to remove and it’s both cohesive and dispersive,” Dr. Vasavada said.

Occlusion with DisCoVisc does not occur, so surgeons do not have to remove the viscoelastic before performing phaco, he added. Because of the product’s cohesive quality, Dr. Vasavada said, he found no need to aspirate behind the IOL to remove it.

“DisCoVisc is an alternative to separate use of [Alcon’s] Provisc (sodium hyaluronate) and Viscoat, which I’ve always enjoyed,” Dr. Vasavada said. “You don’t need to use separate viscoelastics to get both properties. It is the first viscoelastic optimized for cataract surgery.”