EW MEETING REPORTER70 May 2015

Reporting from the 30th APAO Congress in conjunction with the 20th COS Congress, April 1–4, 2015 Guangzhou, China

Reporting from the 30th APAO Congress in conjunction with the 20th COS Congress

Opening Ceremony officiallykicks off APAO meetingThe 30th Asia-Pacific Academy ofOphthalmology (APAO) Congress in conjunction with the 20th Chinese Ophthalmological Society (COS) Congress officially opened withan Opening Ceremony. It featured Chinese acrobatic performances, welcome addresses from society presidents and organizing members, and the presentation of a number of awards.

Ningli Wang, MD, Beijing, Congress president and COS presi-dent, gave the first welcome address,followed by Rajvardhan Azad, MD, New Delhi, India, APAO president. Ling Luo, MD, CMA deputy sec-retary-general; Hugh Taylor, MD, Melbourne, Australia, International Council of Ophthalmology (ICO)

president; Russell van Gelder, MD, Seattle, AAO president; and Prof. Guo Ying Li, secretary-general of the Guangzhou Medical Association, a special guest at the session, also gave speeches.

The ceremony concluded with the inauguration of and speech from the APAO incoming president, Dennis Lam, MD, Hong Kong.

Ophthalmic Premier League back at APAOThe Ophthalmic Premier League was back again at this year’s APAO meeting, with 4 teams competing in the video competition of man-agement of cataract complications. David Chang, MD, Los Altos, Calif., and Amar Agarwal, MD, Chennai, India, were the chairs of the session. Dennis Lam, MD, Hong Kong, and

Clement Tham, MD, Hong Kong, served as judges, with Marguerite McDonald, MD, Port Washington, N.Y., and Sujatha Mohan, MD, Chennai, India, as the match refer-ees. Vineet Ratra, MD, Bangalore, India, and Rajvardhan Azad, MD, New Delhi, India, were the offside umpires. The Surgeless Sultan team was made up of Mohan Rajan, MD, Chennai, India, Ramamurthy Dandapani, MD, Bangalore, India, Soon Phaik Chee, MD, Singapore, and Marie-Jose Tassignon, MD, Antwerp, Belgium. The Chopping Conquerors team was made up of Abhay Vasavada, MD, Ahmedabad, India, Geoffrey Tabin, MD, Salt Lake City, Athiya Agarwal, MD, Chennai, India, and Kumar Doctor, MD, Mumbai, India. The Diffractive DareDevils team was made up of

Attendees of the 30th APAO Congress network and browse in the main entrance of the exhibit hall.

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Mahipal Sachdev, MD, New Delhi, India, Richard Packard, MD, Lon-don, George Beiko, MD, Ontario, Canada, and Ravindran Ravilla, MD, Madurai, India. Finally, the Bursting Buccaneers team consisted of Chitra Ramamurthy, MD, Bangalore, India (filling in for Jorge Alio, MD, Alicante, Spain), Boris Malyugin, MD, Moscow, Arup Chakrabarti, MD, Trivan-drum, India, and Sri Ganesh, MD, Bangalore, India.

Dr. Tabin highlighted a case where he experienced complications when using a power chop technique. A lot of ophthalmology requires skill and technique, but sometimes you just need a little more power, he said. This is useful when you have a particularly hard cataract. Dr. Tabin did routine phaco in his case, but the cornea began to get dry, and he asked his resident to put water on the cornea.

At this point in the case, he had already done a full power chop and chopped down to the retina. Unfortunately, the resident lost her balance and hit Dr. Tabin’s hand with the chopper. The first thingto remember, he said, is to remain calm. However, he lost the last nuclear fragments and the posterior capsule was open.

You want to put viscoelastic into the anterior chamber to make sure there’s not more prolapse of the vitreous, he said. Following this, Dr. Tabin proceeded to do a bimanual vitrectomy. The power chop had been completed, and there was still a good anterior capsulorhexis, so he proceeded with the bimanual vitrectomy.

Dr. Ramamurthy described a case she handled with a 32-year-old patient with a post traumatic sub-luxated cataract. She decided to use a femtosecond laser. “Femto cataract surgery is the definite way when youwant that pristine capsulorhexis,” Dr. Ramamurthy said.

Other topics discussed included YAG laser capsulotomy, traumat-ic cataracts, capsular fibrosis, andrefractive lensectomy.

Dr. Chee won for “Best Video,” while Dr. Beiko won “Best Entertain-er.” The Bursting Buccaneers, who had dressed as the “Pirates of the Caribbean,” won for “Best Team.”

Jose Rizal Medal Lecturer: ‘Glass no longer empty’Among the medal lectures that the APAO awards its most outstanding members, the Jose Rizal medal, said Dennis Lam, MD, Hong Kong, incoming president of APAO, is “the most important one.”

The honor of delivering this year’s Jose Rizal Medal Lecture went to Hugh Taylor, MD, Australia, cur-rent president of the International Council of Ophthalmology (ICO).

In his Jose Rizal Medal Lecture, “The Global Issue of Vision Loss and What We Can Do About It,” Dr. Taylor reviewed the current state of global blindness, particularly in light of the Vision 2020 initiative.

Going back a few years to 1994, Dr. Taylor said that 60% of global blindness was caused by cataracts and refractive errors; 15% was caused by conditions like trachoma, vitamin A deficienc , and oncho-cerciasis—conditions that needed to be addressed as public health issues more than strictly ophthalmological issues; 15% was caused by diabetic retinopathy and glaucoma—at the time considered more medical/oph-thalmological, treated case to case rather than as public health issues; and 10% by age-related macular degeneration and other diseases that, at the time, no one could do anything about.

Moving forward to 1996, the 30–50 million blind in the 90s was projected to double to 90 million by 2020.

By the end of the decade, the World Health Organization would

should also spur the ophthalmic community to continue the struggle.

“The glass isn’t full yet,” Dr. Taylor said. “But it’s no longer empty.”

Building education in ophthalmology a major focus for Asian countriesIn a session on building educational programs, Mark Tso, MD, Baltimore, who introduced the session, high-lighted critical building blocks of major eye centers. Some of the pri-mary aspects of this are focusing on the delivery of quality general and specialty eye services, biomedical research discovery, and education.

Education is the backbone of clinical service, the foundation of clinical and basic research, and the core value of the faculty, Dr. Tso said. “Furthermore, education builds people, and people go on to make history.” That’s why education is critical in the building of a major eye care center, he said.

launch the Vision 2020 initiative, which aimed to develop sustainable programs with the goal of eliminat-ing avoidable blindness by 2020.

Vision 2020, Dr. Taylor said, “is all about partnerships”—among the ophthalmic community, represented by individuals and larger regional and international societies, non-gov-ernment organizations, and the governments of the world.

It has 3 main components: effective disease control, human resource development, and infra-structure development.

Back in 1996, it was projected that “if we did what we knew,” Dr. Taylor said, the 60 million blind projected for 2010 without any intervention would be reduced to 40 million; by 2020, the projected 90 million would be reduced to 25 million.

So where are we now? Actual-ly, Dr. Taylor said, “doing what we knew to do,” there were only 32.4 million blind from avoidable causes globally in 2010.

That’s a drop of 42%.While these results clearly show

there’s room for optimism, they

View videos from Wednesday at APAO 2015: EWrePlay.org

Amar Agarwal, MD, Chennai, India, describes the “turn around technique” to overcome false channel dissection during intrastromal corneal ring placement.

continued on page 72

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Reporting from the 30th APAO Congress in conjunction with the 20th COS Congress, April 1–4, 2015 Guangzhou, China

The Asia-Pacific Academy has19 national members, he said, and the health spending in percentage of GDP varies from 1.9% in Myanmar to 9.8% in Malaysia (compared to 15.7% in the United States).

Prashant Garg, MD, Hy-derabad, India, presented on the “Opportunities and Challenges in Developing Quality and High Impact Educational Programs in Developing Countries.” There are 8.9 million people blind in India, he said. Together with those in Africa and China, this constitutes nearly 60% of global blindness.

There are a number of chal-lenges facing medical programs in India. When considering medical college-based programs, Dr. Garg said that some of the obstacles are that health is a state issue and there is a lack of funds for these programs. There is also not enough time for training and education, and there is a lack of leadership, proper attitude, and accountability. This results in residents emerging from these programs without the competence to practice independently, Dr. Garg said.

India also has an NBE program, however, it is not popular, there is variability in the standards of training, and it has a centralized ex-amination system with a poor pass percentage.

Possible solutions to these chal-lenges are to provide more funding, more resources, and more time for education, he said. Areas to focus on are the training of trainers, revision of the curriculum, e-learning, and a centralized evaluation system. All of these things are being addressed, Dr. Garg said, however, there is very lit-tle or no effort at this point in time to have a centralized certificationsystem besides the ICO conducted exam. There is some discussion with the All India Ophthalmological Society (AIOS) to have a national certification system so there can besome improvement and uniformity in the quality of residents coming out of residency programs, he said.

In conclusion, Dr. Garg said there are a number of challenges fac-ing ophthalmic education in India. There are some good programs, but

efforts need to be made to bridge the gap, and AIOS is working on this.

Susruta Lecture focuses on cataract in uveitisSusruta lived in India around the 6th century B.C. Author of the Sanskrit text Susruta Samhita, he may have been the first to describeextracapsular cataract extraction (ECCE) surgery.

The APAO honors this ancient physician with the Susruta Lecture.

The Susruta Lecture recognizes “extraordinary contributions to the cataract subspecialty,” prioritizing ophthalmologists who contribute substantially to the control and elimination of mass cataract blind-ness. Cataract remains one of the leading causes of avoidable blind-ness around the world, and blind-ness from the condition remains a perennial problem in the Asia-Pacificregion in particular.

This year, the honor of deliv-ering the Susruta Lecture went to Masahiko Usui, MD, Tokyo.

Dr. Usui delivered his Susruta Lecture on “Cataract/IOL Surgery for Cataract with Intraocular Inflamm -tion.” Specificall , Dr. Usui’s lecture discussed cataract in cases of uveitis —a significant problem in Japan, hesaid.

Describing the pathogenesis of cataract in uveitis, Dr. Usui said the condition begins with inflammato y

changes in the aqueous humor. In-flammation results in characteristicposterior synechiae, and inflamm -tory changes occur in the vitreous body.

Cataract, he said, is the side effect of steroid therapy for uveitis.

Dr. Usui looked at 162 eyes (115 patients) with cataract in a back-ground of uveitis. Of these eyes, 157 eyes (96.9%) underwent phacoemul-sification with IOL implantation and5 (3.1%) underwent planned ECCE with IOL implantation.

The major causes of uveitis Dr. Usui found in these were Behçet’s disease (40 eyes, 26 patients, 24.7%) and sarcoidosis (36 eyes, 28 pa-tients, 22.2%). However, the highest percentage of eyes had no discern-ible etiology (48 eyes, 31 patients, 29.6%).

Out of the total 162 eyes, 69 (42.6%) had posterior synechiae.

When performing cataract surgery in cases of uveitis, Dr. Usui said timing is important. He recom-mends performing cataract surgery when cells in the anterior chamber are minimal, either absent or less than +1, and when flare value is lessthan 100 pc/ms.

Furthermore, he said, the eye should have been free of inflamm -tion for 3 to 6 months.

In this study, postoperative treatment included systemic admin-istration of betamethasone (2–4 mg/

View videos from Thursday at APAO 2015: EWrePlay.org

Boris Malyugin, MD, PhD, Moscow, explains how to identify factors leading to poor capsular support and how to use the capsule itself for IOL support.

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hypothesized that “when tangential retinal traction becomes intense, the inward peak of the outer retinal lay-er is exaggerated, resulting in attach-ment of adjacent parafoveal inner retinal layers,” she said. “Once the attachment occurs, the cells in these layers lose their normal alignment, failing normal neural transduction.”

Dr. Yoon then wondered wheth-er this “blockage” in normal neural transduction can be “reopened” by surgically releasing the traction through ERM removal.

In 57 consecutive patients with idiopathic ERM and decreased vision due to abnormally thick CIRLT, best corrected visual acuity (BCVA) and metamorphopsia improved 12 months after surgery.

In a multivariate analysis of these cases, CIRLT was the only fac-tor significantly associated with v -sual acuity apart from initial BCVA.

Postoperative visual outcomes, she said, correlated well with postoperative restoration of inner retinal layer configuration after ERMpeeling.

“Eyes having a thicker inner retinal thickness at the central fovea and a longer duration of disease at baseline tended to restore poorly after surgery,” she added.

These findings were recentlypublished in Retina. EW

day) for 2–4 days and a nonsteroidal anti-inflammato y drug (NSAID) for 3–4 days, as well as topical admin-istration of steroid (3–5x/day) for 3 months, NSAID (3x/day) for 3 months, and mydriatics (1–2x/day) for 1 month.

After surgery, 117 eyes (72.6%) had better than 0.5 visual acuity. Compared to preoperative visual acuity, 120 eyes (74.0%) had a 2-fold increase, 33 eyes (20.4%) had no change, and 9 eyes (5.6%) had a 2-fold decrease in vision.

These eyes, Dr. Usui said, are prone to recurrent inflammation.

Dr. Usui said that surgeons should carry out the appropriate operation using proper surgical pro-cedures and provide the necessary postoperative care and treatment to control complications including recurrence, cystoid macular edema, ocular hypertension, and posterior synechiae.

Arthur Lim Award Lecture posits determinant for visual acuity in idiopathic ERMThe APAO presents the Arthur Lim Award in recognition of ophthal-mologists who have exhibited exem-plary leadership in ophthalmology, leading to substantial improvements in ophthalmic teaching and training in their region and beyond. It hon-ors the late Prof. Arthur Lim, former

president and secretary-general of the Academy.

This year, the honor of deliver-ing this prestigious lecture went to Young Hee Yoon, MD, Seoul, South Korea. For her Arthur Lim Award Lecture, Dr. Yoon discussed “Micro-structural Change in Foveal Inner Retina as a Visual Predictor of Idio-pathic ERM,” in which she proposed a hypothesis for the main determi-nant of visual acuity in idiopathic epiretinal membranes (ERM). In addition, she proposed an approach to manage the condition based on her hypothesis.

“In clinical practice, we often witness a discrepancy between the morphologic change and visual acuity in persons with epiretinal membrane,” she said. “Several factors have been associated with visual acuity in ERM patients.” These include central retinal thick-ness, inner retinal layer thickness, presence of cystoid macular edema, and photoreceptor inner segment/outer segment (IS/OS) junction layer disruption.

“Among these factors, IS/OS disruption has been suspected as the most significant determinant inmost retinal diseases,” she said.

However, isolating idiopathic ERM from other retinal conditions, IS/OS disruption, she said, is rarely observed.

Dr. Yoon presented OCT images from a case with advanced ERM with poor visual acuity. The OCT image showed the IS/OS junction layer to be intact.

The partner eye had IS/OS dis-ruption secondary to branch retinal vein occlusion.

Numerous diseases, she said, may cause secondary ERM. Among them are those that require flu -rescence angiography for accurate diagnosis, including macular branch retinal vein occlusion.

What, then, determines visual acuity in idiopathic ERM?

Dr. Yoon reviewed eyes with ERM and carefully selected those with idiopathic causes on the basis of fluorescence angiograph .

In this review, Dr. Yoon and her colleagues reported that central in-ner retinal layer thickness (CIRLT) of the fovea was the major determinant of visual acuity—they found that eyes with thick foveal centers could still have very good visual acuity if the inner retinal layer at the foveal center was not thickened.

In fact, she said, only 2 eyes out of 134 with idiopathic ERM were ob-served to have IS/OS junction layer disruption.

How inner retinal layer thick-ening in idiopathic ERM affects visual acuity remains the subject of speculation. Dr. Yoon herself

View videos from Friday at APAO 2015: EWrePlay.org

Elizabeth Yeu, MD, Norfolk, Va., discusses how to approach the unhappy postoperative patient and identify factors preoperatively that can lead to dissatisfaction.

View all the daily news and photos at daily.eyeworld.org

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