EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW MEETING REPORTER 70 August 2014 Reporting from the 2014 ASEAN Ophthalmology Society (AOS) Congress Bangkok, Thailand These days, Dr. Levin tells them, with utmost certainty: "There will be a treatment in your lifetime." "The idea of referring that child to an ocular genetics specialist is so important," he said. "Should you refer? Yes, refer them all." An ocular genetics referral, he added, is no longer outside the reach of ophthalmologists in the ASEAN region. Among ophthalmologists in the region who trained in ocular genetics under Dr. Levin at the Wills Eye Institute is Wadakarn Wuthisiri, MD, Department of Ophthalmology, Faculty of Medi- cine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand. Low vision underserved According to Jill Keefe, OAM, PhD, who holds positions at the Univer- sity of Melbourne, Australia, and at the L.V. Prasad Eye Institute, India, 80% of countries around the world have less than 10% coverage of low vision. Where such coverage exists, services are not comprehensive. Prof. Keefe gave a talk on "Establishing low vision services in ASEAN countries." The functional (Bangkok) definition of low vision is as follows: –Visual impairment even after treatment and/or standard refractive correction; –Visual acuity <6/18 to PL in the better eye; or –Visual fields ≤10 degrees from the point of fixation; –But with the potential to use vision for the planning and/or execution of a task. Low vision (VA ranging from 6/12 to 3/60) encompasses the lower limit of normal vision (6/12), the WHO definition of low vision (6/18), the welfare definition of legal blindness (6/60), and the WHO definition of blindness (3/60). Ophthalmologists tend not to think of low vision as a significant problem, being primarily concerned with blindness, and so tending to correct refractive error only in that context or in patients who seek out such correction. This—and coming up against barriers that include cul- ture, cost, an attitude and prevail- ing sense of "nothing to be done," refusal to seek consult, distance from eyecare providers, and language— tends to leave out people with low income, people who live in rural areas, ethnic minorities, children, refugees, disabled adults and children, and even women. In fact, said Prof. Keefe, low vision significantly impacts the lives of people who suffer from it, increasing the likelihood of injury, creating difficulties in coping with the demands of life, with organizing assistance needed, and in fulfilling roles in family, work, and commu- nity, and affecting people's ability to have friendships as well as their con- fidence in participating in everyday activities. The Global Burden of Disease study found 172 million and 191 million people with moderate and severe visual impairment in 1990 and 2010, respectively. Low vision is a public health concern. Prof. Keefe said that vision reha- bilitation is now in the WHO Global Action Plan 2014–2019, but called for greater awareness and advocacy among ophthalmologists, govern- ment policymakers, and stakehold- ers, particularly in ASEAN countries. Femto LASIK, ReLEx in Asian eyes LASIK has long been the "widely accepted" method for refractive correction, said Kim Jung-Sub, MD, South Korea. More recently, laser systems such as OptiLASIK (Alcon, Hünenberg, Switzerland) have replaced the microkeratome with a femtosecond laser for flap creation. Ophthalmic surgeons such as Dr. Kim have since been compiling their data, building the case for the substitution. Using the femtosecond laser for flap creation, said Dr. Kim, results in fewer complications. In addition, the laser allows custom flap profiles and makes thin-flap LASIK possible. The repetition rate, he said, is important, with a higher rate decreasing the time it takes to create a flap as well as the energy required and the size of the cavitation bub- bles. Dr. Kim looked at their 12-month results in 215 eyes (108 patients) that underwent LASIK with femtosecond laser flap creation using the OptiLASIK to evaluate the efficacy, safety, and long-term stabil- ity in myopic eyes with and without astigmatism. Targeting 110-μm flaps, they achieved a mean central flap thick- ness of 110.27±9.13 μm, with no flap complications. Visual acuity (VA) was stable, with 96.1% of patients at 20/20 or better at 12 months; spherical equivalent was also stable, with 98.6% changing ≤0.5 D over the 12-month follow-up period. Dr. Kim concluded that LASIK with the laser system was safe and effective, adding that femto LASIK could be used as a substitute for other refractive surgeries. Having used the procedure in a wide range of eyes in patients from all over the region, he further concluded that "Asian eyes are all the same," and hoped that his find- ings will be helpful to ophthalmic surgeons working in their respective countries in the ASEAN region. Meanwhile, in Thailand, LASIK has been in use for 20 years, ac- cording to Ekktet Chansue, MD, Thailand. Dr. Chansue was the first to perform the procedure in the country. He called LASIK with the fem- tosecond laser the "gold standard today," with a high success rate and very good safety profile. However, he said, it is still LASIK, and the fully cut and lifted flap compromises the structural strength of the cornea. While he ad- mitted that all surgery on the cornea will of course weaken it structurally, it is possible to minimize that weak- ening. Dr. Chansue has since gone on to be the first in Thailand to perform ReLEx, which uses the VisuMax fem- tosecond laser (Carl Zeiss Meditec, Jena, Germany) to create a refractive lenticule within the stroma. This lenticule is then extracted through a small incision to change the shape of the cornea. In addition to minimizing the structural weakening of the cornea, Dr. Chansue said that the curvature change was much better with ReLEx than with LASIK. continued on page 72