Eyeworld

EW MEETING REPORTER 130 Reporting from the 28th APACRS annual meeting, August 5–8, Kuala Lumpur, Malaysia is being hailed as revolutionary and even Nobel-prize worthy. Rohit Shetty, MD, Bangalore, India, had a simple request concern- ing all this waste: "Don't discard! Send it to the lab." "The future of medicine is not an extension of your past," he said. "Just because we are very comfort- able with what we have today, and we have the answers to a lot of stuff, does not mean that we have to stick to it." In fact, rather than proceeding necessarily from past experience, the philosophy behind Dr. Shetty's approach seems focused almost exclusively in the moment, proceed- ing from case to case, treating every individual as unique, the idea being to create a more "bespoke" approach to medicine. Consider how drugs are devel- oped and tested for dry eye. Numer- ous agents have been developed to act on certain inflammatory bio- markers associated with the con- dition. But, Dr. Shetty asked, how sure are we that a particular patient's particular form of the condition is influenced by these markers? This, he said, is why not all pa- tients respond to the same drugs. The center of attraction for this approach? "Everything you discard." In the above case, tears collected during a Schirmer's test used in the diagnosis of the dry eye condition could be analyzed for TNF-a, MMP9, LOX, NF-k8, vitamin D and other biomarkers that can aid in the as- sessment of conditions as diverse as keratoconus, uveitis, glaucoma, ret- inopathy of prematurity (ROP), or- bital inflammatory disease, and even degenerative markers in neurological diseases such as Alzheimer's—in addition to dry eye disease. This analysis could be used to develop a more targeted—bespoke— therapeutic regimen. Dr. Shetty identified other biomarkers now known to be found in certain tissues: corneal epithelial tissue can be analyzed for WNT-3, SOX 17, IL6, TGF-B, TIMP I, and Col IA, which are found on the corneal haze pathway and wound healing; corneal lenticules can be tested for TGF-B, Col IA, IL 6, Col IVA, and vimentin which can be used in keratocyte cultures and drug testing, and to assess tissue inflammatory response; aqueous humor can be tested for CD 4 cells, VEGF, and viral markers to assess graft rejection, uveitis, pseudoexfoliation, diabetic retinopathy, and congenital cata- racts; lens matter can be tested for a-SMA, PITX-3, and HSPA-4 to eluci- date the etiopathogenesis of cataract formation; vitreous can be tested for VEGF, miRNA, and TGF-B for VEGF assays, to test genetic predisposition to VEGF response, and as indica- tors in the management of diabetic retinopathy. Dr. Shetty believes that a "titrat- ed approach," customizing therapies based on what are actually con- tained in a patient's discarded tissue, the vast repositories of information contained within all that so-called waste, is the future. All the laboratory tests involved —putting tissue through genetic analysis, quantitative RT-PCR, DNA synthesis, immunohistochemistry, mRNA extraction, flow cytometry, immunofluorescent studies, and more—may seem complicated and daunting, but Dr. Shetty reassured the audience this would not remain so in the future: Dr. Shetty believes at least some of these tests will even- tually come on a chip. "I'm sure this will become much simpler over time, and will become the normal routine in our practice." The best of refractive surgery tips In Saturday's closing session, surgeons from around the region competed to give attendees the best pearls for cataract and refractive sur- gery. Through video presentations, each surgeon presented a practical tip, distilled from years of experi- ence, that attendees can bring home and use immediately in their next visit to the operating room. Dr. Hutauruk opened the session with a pearl for performing iridecto- mies when implanting phakic IOLs. Most surgeons perform a laser pe- ripheral iridotomy 1–2 weeks before phakic IOL implantation, but these are often difficult to perform in Asian eyes because of the dark iris, he said. In these cases, he prefers to perform a surgical iridectomy during implantation of the lens. Using scissors to create the iridectomy can lead to a larger opening in the iris than expected, so Dr. Hutauruk pre- sented his method of performing an iridectomy with a vitrectomy probe. Set the vitrectomy mode to "I/A cut," use a cutting speed of 500, and a vacuum of 300, 400, or 500 for a 20G, 23G, or 25G probe, respective- ly, he said. Laser refractive surgery is 99% boredom and 1% terror, said Khairidzan Mohammed Kamal, September 2015 Sheetal Brar, MD, with Graham Barrett, MD, and Y.C. Lee, MD, after winning the Grand Prize at the APACRS Film Festival.

• Cover