The Asia-Pacific Journal of Ophthalmology



Rapid Assessment of Avoidable Blindness— Past, Present, and Future Kocur, Ivo; Limburg, Hans; Resnikoff, Serge
Just several decades ago, there was very little known about the global magnitude and causes of vision impairment. The early publications were based on a few studies, often reporting on different age groups and using different definitions. With the growing interest in the epidemiology of vision impairment, a wide range of survey methodologies have been used to assess its magnitude and causes. Surveys covering all age groups usually involve a larger population sample compared with those limited to a certain age group. Their completion requires a significant amount of time and resources along with trained support and expert staff. All included individuals undergo a detailed eye examination and interview. Rapid assessments require smaller sample sizes as only a selected age group is covered. The individuals included in the rapid assessments have their visual acuity measured and for those with presenting visual acuity below the cut-off level, the main cause of vision impairment is identified. This issue of the Asia-Pacific Journal of Ophthalmology contains articles on Rapid Assessments of Avoidable Blindness (RAAB): one presenting the results of a RAAB study conducted in the Maldives and the other giving an overview of several recent RAAB studies used in the Southeast Asian region.


Non–Self-Sealing (Leaky) Anterior Chamber Paracentesis: A New Technique in Managing Postphacoemulsification Intraocular Pressure Rise in Glaucoma and Normal Eyes Lam, Dennis; Lee, Jacky; Leung, Enne; Liu, Shirley; Yuan, Julianna; Ratra, Vineet
Phacoemulsification (phaco) for cataract extraction is 1 of the most commonly performed ophthalmic surgeries. With increasing evidence of significant intraocular pressure (IOP) reduction after phaco, the paradigm for glaucoma treatment has been shifting toward more cataract extraction instead of glaucoma surgery; thus, the population of glaucoma patients undergoing phaco is likely to continue to increase in the coming years. Although the safety of surgery has improved over the years with newer technologies and machines, postoperative IOP spike remains an important condition even after an uneventful operation. Glaucoma patients undergoing phacoemulsification are particularly at risk of further glaucomatous optic nerve damage from the transient yet potentially high pressures after phaco. Common treatments include topical, intracameral, oral, and systemic IOP-lowering medications; postoperative anterior chamber paracentesis (ACP); and so on. No single treatment to date can guarantee effective prevention or control IOP rise in the first 24 hours after phaco. Sometimes, the IOP remains high despite all of the above treatments and the risk for further glaucomatous damage may be unavoidable. In this perspective article, we discuss the incidence, causes, and treatments of IOP rise after phaco and introduce a new technique, a non–self-sealing (leaky) ACP that may be of use in regulating postoperative IOP rise, especially for patients with glaucoma.
Pioneer of Chinese Ophthalmology—130th Anniversary of Beijing Tongren Hospital Yusufu, Mayinuer; Wang, Ningli
Much has been achieved in clinical and scientific research in the past 130 years by Beijing Tongren Hospital, which has evolved from an eye clinic to a comprehensive hospital with an ophthalmology department known as one of the best in China. This article presents the most historic moments and events in the development of a hospital with the largest eye care service volume. In addition, given the leading position of Tongren, the development of ophthalmology in Tongren is also the epitome of the development of modern ophthalmology in China. Beijing Institute of Ophthalmology (BIO) was established in 1959 as an affiliated institution under Tongren, aiming at carrying out applied science and basic science research, and directors of BIO have thus far served 4 terms as president of the Chinese Ophthalmological Society. In 2002, Beijing Tongren Eye Center (hereafter referred to as the Eye Center) was established to combine all the ophthalmic resources within Tongren. In 2017, the Eye Center alone had a surgical volume of 78,223, with surgeries for cataract, refractive errors, fundus, glaucoma, and corneal disease being the 5 most common, and 902,409 outpatient visits. Equipped with the leading experts and equipment, Tongren is dedicated to the battle against major eye diseases by carrying out large population-based epidemiological surveys and basic science research on pathogenesis and effective treatments, thereby making contributions to the development of the science of ophthalmology along with the delivery of eye care services in China and beyond.

Original Study - Clinical

Sustainability of Pain Relief After Corneal Collagen Cross-Linking in Eyes With Bullous Keratopathy Ono, Takashi; Mori, Yosai; Nejima, Ryohei; Ogata, Miyuki; Minami, Keiichiro; Miyata, Kazunori
Purpose: This study aimed to examine the efficiency and sustainability of pain relief produced by corneal collagen cross-linking (CXL) in eyes with bullous keratopathy (BK) and to explore the histopathological changes in the stroma by using in vivo confocal microscopy.

Design: Prospective observational case series.

Methods: Fourteen eyes of 14 consecutive BK patients were treated with CXL with dehydration of the corneal stroma and followed up for 1 year after treatment. The best-corrected visual acuity (BCVA), intraocular pressure, and central corneal thickness (CCT) were examined before the treatments and up to 1 year after. The intensity and frequency of pain were graded on a scale from 0 (minimum) to 10 (maximum). At 1 year after CXL, the corneal stroma was observed using confocal microscopy at depths of 100 and 200 μm.

Results: The BCVA and CCT did not change significantly. The mean pain intensity and frequency scores were 5.6 and 4.6, respectively, before treatment. The intensity score significantly decreased at 1 week and onward, and the frequency score significantly decreased over 6 months after treatment. The confocal microscopy images showed that keratocytes and nerve fibers were rare and sparsely distributed in the stroma 1 year after CXL.

Conclusions: The CXL efficiently relieved pain due to BK for 1 year after treatment. The in vivo confocal microscopy observations and unchanged CCT demonstrated that the persistence of pain relief was due to the inadequate regeneration of nerve fibers in the corneal stroma.
Advanced Subconjunctival Anesthesia for Cataract Surgery Wu, Sharnie; Tang, Kong Chan
Purpose: Ocular regional blocks generally require blind instrumentation to the posterior orbit, leading to rare but serious complications. However, topical anesthesia does not suppress eye or lid movements and may lead to more surgical complications. Advanced subconjunctival anesthesia (ASCAN) is a technique developed to provide reliable akinesia and anesthesia without anterior dissection or blind intrusion into the posterior orbit, while allowing visualization of the needle-tip position.

Design: Nonrandomized case series at a rural health service.

Methods: Advanced subconjunctival anaesthesia was performed on 60 elective adult patients undergoing phacoemulsification surgery. The technique involves piercing the conjunctiva and Tenon’s capsule in the superior outer quadrant of the globe with a 25-gauge, 16 mm needle, using either lignocaine 2% plain or in equal mix with bupivicaine 0.5%. Up to 10 mL of anesthetic with hyaluronidase 30 IU/mL is injected in a posterior direction into the sub-Tenon’s space. Ocular motor functions were assessed 10 minutes after ASCAN using a Brahma scale. Pain was assessed during surgery and at the end of surgery after subconjunctival injection of antibiotic and steroid using a verbal Numeric Rating Scale.

Results: All patients completed surgery without needing supplemental anesthesia. Fifty-eight patients (97%) were pain free, whereas 2 patients experienced transient mild pain. Adequate globe akinesia and reliable lid paralysis was achieved comparable to other studies, with no major surgical or anesthetic complications.

Conclusions: Advanced subconjunctival anesthesia is a visually guided, minimally invasive technique, achieving satisfactory analgesia and akinesia for phacoemulsification surgery.
Optical Coherence Tomography of Small Retinoblastoma Welch, R. Joel; Rao, Raksha; Gordon, Phillip S.; Say, Emil Anthony T.; Shields, Carol L.
Purpose: To investigate hand-held optical coherence tomography (HH-OCT) characteristics of small (<1 mm thickness) retinoblastoma.Design: Retrospective observational case series.Methods: Patient and tumor data were extracted from the medical record and analyzed along with HH-OCT scans. Determination of tumor layer of origin was performed using a layer-by-layer analysis of HH-OCT data and specific HH-OCT–related features were described.Results: There were 20 sub-millimeter retinoblastomas from 16 eyes of 15 patients. Mean largest tumor basal diameter by HH-OCT was
2.2 mm (median, 1.9; range, 0.7–4.1 mm), and mean tumor thickness was 468 μm (median, 441; range, 151–998 μm). In all cases, the retinoblastoma caused discontinuity or disruption of the inner nuclear (INL), outer plexiform (OPL), outer nuclear (ONL), and external limiting membrane (ELM) layers (20/20, 100%). Tumor origin was in the INL in 19/20 (95%) and equivocal (INL vs ONL) in 1/20 (5%). Intratumoral microcalcification was present in 14/20 tumors (70%). There were 2 characteristic findings (signs) on HH-OCT including the INL “fish tail” sign with splaying of the INL at the tumor margin (19/20, 95%) and the ONL “shark fin” sign with folding of the ONL and OPL, conforming to the lateral tumor margins (15/20, 75%). Both signs were concurrently present in 15 tumors (15/20, 75%).Conclusions: HH-OCT demonstrated that sub-millimeter retinoblastoma seems to originate from the INL, with tumor base and thickness growth progressing in a linear relationship. Characteristic HH-OCT findings included intratumoral microcalcification, INL “fish tail” sign, and ONL “shark fin” sign.
Anophthalmic Sockets in Retinoblastoma: A Single Center Experience Jeyabal, Preethi; Sundar, Gangadhara
Purpose: To evaluate outcomes of anophthalmic sockets in retinoblastoma at a tertiary care center in Singapore.

Design: A retrospective study.

Methods: Patients who underwent enucleation as sole/part of treatment for retinoblastoma were reviewed at our center from 2005–2017. Details including demographics, grouping and staging, adjuvant therapy, surgery, implant, and complications were collected.

Results: Of 42 patients with retinoblastoma managed over the period, the anophthalmic sockets of 31 patients who underwent enucleation were analyzed. Mean age at enucleation was 2 years. Twenty-three enucleations were performed at our institution and 8 enucleations had been performed elsewhere. Seventeen patients (52%) had porous polypropylene, 9 patients (27%) had polymethylmethacrylate, 1 patient (3%) had glass implant, and 3 (9%) had dermis fat graft. The sizes of implants varied from 10 to 20 mm. Twelve patients had attempts at globe salvation before enucleation. Out of 28 patients with primary orbital implants, 3 had implant exposure. The rates of repeat surgery among patients with and without primary implant were 66.67% (2 out of 3) and 10.7% (3 out of 28), respectively. One patient had postenucleation socket syndrome with stock eye. Five patients referred for enucleation were conservatively managed.

Conclusions: Anophthalmic sockets in retinoblastoma have long-term implications if the primary procedure is not performed well. While the majority had good outcomes (structural and esthetic), a minority had complications requiring intervention. Ophthalmologists managing retinoblastoma must be aware of these. Primary implant had favorable outcome with minimal complications.
Blindness and Visual Impairment Profile and Rapid Assessment of Avoidable Blindness in South East Asia: Analysis of New Data. 2017 APAO Holmes Lecture. Das, Taraprasad
Purpose: The International Agency for Prevention of Blindness (IAPB) South East Asia region (SEAR) that consists of 11 countries contains 26% of the world’s population (1,761,000,000). In this region 12 million are blind and 78.5 million are visually impaired. This amounts to 30% of global blindness and 32% of global visual impairment.
Design: Rapid assessment of avoidable blindness (RAAB) survey analysis.
Methods: RAAB, either a repeat or a first time survey, was completed in 8 countries in this decade (2010 onwards). These include Bangladesh, Bhutan, India, Indonesia, Maldives, Sri Lanka, Thailand, and Timor Leste.
Results: Cataract is the principal cause of blindness and severe visual impairment in all countries. Refractive error is the principal cause of moderate visual impairment in 4 countries: Bangladesh, India, Maldives, and Sri Lanka; cataract continues to be the principal cause of moderate visual impairment in 4 other countries: Bhutan, Indonesia, Thailand, and Timor Leste. Outcome of cataract surgery is suboptimal in the Maldives and Timor Leste.
Conclusions: Rigorous focus is necessary to improve cataract surgery outcomes and correction of refractive error without neglecting the quality of care. At the same time allowances must be made for care of the emerging causes of visual impairment and blindness such as glaucoma and posterior segment disorders, particularly diabetic retinopathy.
First Rapid Assessment of Avoidable Blindness Survey in the Maldives: Prevalence and Causes of Blindness and Cataract Surgery Thoufeeq, Ubeydulla; Das, Taraprasad; Limburg, Hans; Maitra; Maharshi; Panda, Lapam; Sil, Asim; Trevelyan John; Sapkota, Yuddha
Purpose: A nationwide rapid assessment of avoidable blindness survey was undertaken in the Maldives among people aged 50 years or more to assess the prevalence and causes of blindness and visual impairment, cataract surgical coverage, cataract surgery outcome, and barriers to uptake of cataract surgical services.Design: Prospective population-based study.Methods: In the cluster sampling probability proportionate to size method, 3100 participants in 62 clusters across all 20 atolls were enrolled through house-to-house visits. They were examined in clusters by an ophthalmologist-led team. Data was recorded in mRAAB version 1.25 software on a smartphone.Results: The age-sex standardized prevalence of blindness was 2.0% [95% confidence interval (CI), 1.5-2.6]. Cataract was the leading cause of blindness (51.4%) and uncorrected refractive error was the leading cause of visual impairment (50.9%). Blindness was more prevalent in higher age groups and women (16.3%). Cataract surgical coverage was 86% in cataract blind eyes and 93.5% in cataract blind persons. Good visual outcome in cataract operated eyes was 67.9% (presenting) and 76.6% (best corrected visual acuity). In this study, 48.1% of people had received cataract surgery in neighboring countries. Important barriers for not using the services were “did not feel the need” (29.7%) and “treatment deferred” (33.3%).Conclusions: Cataract surgical coverage is good, though nearly half the people received surgery outside the Maldives. Cataract surgery outcomes are below World Health Organization standards. Some barriers could be overcome with additional human resources and training to improve cataract surgical outcomes, which could encourage greater uptake of services within the country.
Predictive Value of Baseline Biochemical Parameters for Clinical Response of Macular Edema to Bevacizumab in Eyes With Central Retinal Vein Occlusion: A Retrospective Analysis Madanagopalan, V.G.; Kumari, Bibha
Purpose: To evaluate the influence of baseline biochemical parameters on the improvement in best corrected visual acuity (BCVA) and reduction in central foveal thickness (CFT) in patients treated with intravitreal bevacizumab (IVB; Avastin, Genentech, Inc) for macular edema (ME) secondary to central retinal vein occlusion (CRVO).

Design: A retrospective study.

Methods: Seventy eyes of 70 participants with CRVO who underwent IVB for ME and had at least 1 month of follow-up after the last injection were studied. Demographic variables, systolic and diastolic blood pressure (SBP and DBP), BCVA, CFT measured by optical coherence tomography (OCT), and biochemical investigations [hemoglobin, fasting and postprandial blood sugar (FBS and PPBS), lipid profile, blood urea (BU), serum creatinine (SC), glycosylated hemoglobin (HbA1c)] at baseline were noted. IVB need at every visit was based on clinical and OCT parameters. Changes in BCVA (ΔBCVA) and CFT (ΔCFT) from baseline to last injection were estimated.

Results: After IVB, there was a statistically significant reduction in mean CFT (P < 0.01). The group of patients with normal BU and SC had more than 2 lines of improvement compared with those with elevated values (P = 0.043 and 0.009, respectively). Other parameters like FBS, PPBS, hemoglobin, HbA1c, and serum lipids were not associated with improvement of BCVA and reduction of CFT.

Conclusions: Normal baseline renal parameters (BU and SC) predict better visual outcome after treatment for ME in CRVO and offer additional benefit over and above that obtained with ME reduction.
Leaving No One Behind: Strengthening Access to Eye Health Programs for People With Disabilities in 6 Low- and Middle-Income Countries Mörchen, Manfred; Bush, Asahel; Kiel, Petra; Lewis, David; Qureshi, Babar
Purpose: To assess the impact of inclusive eye health programs for people with disabilities.

Design: A synthesis evaluation study.

Methods: A cross-disciplinary team of ophthalmologists, evaluation, and disability-inclusive development advisors purposively selected evaluation reports of CBM-supported inclusive eye health programs in low- and middle-income countries. Employing a change-promoting paradigm, salient achievements and challenges were narratively analyzed and recommendations suggested based on a previously developed framework for strengthening disability inclusion in eye health programs.

Results: Evaluations from 10 programs implemented in 6 countries (Cambodia, Egypt, Ethiopia, Indonesia, Pakistan, Vietnam) from 2011 to 2016 were identified. Training of medical staff and government officials resulted in increased awareness about disability rights and improved physical accessibility of eye health facilities. Relevant information about inclusion in eye health was incorporated in national eye health training curricula in some countries. Information, education, and communication material about eye health neglected patients with hearing and learning impairments. An overly narrow focus on disability inclusion confounded intersectoral barriers to eye health services. Collaboration of eye health staff with disability peoples organizations improved significantly but evidence of its impact was elusive. Collection of disability-disaggregated data posed significant challenges and made it difficult to demonstrate increased access to eye health programs by people with disabilities.

Conclusions: Introduction of disability inclusion in eye health systems of countries with limited resources poses significant challenges. Future programs striving to improve access to eye health services for marginalized populations including people with disabilities might consider more flexible and contextualized approaches.

Review Article

Does Nd:YAG Capsulotomy Increase the Risk of Retinal Detachment? Grzybowski, Andrzej; Kanclerz, Piotr
Laser capsulotomy is accepted as a standard and effective treatment for posterior capsule opacification. It is generally believed that neodymium:YAG (Nd:YAG) capsulotomy is related to an increased risk of retinal detachment (RD). The aim of this study was to evaluate the association between Nd:YAG capsulotomy and risk for developing RD. A PubMed and Medline search was conducted using the terms “retinal detachment” and “Nd:YAG laser capsulotomy.” Of the articles retrieved by this method, all publications in English and abstracts of non-English publications were reviewed. The literature analysis presented no convincing evidence supporting the association between Nd:YAG capsulotomy and increased risk for developing RD. The existing discrepancy between some studies might be related to inadequate group sizes, short observation period, and co-existing disorders. We also reviewed the possible risk factors for RD after Nd:YAG capsulotomy and found no association with preceding surgical approach, existing posterior vitreous detachment, and intraocular lens design. Myopic patients should be treated with caution, as it cannot be concluded that Nd:YAG capsulotomy does not increase RD rate in this cohort. Treatment energy should be as low as possible, as high energy levels and anterior hyaloid damage might increase the chance for RD development. Cataract surgery itself is a potential RD risk factor, particularly after intraoperative capsule complications.
Glaucoma Drugs in the Pipeline Kaufman, Paul L.; Mohr, Mary E.; Riccomini, Scott P.; Rasmussen, Carol A.
Glaucoma is a chronic disease that can be challenging to treat for both patients and physicians. Most patients will require more than 1 medication over time to maintain their intraocular pressure (IOP) at a physiologically benign level. Patients may become refractory to existing compounds and many struggle with adherence to multiple topical drop regimens. The field of glaucoma therapeutics has been advancing rapidly with an emphasis on compounds comprising multiple molecules/mechanisms of action that offer additivity and are complementary to current therapeutics. Several new topical drop compounds directly targeting the trabecular meshwork (TM)/Schlemm canal/conventional outflow pathway to reduce outflow resistance have obtained US Food and Drug Administration approval in the past year. These include rho kinase inhibitors and nitric oxide donating compounds. Alternative therapies that offer long-term IOP lowering while removing the patient from the drug delivery system are moving forward in development. These include gene therapy and stem cell strategies, which could ease or eliminate the burden of topical drop self-administration for several years. Additionally, a variety of novel formulations and devices are in development that aim for controlled, steady state delivery of therapeutics over periods of months. The future of glaucoma therapy is focusing on an increase in specificity for the individual patient: their type of glaucoma; underlying mechanisms; genetic make-up; comorbid conditions; and rate of progression. Maintaining functional vision and improving patient outcomes remains the goal in glaucoma therapeutics. The current collection of novel therapeutics offers an expanded set of tools to achieve that goal.
Visual Evoked Potentials and Glaucoma Tai, Tak Yee Tania
Visual evoked potentials (VEP) can be used to assess the function of the visual system objectively. Research on VEP testing as a method of glaucoma evaluation has been performed for many years. Pattern VEP has shown good specificity and sensitivity in the detection of glaucoma in some studies, but other studies have not shown similar efficacy. Multifocal VEP can produce a topographical measure of glaucomatous damage and has been shown to be able to detect a similar number of defects in patients with glaucoma or ocular hypertension as compared with the visual field test. Despite promising data on these VEP test modalities in the assessment of glaucoma, multiple aspects of test administration make their routine use impractical in a clinical setting. New VEP testing modalities, such as short-duration transient VEP and isolated-check VEP, allow the test to be performed more quickly and easily. Further research on these more recent technologies may allow us to use VEP effectively in the diagnosis and management of glaucoma.
Vascular Anomalies of the Orbit—A Reappraisal Sullivan, Timothy John
The recent International Society for the Study of Vascular Anomalies (ISSVA) classification of vascular anomalies can be applied to orbital lesions, dividing them into vascular tumors and vascular malformations. Orbital cavernous hemangiomas are probably best considered cavernous venous malformations under this classification. Management of symptomatic lesions can be with surgical excision or stereotactic fractionated radiotherapy in selected cases. Beta-blockers including propranolol and topical timolol maleate represent first-line therapy for infantile hemangiomas, although surgery has a role in selected cases. Orbital venous-lymphatic malformations are problematic but with improved imaging, neuroradiological intervention, and a multidisciplinary approach to management, outcomes are improving.


In Saonanon P, Thongtong, P, Wongwuticomjon T. Differences Between Single and Double Eyelid Anatomy in Asians Using Ultrasound Biomicroscopy. Asia-Pac J Ophthalmol. 2016;5:335–338, there was an error in eyelid layer identification by ultrasound biomicroscopy (UBM) that caused misinterpretation that affected the main outcome. Further investigation of the eyelid with UBM revealed that the middle hypoechogenic layer seen throughout the length of the eyelid was the orbicularis oculi muscle, not the levator aponeurosis. Muscle fiber (eg, extraocular muscle) normally possesses low echogenicity on ultrasound. The correct layer identification should be C2, orbicularis oculi muscle; C3, levator‒Mueller‒conjunctival complex; C5, skin and subcutaneous tissue 7 mm above eyelid margin; and C6, skin and subcutaneous tissue 5 mm above C5. Corrected UBM image label (Fig. 1), schematic drawing (Fig. 2), and Table 2 describing thickness of each eyelid layer on UBM are as shown.

With the revised layer identification, the main outcome of this in vivo study in young healthy volunteers is opposed to previously published anatomical differences between single and double eyelids in cadavers. The single eyelid and double eyelid subjects showed no difference in orbicularis oculi thickness. Nevertheless, slightly thicker skin and subcutaneous tissue both in the pretarsal area and at the eyelid crease but not at 5 mm above the eyelid crease was demonstrated. During double eyelid surgery, the surgeon should not excessively remove the muscle but meticulously trim off an amount just enough to create a more permanent eyelid crease.
In Shulman JP, Hartnett ME. Pharmacotherapy and ROP: Going Back to the Basics. Asia-Pac J Ophthalmol (Phila). 2018;7:
130–135, no financial disclosure was declared by the authors. The correct disclosures are as follows:

Financial disclosures: MEH (PI): R01EY015130 and R01EY017011 (from NEI/NIH), and a grant to the Department of Ophthalmology
and Visual Sciences at University of Utah from Research to Prevent Blindness.
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