THE DISPARITY and FUTURE of EYE CARE in ASIA-PACIFIC What About Our Future?

THE WORLD’S FIRST FUNKY OPTOMETRY MAGAZINE 01 THE PREMIERE ISSUE October 2020 cookiemagazine.org

Cover Story p18 THE DISPARITY AND FUTURE OF EYE CARE IN ASIA-PACIFIC What about our future?

“I’m going to be a surgeon !” Joe, 8 years old

“I’m going to be a designer !” Lilly, 10 years old

OCULUS Myopia Master® For early myopia detection and management

Myopia in children and young people is increasing worldwide. Early detection and treatment can slow or stop the progression of myopia. The new Myopia Master® combines all important parameters for myopia management in a myopia analysis software: axial length, refraction values and the central corneal radii.

Myopia management – much easier and more reliable than ever!

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COOKIE Myopia Master International Joe and Lilly A4 4c 10.20.indd 1 22.10.2020 12:50:12 IN THIS ISSUE...

Cool Optometry Optics Therapies for Color Blindness: Do they 12 really work? Matt Young CEO & Publisher Sustainability and Coronavirus Dominate 14 Discussion Among Optometry’s Next Robert Anderson Generation Coverage from the Eye2Eye Webinar Media Director Series Can OCT be efficacious in Hannah Nguyen 06 uncovering Alzheimer’s disease? Production & Circulation Study Shows Myopia Progression in Manager 08 Children Slowed with Use of Multifocals Eyewear Designers Remain Jeepers Scooby! Myopia . . . Now Optimistic Despite Coronavirus Gloria D. Gamat 10 Managed Better than Ever Before 16 Coverage from the Eye2Eye Webinar Series Chief Editor

Brooke Herron Editor Cover Story

International Business The Disparity and Future of Development Eye Care in Asia-Pacific Ruchi Mahajan Ranga 18 Looking at the imbalance in access Brandon Winkeler to eye care in the region and future considerations for improvement

Writers Andrew Sweeney Chow Ee-Tan Hazlin Hassan Joanna Lee Sam McCommon Kudos Enlightenment Tan Sher Lynn Protecting Sight in Some of Asia’s 22 Poorest Communities Maricel Salvador 30 Graphic Designer Optical’s Most Influential Women Scratching the 24 On leadership, COVID-19 and community Surface Talking dry eye with Published by Innovation Dr. Laura Periman New Transmitter Device Enables 26 Patients to Monitor IOP 33 Dry Eye, Be Gone! 28 Eye Screening? There’s an App for that! Media MICE Pte. Ltd. Conference Highlights 6001 Beach Road, #19-06 Golden Mile Tower, Singapore 199589 Updates in Controlling and Correcting Tel: +65 8186 7677 / +1 302 261 5379 35 Myopia Progression in Children Email: [email protected] www.mediaMICE.com Highlights from the OIS Dry Eye Innovation 38 Showcase Making great strides in therapeutics and technology

We are looking for eye doctors who can contribute articles to COOKIE magazine. Interested? Let's talk! Send us an email at [email protected]. To place an advertisement, advertorial, symposium highlight, video, email blast, or other promotion in COOKIE magazine contact CEO Matt Young at [email protected]. LETTER TO READERS

to COOKIE magazine! Welcome ou may know us from PIE, you may know us from CAKE . . . and now, we are thrilled to present you with the latest “bun” from our editorial eye care oven: YCOOKIE, which stands for Cool Optometry, Optics, Kudos, Innovation and Enlightenment.

As my latest brainchild (that’s me, Media MICE CEO Matt Young), COOKIE completes our “menu” of educational (and funky) publications devoted to eye care. And although we are Asia-Pacific-based, our coverage is global — which allows for information and knowledge sharing from the world’s top experts.

We are, of course, also a bit more “funky” than your traditional eye care magazine or journal — let’s say, we’re the publication with “extra sprinkles.” Part of that is attracting the talent and expertise to take us to that next level of “cool.” So, when we met Dr. Kristie Nguyen, an optometrist from Florida, we knew we had met a key ingredient of COOKIE. As an advisory board member, Dr. Nguyen will help guide our stories, adding her own fresh insights, style and delicious ingredients.

But rather than me rambling on . . . let’s hear from her. Cheers, Matt Young.

hanks, Matt! I have to say that when I was approached to join the COOKIE Advisory Board, I was quite intrigued! Especially because the magazine was Tbased in Asia-Pacific. This hit home, and I felt it would be a great opportunity to give a voice to optometry in other countries — especially my roots.

It’s also an opportunity for me to share what has become a lifelong passion for me: Returning sight to those who have lost it. This idea came to me during junior high while in church — there was a sermon on how God returned vision to the blind. This was my “a-ha” moment . . . this is something I could do: I could give people back their sight with eyeglasses or contact lenses. To me as an optometrist, there’s nothing better than helping someone else see.

And although I’m based in the United States, I hope my experiences here will benefit others . . . and to see things from another perspective. Even in Florida, where I’ve practiced for 15 years, there are still so many people who don’t know what we, as optometrists, do. So, I’ve made it part of my mission to educate people through social media. I create “fun” posts to bring more awareness to our industry, this includes my #WednesdayWisdom posts on LinkedIn.

I also don’t believe that education about eye care should be limited to a region or location — everyone has eyes, and there are simple things we can do daily to improve our eye health.

Not only that, but eye care should be accessible to all. (See our cover story on this topic in our called “The Disparities and Future of Eye Care in Asia-Pacific” on page 18.) Further, it’s my dream to visit these places and to do more mission trips internationally to help improve the life of those who need to see who can’t afford it otherwise.

Working together, to continue spreading awareness, education and access, we can truly make a difference.

All the best,

O.D. Kristie Nguyen

4 | October 2020 ADVISORY BOARD MEMBERS

Dr. Kristie Nguyen is a board-certified optometrist. Optometric Association, Young ODs of America, She currently serves as a contract doctor for OD Divas, Optometry Divas and the Central Florida Perez and Associates and Phan-Tastic Eye Care in Optometric Society. Altamonte Springs, Florida, USA. In addition, she has been an executive board After graduating in the top 10 of her high school member for Optometry Divas for the past two class with honors, she went on to obtain her years. She is also a brand ambassador for an Bachelor of Science degree from the University of independent eyewear brand called Kazoku Lunettes Houston, Texas. While at U of H, she volunteered and director of business development for an online at a local hospital and worked as an optometric optical company called Optazoom. She is also an assistant. Dr. Nguyen obtained a Doctorate of independent consultant for Rodan+Fields, which is Dr. Kristie Nguyen Optometry (O.D.) in 2005 from Nova Southeastern a global clinically tested skincare brand. OD University College of Optometry in Fort Lauderdale, Florida. She conducted her medical internships at Dr. Nguyen is married and has two beautiful the Chickasaw Nation Health Clinic in Ardmore, daughters. She enjoys going to the beach, hanging Oklahoma and the Lake Mary Eye Care in Lake out at Disney, and reading. Mary, Florida. Dr. Nguyen is a member of the American Optometric Association, the Florida [email protected]

Dr. Oliver Woo graduated from the School of Branch) as an instructor and mentor for FIAO of Optometry, University of New South Wales, Chinese ophthalmologists, as well as in many local Australia in 1994 and established an independent and international optometry and ophthalmology optometrist practice in Sydney, Australia in 1997. conferences as a lecturer and mentor. In 2007, he became the first Australian Fellow of the International Academy of Orthokeratology He served on the board of directors of the Oceania (FIAO) and mentor. Dr. Woo has special interests in Society of Orthokeratology (Australia and New pediatric optometry, myopia prevention and control Zealand) from 2014 to 2020. He was the FIAO contact lens fitting of orthokeratology and specialty Section Chairman (Oceania — Australia and New contact lenses. Zealand), senior member examination chair and examiner from 2014 to 2017. Dr. Woo actively Dr. Oliver Woo He opened an Orthokeratology and Myopic Control participates in many local and international B Optom, FIAOMC Clinic in 2010. Dr. Woo uses and provides a variety optometry and ophthalmology conferences as a methods in myopic management. lecturer, mentor and coach, with more than 90 international presentations. Dr. Woo has been actively participating in the continuing education conference of the IAOA [email protected] (International Academy of Orthokeratology Asian

Dr. Carmen Abesamis-Dichoso received her Doctor Program and provision of eyeglasses with the of Optometry from the Central Colleges of the United Nations Development Program in 10 Philippines in 1989, and earned her Master of areas and four Regions in the Philippines; and Arts in Teaching from the Central Colleges of the chairperson of the Special Olympics Healthy Philippines in 2001. Her specialties include special Athletes Program in the Philippines. contact lens design for keratoconus, children and high astigmatism; and visual assessment of the Dr. Abesamis-Dichoso is a fellow of the American mentally challenged, autistic, ADHD, cerebral palsy Academy of Optometry; a founding fellow at the and learning disabilities. In addition, Dr. Abesamis- Philippine College of Optometrists; a fellow of Dichoso has been an orthokeratology practitioner in the International Association of Contact Lens the Philippines since 2005. Since 1998, she has Educators; an Asia-Pacific Regional advisor for the Dr. Carmen been self-employed in a private practice at Medical Special Olympics Opening Eyes; treasurer at the Abesamis-Dichoso Plaza Makati. Asia-Pacific Council of Optometry; and is an Asia- OD, MAT, FPCO, Pacific Council of Optometry (APCO) representative FIACLE, FAAO She was awarded “Outstanding Optometrist of the for the World Council of Optometry, in addition to Year” in 2017 by the Optometric Association of being a member of the Legislation, Registration the Philippines. Currently, Dr. Abesamis-Dichoso and Standards Committee. She has also authored serves as the International Affairs Committee chair numerous published papers and is a popular of the Optometric Association of the Philippines; lecturer at industry meetings. director of the Special Olympics Opening Eyes in the Philippines; program manager of Optometric [email protected] Association of the Philippines Vision Screening

| October 2020 5 ATARACTCOOL OPTOMETRY | OCT IMAGING

Study Discovers OCT Efficacy in Uncovering Alzheimer’s Disease by Andrew Sweeney

Family history can be an important diagnostic tool.

f all the inequities, indignities A disease of global lack of exercise and high blood pressure and hardships life hoists upon proportions all have correlation with AD, among Ous as we grow older, Alzheimer’s others. Symptoms are usually mild, disease (AD) is perhaps the most According to the World Health almost unnoticeable in the early stages fearsome and well-known. The disease Organization, 50 million people of AD, and include forgetfulness, poor is silent, insidious and robs the patient worldwide are currently living with judgement, shaky hands and difficulty of their identity and personality until dementia, of which 60-70% have with cognitive thinking. all that remains is a shell. Despite its AD. This number is expected to reach commonality, AD in many ways remains 82 million in 2030 and 152 million The onset of symptoms usually poorly understood. by 2050, the majority of which will occurs between 10 and 20 years after be people residing in low to middle pathological changes begin to occur For all our fears of dementia robbing income countries. As you can imagine in the brain. Clearly, the ability to us of our identities and memories as this entails significant cost, with the successfully identify these alterations we grow older, AD is inevitable once total global societal cost of dementia to the brain before symptoms begin to detected, and treatment can only estimated to be U.S. $818 billion in manifest is an important area of study. slow the progression of the disease. 2015, equivalent to 1.1% of global Over the last five years research has The disease is more than just a gross domestic product (GDP).1 identified several ocular biomarkers for degeneration of the brain cells — it neurodegenerative disease which puts can affect multiple parts of the body in Of course age is the primary risk factor the optometry community at center- many ways. Early detection is crucial to for AD, with the vast majority of cases stage in addressing the public health slowing the progression of the disease, occurring in people over 65. Other crisis of AD. and this is where optometry and risk factors are less well understood, ophthalmology can play a pivotal role. however a history of poor diet, smoking,

6 | October 2020 The window into a degenerated brain

Optical coherence tomography (OCT) is finding increased usage by researchers in their quest to find a non-invasive way to discover AD biomarkers. OCT is a non-invasive tool to measure specific retinal layers in the eye. As the retina is an extension of the central nervous system and shares similar structures and properties with our brain, the retina could mirror what is happening inside the brain, including the neurodegeneration caused by AD.2 A history of poor dietary habits is correlated with AD. Dr. Victor T.T. Chan is an ophthalmologist at the Hospital Authority in Hong Kong and is a of AD. The potential in optometry “Our research has also shown that research investigator at the Department in helping to mitigate the societal Alzheimer’s disease is associated of Ophthalmology and Visual Sciences impact of AD is therefore profound, with capillary changes in the retina, at the Chinese University of Hong and in more than OCT technology including decreased capillary network Kong. He is the lead author of Spectral alone. A number of other areas hold density and enlarged area deprived of Domain-Optical Coherence Tomography considerable potential as well. capillary blood supply in the fovea,” he Measurements in Alzheimer’s Disease: said. A Systematic Review and Meta-analysis, Dr. Chan reports that work is ongoing an overview of the potential of OCT in to develop an artificial intelligence “We still only have very little AD diagnosis. The doctor is enthusiastic (AI) program that can automatically understanding of this disease, hence I about optometry’s potential to find AD. identify individuals with a high risk have a great interest in discovering new of developing dementia based on biomarkers that can identify individuals “Our research has shown that retinal images. AI technology holds with AD at earlier stages of the disease Alzheimer’s disease is associated with considerable promise in revolutionizing and who are more likely to benefit from thinning of the retina, including the swathes of ophthalmology and any effective treatments and lifestyle retinal nerve fiber layer (RNFL) and optometry. Some notable examples modification,” he concluded. the ganglion cell-inner plexiform layer. of this trend include diagnostic tools Consistently, two large-scale population- for diabetic retinopathy and improved based studies, the U.K. Biobank fungal imaging. Study and the Rotterdam Study, also REFERENCES: demonstrated that thinning of RNFL was Indeed, imaging is at the forefront 1. The World Health Organization. Dementia. Available at https://www.who.int/news-room/fact- associated with a significantly increased of development in both optometry sheets/detail/dementia. Accessed on October risk of developing both cognitive decline generally, and AD research specifically. 11, 2020. and AD,” Dr. Chan said. Dr. Chan in particular reports he will 2. Chan VTT, Sun Z, Tang S, et al. Spectral- Domain OCT Measurements in Alzheimer’s continue to work on fundus photography Disease: A Systematic Review and Meta- “OCT can be used in our community to as a risk stratification tool for AD. This analysis. Ophthalmology. 2019;126(4):497- identify individuals with changes in the is in addition to more developments 510. retina associated with AD. This serves specifically pertaining to OCT in the as a risk stratification tool as those same area. individuals might have a high risk of AD and warrant early medical intervention with more advanced diagnostic imaging Fighting an insidious foe Contributing Doctor for the definite diagnosis of AD,” he said. “Another important development Dr. Victor T.T. Chan is an infield is the introduction of OCT ophthalmologist at the Hospital angiography (OCTA). With this Authority in Hong Kong and is Clearer pictures than ever technology, we can now visualize a research investigator at the the retina at the capillary level. The Department of Ophthalmology before and Visual Sciences at the Chinese images can be assessed automatically University of Hong Kong. He received his According to the results of Dr. Chan’s using an advanced image analysis joint bachelor of medicine and bachelor of study there are associations between program, which generates a spectrum surgery degree from the same university. retinal measurements of SD-OCT, and of parameters quantifying the health [email protected] AD, highlighting the potential utility of status of the retinal capillary network,” SD-OCT measurements as biomarkers Dr. Chan said.

| October 2020 7 ATARACTCOOL OPTOMETRY | CONTACT LENSES

Myopia Progression in Children Slowed with Use of Multifocals,

Study Shows by Hazlin Hassan

ultifocal contact lenses get worse. Therefore, the eye slows its (MFCLs), normally used in aging growth so vision doesn’t get worse at “If the eye continues to Meyes, can slow the progression the same rate,” he added. of myopia in children, according grow at the normal rate to results of the Bifocal Lenses In These results highlight the exciting when light focuses in Nearsighted Kids (BLINK) study.* discovery of the option to control the development of nearsightedness in front of the retina, then “These lenses are believed to work by children, a condition that can increase vision continues to get focusing some of the light directly on the risk of cataracts, glaucoma and worse. Therefore, the eye the retina, which enables children to retinal detachment later in life if left see clearly, and focusing some of the untreated. Slowing myopia progression slows its growth so vision light in front of the retina, which acts could decrease the risk of these sight- doesn’t get worse at the as a signal to slow eye growth,” said threatening complications. BLINK study chair, Jeffrey J. Waline, same rate.” OD, PhD, associate dean for research at the Ohio State University College of BLINK for children population is expected to be myopic Optometry (USA). by 2050, with 10% of the population Myopia is the most common ophthalmic being highly myopic. “If the eye continues to grow at the condition in the world with an normal rate when light focuses in front estimated 34% of the world population If untreated, myopia can inhibit of the retina, then vision continues to being affected. Half of the world’s academic performance in children.

8 | October 2020 Visual impairment among preschool or multifocal lenses, the outer lenses Also, the parents of all myopic children children is estimated to increase of which were either high add power should be educated about myopia by 26% by 2060, with uncorrected (+2.50 diopters) or medium add power control,” noted Walline. refractive error comprising 69% of (+1.50 diopters). cases. According to Walline, the contact lenses The results? Children in the high add are safe to be used by children. When a child has myopia, their eyeball multifocal contact lens group saw the is slightly longer than normal from slowest progression in their myopia: “Children have repeatedly been shown front to back and images are focused Only the high add power contact lenses to be able to independently wear and at a point in front of the retina instead significantly reduced the rate of myopia care for soft contact lenses. In fact, of directly on the retina. When this progression over three years compared they typically have fewer problems than happens, objects at a distance seem with medium add power multifocal and college-age students. These lenses also blurry and unclear — and the higher the single vision contact lenses. provide clear vision and freedom from power added, the further in front of the glasses, so the benefits outweigh the retina the lens focuses peripheral light. Mean myopia progression, as measured small risks that are associated with any by changes in the eye prescription contact lens wear,” he said. By comparison, single vision glasses required to correct distance vision, and standard contact lenses, was -0.60 diopters for the high-add “This study shows that if fitting soft traditionally used to correct myopic group, -0.89 diopters for the medium- multifocal contact lenses for myopia vision, focus peripheral light to a point add group, and -1.05 diopters for the control, optometrists ought to use behind the retina, which encourages single-vision group. The multifocal the high-add power. Ultimately, this eyeball growth. lenses also slowed eye growth. provides another option for myopia control in young children, and enforces Several other advances in the treatment The three-year adjusted eye growth was the fact that parents of myopic of nearsighted children include eye .42mm for the high add group, .58mm children need to be educated about the drops (such as atropine) which have for the medium-add group, and .66mm benefits of myopia control,” Dr. Walline previously been found to help slow the for the single-vision group. concluded. progression of myopia, but Dr. Walline said that multifocal contact lenses “When fitting soft multifocal contact appear to provide better slowing of lenses for myopia control, the strongest eyeball growth. add power that provides children with * Walline JJ, Giannoni AG, Sinnott LT, et al. A Randomized Trial of Soft Multifocal Contact clear vision ought to be used, and that Lenses for Myopia Control: Baseline Data and “While these contact lenses do not add power is almost always the highest Methods. Optom Vis Sci. 2017;94(9):856-866. slow myopia progression, on average, add power available (+2.50 diopters). as much as atropine eye drops, they do provide better slowing of eye growth (on average). Eye length is highly related to vision-threatening complications in adulthood, so that may be a very important factor when determining the best option for myopia control for young children,” he explained.

The study examined whether high add power contact lenses provided better slowing of myopia progression and eye growth than medium add power contact lenses and single vision contact lenses.

Almost 300 myopic children, aged between 7 to 11 years old, took part in the study, conducted at Ohio State and the University of Houston, USA, and funded by the National Eye Institute, part of the National Institutes of Health.

At baseline, the children required -0.75 to -5.00 diopters of correction to achieve clear distance vision.

The children were randomly assigned to wear single vision contact lenses

| October 2020 9 ATARACTCOOL OPTOMETRY | MANAGING MYOPIA Jeepers Scooby Myopia is Getting Managed Better

than Ever Before by Andrew Sweeney

o you remember that catchphrase from childhood? If you can’t — or Dif you don’t recognize it at all — you’re truly missing out on a classic.

Scooby Doo was a childhood staple for many of us — and the mystery-solving gang, including the eponymous dopey dog, offered a plethora of cathphrases to remember. “Jinkies” was the catchphrase of the bespectacled Velma, but throughout the show she also frequently lost her glasses, to the extent that “I can’t find my glasses” became a catchphrase in its own right. Velma is one of the first cultural characters to suffer from myopia that many of us encountered in childhood.

According to The Epidemics of Myopia: cure, management and diagnosis are The many multitudes of Aetiology and Prevention,2 one of the still the primary focus areas of most myopia foremost studies into myopia, the companies working in the optometry prevalence of myopia in young adults industry. Of these, perhaps the foremost Myopia, is of course, one of the most living in East and Southeast Asia is OCULUS Optikgeräte GmbH (Wetzlar, pervasive conditions in eye care and was 90% — and high myopia has a Germany). its impact on society extends far prevalence rate of up to 20% in the beyond cartoons. Also known as short- same group. The risk factors include With a history of more than 125 years sightedness, myopia is a refractive error a high level of education and limited in ophthalmological and optometry — meaning that a myopic eye cannot time spent outdoors. Causality has equipment, Oculus is one of the bend light properly. been demonstrated through randomized stalwarts of the industry. Based in clinical trials in which increased time Germany, the company has steadily According to the American Association outdoors in schools has prevented the expanded into the Asia-Pacific region of Ophthalmology, over 25% of the U.S. onset of myopia. over the last decade, putting myopia population suffers from myopia, with front-and-center as a priority. This onset usually presenting in children development resulted in the creation of aged 8-12 years old.1 Myopia is Make sure your kids spent the Myopia Master. incredibly common in all parts of the time outdoors world, and although it is a significant Marketed as the first device to combine issue in the Americas, it is most The global presence of myopia is the important measurement parameters noticeable in the Asia-Pacific region. so expansive that experts view the for making myopia management much Myopia is a pervasive and deeply condition as a societal problem, as easier, the Myopia Master promises ingrained disability in this part of the much as a medical disease. While to revolutionize patient outcomes and world. research continues into a potential satisfaction. It can take risk factors

10 | October 2020 into account, like ethnicity, the number its science, technology and research about the role Oculus plays in its of myopic parents, as well as time based on the work of the Brien Holden continued work in combating myopia. spent with near-vision and outdoor Vision Institute. This is big data, which activities — all of which influence the you can use to present parents with “Oculus is invested in both the growth of the eye. The tool is a way projections of how their children will technology and science to develop to effectively combine measurement see at age 18,” said Dr. Woo. the Myopia Master, as much as it was parameters with software that allows willing to collaborate with research the optometrist to make data-driven “It is an entire system we can use to centers. Looking forward, Oculus is decisions and evaluation-based action present an accurate picture of a myopic creating educational tools for both recommendations. patient’s progression with the disease. optometry and ophthalmology on how to Parents in particular are able to see manage myopia in a more systematic, their child’s condition stabilizing, it’s a evidence-based and scientific way,” Dr. The “master of myopia” really positive development to see,” he Woo said. said. “That’s why I see the need to invest “The Myopia Master Current treatments for myopia, back into the industry, as well including the application of atropine as looking forward to improving is the most systematic can’t be replaced by the Myopia Master, educational initiatives to train more way for me to manage however they can be supplemented. optometrists and ophthalmologists to High-dose atropine (0.5%-1%) is the understand how to manage myopia,” he myopia from the most effective but it has significant concluded. early stage. It has its side effects, such as photophobia and science, technology difficulty with near work (decreased accommodation). Low doses of atropine and research based on show a dose-dependent efficacy.3 the work of the Brien Contributing Doctor Holden Vision Institute. Low dose cocktails and This is big data, which Dr. Oliver Woo, B Optom, optimism FIAOMC, graduated from School you can use to present of Optometry, University of New According to Dr. Woo, doses South Wales, Australia in 1994 parents with projections of between 0.01% to 0.05% of and established an independent atropine have been used to effectively optometrist practice in Sydney, Australia of how their children in 1997. In 2007, he became the first will see at age 18.” manage myopia without incurring Australian fellow of International Academy significant side effects. Orthokeratology of Orthokeratology (FIAO) and mentor. has also proven to be considerably Dr. Woo has special interest in pediatric —Dr. Oliver Woo effective in treating myopia, especially optometry, myopia prevention and control contact lens fitting of orthokeratology and when combined with low doses of specialty contact lenses. He opened an atropine. Prismatic bifocal lenses and Orthokeratology and Myopic Control Clinic The Myopia Master’s implications for specially designed multifocal soft in 2010. Dr. Woo uses and provides a variety methods in myopic management. myopia and wider optometry have the contact lenses have recently been 4 potential to be remarkably significant, tested with promising results. Dr. Woo has been actively participating according to Dr. Oliver Woo. An in the continuing education conference optometrist with over 22 years of It is this multi-focused approach to of the IAOA (International Academy of Orthokeratology Asian Branch) as an experience working in orthokeratology, myopia management that Dr. Woo instructor and mentor for FIAO of Chinese Dr. Woo has been using the Myopia believes works best, describing it ophthalmologists as well as in many Master for the last five months and is as a “cocktail.” Combined with a local and international optometry and ophthalmology conferences and as lecturer highly enthusiastic about the device. management tool like the Myopia and mentor. Master, Dr. Woo is optimistic that “The Myopia Master is the most significant progress will be made in He served on the board of directors systematic way for me to manage treating and mitigating the impact of of Oceania Society of Orthokeratology (Australia and New Zealand) from 2014 to myopia from the early stage. It has myopia. He is also considerably positive 2020. He was the FIAO Section Chairman (Oceania — Australia and New Zealand), senior member examination chair and examiner from 2014 to 2017. Dr. Woo REFERENCES: actively participates in many local and international optometry and ophthalmology 1. The American Association of Ophthalmology. Nearsightedness: What is Myopia? Available at https:// www.aao.org/eye-health/diseases/myopia-nearsightedness. Accessed on October 9, 2020. conferences as a lecturer, mentor and 2. coach, with more than 90 international Morgan IG, French AN, Ashby RS, et al. The epidemics of myopia: Aetiology and prevention. Prog Retin presentations. Eye Res. 2018;62:134-149. 3. Tran HDM, Tran YH, Tran TD et al. A Review of Myopia Control with Atropine. J Ocul Pharmacol Ther. [email protected] 2018;34(5):374-379. 4. Spillmann L. Stopping the Rise of Myopia in Asia. Graefes Arch Clin Exp Ophthalmol. 2020; 258(5):943-959.

| October 2020 11 OPTICS | COLOR VISION LENSES

the Institute for Ophthalmic Research at the University Hospitals in Tübingen, and the Departments of Pharmacy and Ophthalmology at Ludwig Maximilian University (LMU) of Munich, has developed a treatment that should, in principle, correct this genetic defect.

“It involves introducing the normal version of the CNGA3 gene directly into the patient’s retina with the aid of a harmless virus. After a few weeks, the retinal cells can express this functional version of the CNGA3 gene and are able to produce the intact form of the corresponding protein, which should restore the function of the defective cones,” explained Prof. Sharanjeet. In this case, the healthy gene is transported by an adeno-associated virus developed by Professors Stylianos Michalakis and Martin Biel at LMU.

The first clinical study of this approach, Therapies for which involved nine achromatopsia patients aged between 24 and 59 years, has been completed at the University Eye Hospital Tübingen and its results Color Blindness appeared in the JAMA Ophthalmology.2 The patients’ visual function improved, both in terms of visual acuity and in Do they really work? relation to contrast and color vision, by Chow Ee-Tan and without their retinas showing any permanent changes.

olor blindness, more accurately Faculty of Health Sciences, Universiti known as color vision defect, Kebangsaan Malaysia (UKM). Lenses for color vision Ccan be divided into two types – congenital color vision defects and As deficiency in color perception is What about lenses for the color blind? acquired color vision defects. It is due to the absence of cone pigments Prof. Sharanjeet says there are some caused by abnormalities in the eye’s (in the case of dichromats) or different lenses available that might help color three types of cone photoreceptors absorption properties of the cone defectives to distinguish between some (anomalous trichromatism, pigments (as in the case of anomalous color combinations in certain situations, dichromatism and monochromatism). trichromats) in the retina, they cannot while others report no benefit or cause regenerate or be replaced, she said. further confusion. One Indian study found the prevalence of color vision deficiency in 2015 There are both active and passive ranged from 5.26% to 11.36% among Gene therapy offers hope tools that aid people with color vision males and 0.00% to 3.03% among deficiency. The active tools help color females of six different populations.1 “However, there is ongoing research vision deficiency observers in their daily They have varying levels of color vision in gene therapy that has promising life as they change the appearance deficiency — from mild difficulty in outcomes, which could help convert of the objects (by recoloring images) distinguishing different colors, usually color defectives to normal color through image processing algorithms. red and green, to a total lack of color perception,” said Prof. Sharanjeet, This increases the contrast between vision. adding that an initial trial with patients colors that are indistinguishable for the indicates that this new genetic user.3 Presently, there is no treatment or treatment for complete color blindness cure for congenital color deficiency, is safe. “These solutions require a display to says Professor Dr. Sharanjeet Kaur show the image to the subject, such Malkeet Singh, deputy chairman and In about one-third of all patients with as, for example, prototypes of smart graduate coordinator, Research Centre total color blindness, the defect lies in glasses. However, this results in a for Rehabilitation & Special Needs, the CNGA3 gene, she says. A team from decrease of naturalness,” she noted.

12 | October 2020 The passive tools are colored filters to “cheat” on color tests. Mastey also “The study does not clearly state how or tinted lenses, which have recently concluded that color vision defective the chromatic contrast responses were received increased interest. individuals cannot “see new colors” determined, but there was an increase either with VINO or EnChroma glasses.5 in color contrast with long-term usage “In the 1960s, two companies exploited of these filters, which may have the original idea of Seebeck (1837) “From the literature, it appears that reduced the overlap in stimulation of and introduced a lens that just filters EnChroma lenses do not provide any the cone sensitivities. one eye (usually the non-dominant eye) benefit to color vision defects. However, for people exhibiting deuteranomalous evidence shows that VINO lenses may “The contrast response enhancements color vision. The X-Chrom Color be helpful to some individuals with generated by the filters may have led Deficiency Contact Lens and a green color vision deficiency,” says the observers to become more aware ChromaGen Lenses for Color Blindness Prof. Sharanjeet. of weak perceptual signals and, thus, and Dyslexia are still available on the to have learned to be more attentive market today. She says most lenses seek to improve to them,” says Prof. Sharanjeet, who the vision of color-deficient observers notes that the study was done on a “In 2008, X-Chrom was rebranded to by principally modifying the illuminant, small sample size and therefore its Zeltzer X-Chrom. While the X-Chrom but are largely ineffective in enhancing outcome is limited. tinted lens covers the iris and the pupil, discrimination or perception because ChromaGen tinted lenses only cover the they do not sufficiently change the pupil,” continued Prof. Sharanjeet. relative activity of the red and green photoreceptors.7-8 She says analysis has been done on X-Chrom and ChromaGen contact However, a new study found that Contributing Doctor lenses, and report improvement, as well special patented glasses engineered as worsening on some color vision tests. with technically advanced spectral notch filters enhance color Prof. Dr. Sharanjeet Kaur Malkeet Singh is deputy chair for iCaRehab “As such, their use can be dangerous vision for those with the most and postgraduate coordinator; for activities such as driving and flying common types of red-green color and a professor and lecturer in at low light levels, when visual acuity vision deficiency (anomalous Universiti Kebangsaan Malaysia is reduced. It can result in distortions trichromacy).9 (UKM). She completed her Bachelor of Optometry (Hons) in 1986 at UKM and of apparent velocity, visual distortions Ph.D. at University of Manchester Institute and impairment of depth perception. The absorption spectra of EnChroma of Science and Technology (UMIST) in the The studies conclude that these lenses and red and green pigment are United Kingdom in1991. Her Ph.D. was lenses do not provide a true color hue very close. In anomalous trichromats, on color perception and her main areas of research currently are in color vision, perception,” she said. the red pigment and green pigment psychophysics, amblyopia, myopia and have very similar absorption visual dysfunction in pathology. Prior to her Recently, other companies have characteristics. EnChroma lenses current portfolio, she was appointed UKM’s Head of Optometry & Vision Sciences marketed glasses with color filters for separate the transmission of wavelength Programme, School of Healthcare Sciences both eyes, among them EnChroma (color) to below 600nm and above from 2017-2019. (Calif., USA) and VINO Optics (St. 600nm. This feature might increase the Thomas, Virgin Islands). Some research difference of anomalous red and green- [email protected] has suggested that EnChroma lenses cone signals. neither improve results in the color vision tests nor allows the color defective individuals to have a more REFERENCES: 4-5 normal color perception. 1 Fareed M, Anwar MA, Afzal M. Prevalence and gene frequency of color vision impairments among children of six populations from North Indian region. Genes & Diseases. 2015; 2(2):211-218. Meanwhile, VINO glasses were initially 2. Fischer MD, Michalakis S, Wilhelm B, et al. Safety and Vision Outcomes of Subretinal Gene Therapy Targeting Cone Photoreceptors in Achromatopsia: A Nonrandomized Controlled Trial. JAMA Ophthalmol. designed to enhance the O2 signal from 2020;138(6):643-651. hemoglobin under the skin, but the 3. Popleteev A, Louveton N, McCall R. Colorizer: Smart Glasses Aid for the Colorblind. In Proceedings inventors claim that their technology of the 2015 workshop on Wearable Systems and Applications. Association for Computing Machinery. “aids red-green deficiency,” said 2015:7–8. 4. Gómez-Robledo L, Valero EM, Huertas R, et al. Do EnChroma glasses improve color vision for colorblind Prof. Sharanjeet. Some research has subjects? Opt Express. 2018; 26(22):28693-28703. suggested that contrary to EnChroma 5. Mastey, R. Patterson Ej, Summerfelt P, et al. Effect of “color-correcting glasses” on chromatic glasses, VINO glasses improved discrimination in subjects with congenital color vision deficiency. Investig Ophthalmol Vis Sci. discrimination for red-green, but only in 2016;57:192. 6. 5-6 Martínez-Domingo MA, Gómez-Robledo L, Valero EM, et al. Assessment of VINO filters for correcting green defective individuals. red-green Color Vision Deficiency. Opt Express. 2019; 27(13):17954-17967. 7. Sharpe LT, Jägle H, Wissinger B, et al. CNGA3 mutations in hereditary cone photoreceptor disorders. The study by Mastey et al., claimed that Am J Hum Genet. 2001; 69(4):722-37. colored filters can introduce sufficient 8. Moreland JD, Westland S, Cheung V, et al. Quantitative assessment of commercial filter ‘aids’ for red- green colour defectives. Ophthalmic Physiol Opt. 2010;30(5);685-692. luminance or brightness cues that allow 9. Werner Js, Marsh-Armstrong B, Knoblauch K. Adaptive Changes in Color Vision from Long-Term Filter individuals with color defective vision Usage in Anomalous but Not Normal Trichromacy. Curr Biol. 2020;30(15):3011-3015.e4.

| October 2020 13 OPTICS | EYEWEAR TECH

Sustainability and Coronavirus Dominate Discussion Among Optometry’s

Next Generation by Andrew Sweeney

here is an old adage about what Getting the right frames for to find the right frame for the right face is required to be a gentleman: the right face as opticians increasingly use facial T“Manners maketh the man.” If recognition technology to make frames you suffer from poor vision and require Certainly, it has become far easier to to fit faces virtually. the use of eyeglasses, then you will get the right pair of spectacles for the know a similar adage also holds true — “right face” over the last decade. When So, the questions on everyone’s this is that “glasses maketh the man (or your correspondent started wearing mind should be: What’s coming woman),” and that getting the right pair glasses at the age of 7, the options next in eyewear; and what can the of glasses matters. offered by his country’s national health new generation offer to patients and service were fairly limited. It was clinicians alike? That was the hot topic For those of us who wear them, expected that you would like round and of discussion during Vision Expo’s spectacles are glued to our faces all brown, for that was pretty much your online symposium entitled Virtual day and accompany us throughout only option. EYE2EYE Series: Coffee Talk — The almost every aspect of our lives, Next Generation of Eyewear. Held last except perhaps, for sleeping. Despite Fast-forward to 2018 and my last June (entirely online of course), the prognostications of their imminent eye test — yes, I know I’m overdue… seminar was one of many, described demise — especially with the increase apologies to Specsavers Glasgow — as a “complimentary series of virtual in use of contact lenses — eyeglasses but there is something of a pandemic panels and interactive conversations are resolutely here to stay. They will going on and options for the glasses- inspired by Vision Expo’s EYE2EYE remain an integral part of the eye care wearer abound. Every time one goes educational series.” industry, thus getting the right pair for for a test it seems as if there are more the right customer will always be of frames, lenses and styles to choose Participants during Coffee Talk — paramount concern. from than ever before. It is also easier The Next Generation of Eyewear’s

14 | October 2020 webinar offered the best advice and “If someone says their glasses are made Emphasizing the link insight for optometrists, as well as from bottles from the beach that’s between community, the latest creative movements in the great, but that’s not sustainable. You’re eyewear industry. The session was green, you’re trying to clean the world, customer and clinician chaired by Tarrence Lackran, a.k.a. but you’re not sustainable, this is a “Millennials are taking eyewear to @TheOpticalPoet (on Instagram), human factor and it’s about how your another level, we are all excited about and the director of partnerships and team works,” Mani-Platt said. the direction in which it is going,” said programming at The Vision Council. Lackran. Lackran is an eyewear ambassador and As companies move to secure their a social media influencer. sustainability, more of them are moving “Some of my favorites, the legends to online only operations. Karabelas and pioneers in the industry, have set Lackran was joined by four main discussed his experience moving more the tone and cleared a path for the pannelists: Kyly Zakheim-Rabin, owner into online sales, embracing social next generation of eyewear. These four of Zak; Wes Stoody, founder and CEO at distancing conditions and altering his vendors [from the main panel] and Article One; Ahlem Mani-Platt, founder company’s working practices. He has retailers represent that next generation,” and designer at Ahlem Eyewear; and adjusted his customers’ eyeglasses in Lackran added. Christos Karabelas, owner at SOMA his own car, and rerouted his company’s Optical. All young opti-entrepreneurs, phone number to his cell phone. The Virtual EYE2EYE Series holds a representing both the vendor and retail seminar every Wednesday and can aspects of the eyewear business, talked Stoody echoed these comments, be accessed from the platform’s own about their creations, innovations, pointing out that at his company there website or on its YouTube page. The inspirations, and how retailers and is no pressure on the employers to work series is produced by Reed Exhibitions vendors can support one another during from the office. Conversely, customers and supports the American Optometric the ongoing coronavirus pandemic. are no longer able to randomly visit Association’s Think About Your Eyes stores in many cases. Mani-Platt used Campaign. the analogy of the personal shopper, Focusing on creating a and how providing a more tailor-made sustainable environment for experience for the customer can help improve their experience, while also clinician and customer ensuring social distancing compliance. The seminar began with a round of introductions from all the participants. Community relations and the correct Editor’s Note: Some, like Mani-Platt, had no familiaal use of social media also dominated Vision Expo’s Virtual EYE2EYE background in optometry, whereas for toward the latter part of the webinar. Series: Coffee Talk — The Next other participants there was a clear The participants broadly agreed that Generation of Eyewear webinar family heritage in the business. Mani- a positive aspect of the coronavirus took place on June 10, 2020. Platt used this section to speak about pandemic was that it enabled them Reporting for this story also the importance of sustainability in to improve their e-commerce and took place during the webinar. eyewear, and how she couldn’t sleep social media platforms. There is also at night if she thought improved connectivity within their own her products were companies, as well as the The impact o f soci al d easily damaged. communities they serve. i st an ci ng ru les is bei ng fel t a cr os s o pto me try.

| October 2020 15 OPTICS | INDUSTRY UPDATE

Eyewear Designers Remain Optimistic Despite Coronavirus by Andrew Sweeney

In these troubling times, choose optimism.

oronavirus has changed many The future’s in the glasses ongoing viability of the luxury eyewear aspects of ophthalmology and market as the world moves through the Coptometry, some of which are Over the last year, Vision Expo, an challenges of 2020, and how luxury and more obvious than others. Visits organizer of conferences pertaining high-end eyewear design, price level to clinics have been significantly to eyewear and optometry, has been and availability may change as a result. curtailed, tens of thousands of surgeries running a series of online webinars across the world remain on hold, and which cover the many aspects of the distanced medicine (or telemedicine) optometric industry. Inspired by Vision A who’s who in eyewear has become far more prominent. With Expo’s education-based webinars, the the latter development in particular, Virtual Eye2Eye series occurs every The symposium was chaired by Erinn one must consider the full impact of Wednesday. Each webinar is on average Morgan, an eyewear industry expert and coronavirus on eyewear too. 1-1.5 hours, and offers a spotlight on editor-in-chief and editorial director of the state of optometry. Eyewear Business. The were four main Eyewear, as an industry, has been participants, including Selima Salaun, significantly affected by the coronavirus Earlier this year, on May 29, Vision the founder of the luxury eyewear brand in ways that are obvious, and some Expo held edCFDA: What is The Future Selima Optique; and Blake Kuwahara, less so. The impact of social distancing of Eyewear + Design? (The acronym the creative director of his eponymous on the ability of optometrists to test edCFDA stands for eyewear designers eyewear company. Kuwahara is also the their patients’ eyes is widely reported, of the Council of Fashion Designers founder of Focus Group West, a design but the pandemic’s impact on eye of America.) The webinar featured collective uniting eyewear designers, manufacturing, for example, is a less discussion on how the coronavirus architects, managers and others working well-known issue. Given that many pandemic has changed the eyewear in the eyewear industry. countries are now experiencing a landscape and how elements such second wave of the virus, understanding as concept, design, engineering, They were joined by Gai Gherardi, the full impact on eyewear is an manufacturing, price point and even the co-founder and designer of important issue. marketing, will shift and change as l.a.Eyeworks, an international eyewear consumer preferences are reshaped. company; and Ahlem Manai-Platt, the The discussion also considered the award-winning founder of the luxury

16 | October 2020 eyewear brand AHLEM. All of the wholesaler makes all the difference,” it over the phone, that is fantastic,” participants interacted with others Manai-Platt added, following Gherardi said. in a positive manner, and there was Kuwahara’s comments. a clear spirit of solidarity in the face of coronavirus. Gherardi began the PPE and perfect fashion session by reminding the participants of Finding optimism in previous difficult times, having opened sustainability Design would perhaps be the most her first business during the economic obvious way eyewear will change slump of 1979. There is optimism to be had in the due to coronavirus. People wearing eyewear industry, despite the shock eyeshields and other aspects of PPE are caused by coronavirus. The participants influencing eyewear, a point that Salaun Travel no more agreed on that, but also considered that was keen to mention, and she argued this requires considerable adaptability. that this will have a considerable Kuwahara discussed the importance of As people become comfortable impact on design. This goes beyond international shows to his own business, with the coronavirus “new normal,” purely aesthetic considerations, and how the lack of international events the behaviors they adopted during pointing to her own experience of has significantly impacted operations. the pandemic will likely become contracting conjunctivitis. He spoke about the importance of permanent. This means e-commerce adaptability during the coronavirus will become even more prevalent, and On the other hand, Ahlem-Patt, pandemic and postponing launches home visits for testing will become while echoing Salaun’s comments when necessary. However, the stability more common. about changing designs, described of optometry was also referenced. her company’s products as being Quality rather than quantity, and brand like a family heirloom. She views her “We straddle both the medical and the sustainability, will become crucial for glasses as items that could be passed fashion worlds, and even at the optician eyewear businesses to survive. There down from grandfather to grandson. side we’re used to the highest standards was considerable discussion among the She emphasized her commitment to of hygiene, so we were better prepared panelists about how companies can continuing her activity as normal and than most retailers for coronavirus,” better innovate to survive. For Gherardi, focusing on quality. Kuwahara said. the current climate requires both determination and ingenuity. “In the optical industry we have a “We have to continue to produce, you wonderful community, we know the cannot say to a factory that we’ll stop “We are going to have to prove ourselves transformation eyewear can express, it’s production and not pay them for six again, as coronavirus is going to be a heartwarming and I think we’ll make months, you have to move forward. real reset, if I can deliver a customer good choices for our industry,” Gherardi The relationship you have with your a frame to try, and we can talk about said, summing up the symposium.

The Virtual EYE2EYE Series holds a seminar every Wednesday and can be accessed from the platform’s own website or on its YouTube page. The series is produced by Reed Exhibitions and supports the American Optometric Association’s Think About Your Eyes Campaign.

Editor’s Note: Vision Expo’s Virtual EYE2EYE Series: edCFDA: What is The Future of Eyewear + Design? webinar took place on May 29, 2020. Reporting for this story also took place during the webinar.

Coronavirus’ affect on eyewear is more than just fogged glasses.

| October 2020 17 COVER STORY

The Disparity and Future of Eye Care in Asia-Pacific by Brooke Herron

In this first issue of COOKIE, our cover story takes a look at the imbalance in access to eye care in Asia-Pacific, as well as future considerations for improvement. COOKIE magazine is designed to help increase optometric and optical awareness and education worldwide, with a special focus on countries in the Asia-Pacific region.

round the world, there are major Ainequalities when it comes to access to vision and eye care. This tends to affect the lower-income, or more rural regions disproportionately, where access to simple vision screening and spectacles can be cost-prohibitive, leading to higher rates of myopia and presbyopia. Meanwhile in higher- income countries around the world, the more likely causes are age-related, like cataract and age- related macular degeneration (AMD).

According to the World Health Organization’s (WHO) World Report on Vision,1 there are 2.2 billion people with visual impairment globally — and at least 1 billion of those cases could have been prevented, or have yet to be treated. Unaddressed presbyopia (826 million) and uncorrected refractive error (123.7 million) are the most common cause of preventable blindness worldwide. On further investigation,

18 | October 2020 countries in Asia-Pacific own a care isn’t the only problem in Asia- 2017, Dr. Taraprasad Das (India) disproportionate share of the burden. Pacific — in fact, the prevalence of presented the Holmes Lecture, titled: myopia is the highest in high-income Blindness and Visual Impairment Profile The WHO report stated: “The economic countries in the region (53.4%). For and Rapid Assessment of Avoidable burden of uncorrected myopia in the example, in-country numbers among Blindness (RAAB) in Southeast Asia: regions of East Asia, South Asia and adolescents in urban China and South Analysis of New Data.3 What he Southeast Asia were reported to be Korea are quite startling, with myopia revealed was very telling of the situation more than twice that of other regions rates of 67% and 97%, respectively.1 on the ground in Southeast Asia — and — and equivalent to more than 1% is still relative today in 2020. of gross domestic product.” This In addition, low vision that cannot illustrates widespread visual be corrected with spectacles, The International Agency for Prevention disability in the region, which contact lenses or laser surgery is also of Blindness (IAPB) includes 11 is also associated with comparatively higher in lower income countries in its Southeast Asia region decreased productivity countries in Asia-Pacific.2 (SEAR) — in this region, 12 million and quality of life are blind and 78.5 million are visually (QoL). Therefore, in the premiere COOKIE impaired; this amounts to 30% of global cover story, we take a look at disparities blindness and 32% of global visual However, and barriers to eye care in Asia-Pacific, impairment, according to Dr. Das. lack of with insight from an Asia-based access optometrist on how to improve access His analysis included moderate to to — and thus, improve vision — in the severe vision impairment (MSVI) and region. blindness from eight SEAR countries: Bangladesh, Bhutan, India, Indonesia, Maldives, Sri Lanka, Thailand and Timor The imbalance is great Leste. Not included were Myanmar, Nepal and North Korea. Back at Asia-Pacific Academy of Ophthalmology (APAO) congress in In all eight countries, cataract was the

Representing 51% of the world’s population, three regions in Asia account for 62% of the estimated 216.6 million people in the world with moderate and severe bilateral presenting distance vision impairment.1

61.2M South Asia

52.9M East Asia

20.8M Southeast Asia

| October 2020 19 COVER STORY

primary cause of blindness (presenting service delivery.” Further, expenses visit the doctor. Cataract is still the visual acuity (PVA) worse than 3/60) could be met either by national eye number one cause of preventable, and severe visual impairment (PVA care subsidies or appropriate health avoidable blindness in the Philippines,” worse than 6/60). However, in four insurance, he continued. said Dr. Carmen Abesamis-Dichoso, a countries, uncorrected refractive self-employed optometrist in private error (URE) was the primary cause “However, the key will always remain practice at Medical Plaza Makati and a for moderate vision impairment (PVA in human resources and equitable COOKIE advisory board member. worse than 6/18): Sri Lanka (64%); distribution of skilled eye health Bangladesh (63.6%); Maldives personnel,” shared Dr. Das. “We The second is URE. She says many (50.9%); and India (32.9%). And strongly believe that training and people in the Philippines can’t afford although cataract is the main cause of deployment of allied eye health to buy eyeglasses, which cost about moderate visual impairment in Bhutan, personnel hold the key to reduction of US$4. “They don’t have glasses Indonesia, Thailand and Timor Leste, preventable blindness.” because they don’t have food on the the rates of impairment from URE are table. Eyeglasses are a luxury for still concerning at 34.7%, 36.8%, them.” 26.7% and 32.2%, respectively. Spotlight on the Philippines Myopia is also on the rise due to URE also accounts for higher levels The top reason for blindness in the changes in lifestyle, especially among of severe impairment in Sri Lanka Philippines is cataract: “People don’t those in urban areas. “About 52% (46.7%) and Thailand (26.7%). In have access to eye care and/or they of the population in the Philippines addition, URE accounts for 12.5% of don’t have is potentially myopic . . . blindness in Sri Lanka. Although these money statistics are unsettling, there is a bit to of good news: Progress is slowly being made. The RAAB survey noted that the prevalence of both blindness and MSVI has reduced from 1990 in [the region], though it was higher than the world average, according to Dr. Das.

Among the barriers noted, accessibility was the biggest hurdle in Maldives and Timor Leste. In Sri Lanka, the primary barrier was cost.

“In addition to accessibility and expenses, we identified two further barriers to effective eye care delivery in the Southeast Asian region in an earlier publication; they were lack of human resources and the urban centric distribution of eye care personnel,” said Dr. Das.

To address accessibility, Dr. Das said points of care could be placed “as close as possible to people through Major inequalities in eye care remain the eye health pyramidal system of in Asia-Pacific.

20 | October 2020 everyone is taking online classes and focusing on education. and working online — and this is adding to the risk,” she Charitable organizations, along said. “Myopia is the other with continued education pandemic.” and awareness of preventable blindness, And while the will certainly help Philippines enjoys make strides to the longest history eradicate vision in optometry in the impairment Asia-Pacific region, in the region. with its first law Improvements enacted in 1917, have already this nation of more been made, than 7,000 islands and with the has issues with combined efforts accessibility. and commitment from those in the In the Philippines, industry and beyond, distance to vision more and more services is the biggest people will finally have barrier, according to Dr. access to eye care in Abesamis-Dichoso: “It’s Asia-Pacific and around very dispersed, so it’s not the world. balanced when it comes to accessibility or availability. Eye glasses not only improve sight, but also drastically improve quality of life. REFERENCES: “People from far-fetched islands, they 1. World Report on Vision, 2019. World Health have to take a boat, a land trip and Organization. Available at: https://www.who. then another boat, just to get to the city int/publications/i/item/world-report-on-vision Accessed on October 26, 2020. and that’s very challenging to them,” dedicated volunteers — who are helping she continued. to lessen the burden and alleviate some 2. Chiang PP, Marell M, Ormsby G, Keeffe J. of the region’s preventable blindness. Critical issues in implementing low vision care in the Asia-Pacific region. Indian J Ophthalmol. Another issue is economics — for both 2012;60(5):456-459. physicians and patients. “Optometrists One such example is the Fred and ophthalmologists are more Hollows Foundation, an international 3. Taraprasad D. Blindness and Visual Impairment attracted to practicing in the cities — development organization whose Profile and Rapid Assessment of Avoidable Blindness in South East Asia: Analysis of New you would rarely see an optometrist purpose is to make sure everyone — Data. 2017 APAO Holmes Lecture. Asia Pac J or ophthalmologist going to those whether they’re rich or poor — has Ophthalmol (Phila). 2018;7(5):312-315. provinces,” said Dr. Abesamis-Dichoso, access to high quality, affordable eye adding the reason for this is that there health care. The Foundation’s work isn’t the same earning capacity in the continues the mission of Prof. Fred remote villages and islands. Hollows, whose vision was to end avoidable blindness. Contributing Doctor Further, Dr. Abesamis-Dichoso says that many Filipino optometrists are working According to Dr. Abesamis-Dichoso, overseas: “Compared to the rest of the Foundation identified six areas Dr. Carmen Abesamis-Dichoso received her Doctor of Optometry Asia-Pacfic, we are very much ahead in the Philippines and “put up” eye from the Central Colleges of the in terms of education. About 70-80% centers there. “There are volunteer Philippines in 1989, and earned of optometrists working in the Middle optometrists and ophthalmologists her Master of Arts in Teaching from the Central Colleges of the Philippines East are Filipino,” she explained, who visit the eye center — and it’s in 2001. Her specialties include special adding that Singapore also employs attached to a hospital. This means that contact lens design for keratoconus, many Filipino optometrists. “They have at least three to four times per week children and high astigmatism; and visual a very high prevalence of myopia — up there is access to eye care in some assessment of the mentally challenged, autistic, ADHD, cerebral palsy and learning to 80% — but they don’t’ have a lot of provinces. There are three in Luzon, but disabilities. In addition, Dr. Abesamis- optometrists.” I don’t think there are any in Manila Dichoso has been an orthokeratology yet,” she shared. practitioner in the Philippines since 2005. Since 1998, she has been self-employed in a private practice at Medical Plaza Makati. On the plus side The Philippine government has also been active in this regard, by promoting [email protected] Although challenges remain, there vision screening, teaching health are philanthropic groups — as well as workers to perform vision screenings,

| October 2020 21 KUDOS | SIGHT-SAVING OUTREACH PROGRAMS

Protecting Sight in Some of Asia’s Poorest

Communities by Hazlin Hassan

n estimated 2.2 billion people sustainable eye care systems and to assist in the development of the worldwide suffer from visual ensure that residents receive the eye supporting curriculum for the policy Aimpairment of some kind. Almost care they need. inclusion,” she added. half of this is preventable or treatable, but some communities simply do not One of their projects is in Cambodia. While Cambodia has recovered since have access to the eye care they need. the civil war and is now a rapidly “We reached a good progression developing Southeast Asian nation, Here, we take a look at two recently through our continued access to quality health care remains a organizations making an impact by advocacy for eye health care to be challenge thanks to cost and inequality. delivering eye care to some of Asia’s added into the National School Health poorest communities. policy, which essentially denotes the A vision center set up by the care parameters for the children of Foundation in Phnom Penh in 2009 Cambodia,” said Selina Madeleine, contributes to the elimination of Brien Holden Foundation director of Brien Holden Foundation. uncorrected refractive error by providing the community with access to eye The Australia-based Brien Holden “Child eye health has now been ratified examinations, affordable prescription Foundation works with local partners by the government to be included in the glasses and referrals. in developing communities to build policy. We are currently in discussions

22 | October 2020 In the last five years, it has worked number of operations performed by operations, 52 had their glasses in collaboration with the Cambodian increasing the number of surgeons, checked, and 29 received pairs of Ministry of Education, Youth and nurses and community workers trained glasses. Sport, the Australian government and in eye health, as well as educating international NGOs, to implement eye people about cataracts and explaining Hasina, who attended the one-day health care education programs for where to get treatment. camp, was diagnosed with cataracts. students at primary schools in five She was referred for surgery at the provinces. Since it was set up in 1950, Community Eye Care and Research Sightsavers has helped to carry out 7.7 (CERC) hospital in Rangpur. According Healthy vision is critical to childhood million cataract operations in poorer to Sightsavers, Hasina has since had development, and screening children countries, and trained more than 1,000 her second eye operation and is doing for eye disease is crucial because the surgeons. well. damage caused to young eyes can have lifelong impacts. One of the many people who have Since 2004, Sightsavers has dispensed benefited from Sightsavers’ work is 4.6 million pairs of spectacles across Research in 2010 found that over 80% 55-year-old Zamurrad, from Rawalpindi Africa, Asia and the Caribbean as part of vision impairment in children across in northern Pakistan, who lost her sight of efforts to boost universal eye care. Cambodia was due to uncorrected to cataracts. refractive error. It has also helped to train 732 When Zamurrad developed cataracts, optometrists and 433 optometric The Phnom Penh Vision Centre has her vision deteriorated and she technicians, who are able to carry out screened and examined over 65,000 struggled to do anything for herself or sight tests, diagnose eye problems and people and delivered over 21,000 her family and she was scared to leave help to treat people with low vision in spectacles to local beneficiaries. the house. One day, she heard that some of the poorest parts of the world, Cambodia has 77 ophthalmologists for a operations were available for free at a who may otherwise not have access to population of 15 million, and according Sightsavers partner hospital, and the eye care. to the Brien Holden Foundation, there rest is history. are no locally-trained optometrists. Sightsavers’ School Health Integrated “When I was not well and I had this Programming (SHIP) project, which The foundation trains refraction nurses cataract, my husband used to do ran throughout 2016, also screened and spectacle technicians at its everything for me,” she said a year after schoolchildren in Cambodia, Ethiopia, National Refraction Training Centre, her surgery. Ghana and Senegal for health problems among other efforts. such as poor eyesight. “I can see everything clearly: I’m very happy and I do all my household chores Teachers were trained to carry out basic Sightsavers now,” she added. eye tests and refer children for further treatment. During the project, 57,400 Sightsavers is dedicated to combating The charity also treats refractive errors, children were screened for eye problems avoidable blindness and promoting which can be particularly problematic and 1,000 were given spectacles. equal opportunities, providing eye in developing countries, where those operations for people who need them, affected may not be able to afford or Together, through efforts like those and training eye care workers and have access to sight tests or spectacles from the Brien Holden Foundation and surgeons. to help improve their vision. Sightsavers, we can hope to make a visible impact on those who need it Through community volunteers, it also In February this year, the foundation most. distributes medication to people in set up a one-day eye screening camp some of the world’s poorest countries. in Rangpur, Bangladesh, for the Bihari community, a minority group of people Some of the eye conditions which it who have experienced discrimination treats and prevents include cataracts, and lacked access to essential services which can lead to blindness if left since they fled violence in India in the untreated. 1940s to live in Bangladesh.

Last year, 403,000 cataract operations Patients diagnosed with cataracts were were supported by Sightsavers, which referred for a free cataract operation. aims to make it easier for people to If a patient needed glasses, or a new be treated for cataracts, especially in prescription, they were prescribed poorer countries where surgery is not glasses or eye drops. always readily available. A total of 321 adults and children It also aims to improve the quality attended the camp. Seventy-five were Photo provided by the Brien Holden of cataract surgery and increase the given eye drops, 57 needed cataract Foundation on their work in Cambodia.

| October 2020 23 KUDOS | WOMEN IN OPTICAL

Optical’s Most Influential Women On Leadership, COVID-19 and Community by Chow Ee-Tan

our of Vision Monday’s “2020 Most Influential Women in FOptical” honorees were featured on the Virtual EYE2EYE Series, a complimentary program of virtual panels and interactive conversations inspired by Vision Expo’s EYE2EYE educational series.

Moderated by Marge Axelrad, senior vice president and editorial director at Vision Monday (VM), the webinar’s panelists were considered this year’s “We rising stars, innovators and modern have mentors. They shared their views on the more future of vision care, career goals and women in what they believe are the priorities for leadership young female leaders. positions, but from my personal experience, very often Introducing the honorees people assume that I’m a technician or a nurse. Sometimes Mollie Tavel Kaback is the director it’s well-received, but sometimes of growth initiatives and community our authority and experience are engagement at Dr. Tavel Family questioned. Eye Care in Indiana (USA), a third generation, family-run business. She “It helps to have a network of strong focuses on growth of the company, from women around me, who can step in and “I am trying to maintain optimism in my technology to community relations. give me support,” she said. own ways. We always base our brand on ‘feel-good’ things. I have been trying to “I’m the only female on the leadership Brooke Hargrove, co-owner of Empire reach out and to connect with others, team. Our family members all have Optical in Tulsa, Oklahoma (USA), staying true to the hope that everything different backgrounds and experience in worked as a nurse before setting up the will be okay,” she said. the industry, and in managing a crisis,” optical store with her husband last year. she said, adding that she’s met many She was well aware of the anxiety and women who were adept in managing worries caused by the pandemic, and COVID-19 impacts in optical crises. took steps to manage them by talking to employees, as well as with customers, The panelists discussed how women in Camille Cohen, an optometrist at Pearle to keep their emotions calm. leadership roles can contribute to the Vision in New York City, earned her optical industry during the pandemic, Doctorate in Optometry from Salus The fourth panelist, Leigh Berberian, and further, the changes the industry University before joining her brother is director of marketing at Todd Rogers needs to undertake. as a business partner. She admitted Eyewear (Massachusetts, USA). Joking that it was not easy being in a position that she married into the business, The common understanding is that with employees who are older and more she explained that her husband is the there is a new level of doing things experienced than her. founder of the company. remotely. There are enhanced safety

24 | October 2020 measures in place to protect against great female mentors for three years. support each other during this time, and COVID-19, and visits to opticians are one way to do that is through pricing. through appointments only. Hygiene has “These are women who wanted to She disclosed that her company offers also been heightened across the board. support other up-and-coming women. a program that converts payments into And from them, I saw successful installments for their customers. Kaback said that staffing became more family relationships and other business predictable once they realized that opportunities. That was when I To Dr. Cohen, public health education is certain aspects of the business could considered coming back to my family vital to emphasize why the eye care and be done from home, such as billing or business — and now I look at the eyewear industry are important. managing the retail operation. industry from a different point-of-view,” she said. “Today more people have binocular The panel agreed that today, there are vision problems, and also follow-up with numerous opportunities for suppliers, Kaback met a group of Transitions glaucoma care. And if you have a family vendors and eye care partners to Change Agents and was encouraged by history of diabetes, hypertension and facilitate interaction and conversation the fact that many industries are filled high cholesterol, it can affect your eyes. in the community. with people who want to help others. But, we must stress the importance of an annual eye examination. With that, “For example, if you’re supplying face “Among them are some incredibly smart not only you are preserving your life, but masks to local schools, you have the and inspiring women leaders in the also your sight as well,” she said. opportunity to introduce your local optical industry, and they have guided eye care provider to their service and me along,” she enthused. Compared to the past, there are fewer resources,” said Kaback. “We have barriers and a lot more opportunities for been trying to get inroads to the school women leaders in the optical industry. partners and reaching out to parents The bright future of women But there is still a lot of work to do. who are watching their kids.” in optical On influencing more young black women So, what are the important things to go into the eye care profession, Dr. Supporting the local that today’s women — with an Cohen said visibility is key for people to community entrepreneurial mindset — can see the opportunity. Black Americans contribute to the industry? Having a comprise 13 percent of the population, Indeed, community support is of common voice is important, according but only occupy 3 percent of the optical great need and importance. Optical to Berberian. profession. companies should ask what they can do to help via products and services — “Americans don’t really understand who The NOA’s “Vision in the Future” which will also be helpful to the growth opticians are and what they do. Now we program seeks to provide a scholarship of their businesses. have a golden opportunity in marketing: and mentorship pathway to historically To find an optical community and to hit black colleges and universities. The For example, Dr. Cohen is working with that point home. first round of recipients were awarded the National Optometric Association this year to four young women, said Dr. (NOA) on a program to provide free “Instead of looking at one another Cohen. eye care and eyewear to minority as competitors, we should find a communities. She has been active commonality, a common voice. This can She is challenged to take on a in the NOA, which was founded in help move each other forward. It also mentorship role in the education 1969, and has served as director of gives the public a better, and healthier, of young students, so that their communications and editor of the understanding of how they choose families are also educated on all the organization’s magazine. eyewear and why they go for eye care. opportunities available to them. We have not done a good job, and now “Education is important,” she stressed. is the time,” added Berberian. “I see how desperate a family can be when they don’t have a laptop, and Hargrove, who is a mother of three, said thus, no access. I believe providing she is always intentional when it comes eye care and eyewear to those in need to hiring women with families — and Editor’s Note: is important for the generation that is in turn, helping them navigate their Vision Expo’s Virtual EYE2EYE coming up,” she added. careers. Series: “Listen In to Tomorrow! A Conversation with Four of VM’s Kaback, who has personal experience “We should be more understanding 2020 Most Influential Women in with the help and support of other of people, especially at this time. We Optical” webinar took place on women leaders, shared about her need to have more patience. Women August 12, 2020. Reporting for “boomerang” work life. After leaving her should empower each other more than this story also took place during family’s business, she began her own judging,” she said. the webinar. journey in the healthcare industry in public relations, where she worked with Kaback agreed that it is important to

| October 2020 25 INNOVATION | IOP MONITOR

New Transmitter Device Enables Patients

to Monitor IOP by Andrew Sweeney

ccording to entrepreneur and You are not a robot … but eye conditions are now being treated potential James Bond Villain we are getting closer or managed with implants, glaucoma AElon Musk, you are already a stands out as a particularly promising cyborg . . . have you not noticed? This is especially true in the biomedical field. Granted you might not have cables sphere, where developments like and computers installed directly implants, mobile apps and wearable Glaucoma is characterized by a high into your brain, but you do have a devices are revolutionizing patient level of intraocular pressure (IOP) — powerful device attached to your hand. treatment and management. Items like and although it’s not the sole cause Smartphones, for many of us, govern Fitbits have been around for a few years of the condition, it is a significant almost every aspect of our life. and they are considerably improving in risk factor. The ability to mitigate quality and efficacy. Implants represent and manage IOP in high-risk patients This is not usually what people have the most exciting aspect of this is therefore important, especially as in mind when they think of cyborgs, development and also hold the greatest glaucoma is one of the leading causes preferring to fall back on science fiction promise for the optometry industry. of blindness in the world. A group of characters like Darth Vader. Musk raises researchers at Purdue University in an interesting point however: We are so Some might say that contact lenses West Lafayette, Indiana, USA, recently dependent on technology that we are in are the original implants, despite their announced a significant development in many ways cyborg in nature. Whether temporary character. Now, of course, this area. or not that is unsettling is beside the we are more familiar with eyelid and point, and cyborg-eque devices are corneal implants, bio-integrations and A group of four researchers from the becoming big business. prosthetic eyes, as well as glaucoma University’s electrical and computer drainage implants designed to improve engineering department have developed aqueous flow. Indeed, while many a 2.4GHz ultra-low power, energy-

26 | October 2020 harvested narrowband transmitter (TX) for wireless sensing and biomedical devices. It’s certainly a bit of a mouthful, but the transmitter deceive represents a remarkable achievement.

The TX comprises a voltage-controlled power oscillator (VCPO) and a loop antenna which is patterned over a flexible Parylene C substrate (which is a polymer) to achieve biocompatibility with the patient. The loop antenna acts as a radiator, as well as an inductive element for the VCPO, eliminating the power amplifier stage and bulky off-chip matching network.

Basically, what this all means is that the transmitter is designed for low-active and sleep-mode power consumption to support both Get comfortable: Can new devices monitor IOP while you sleep? continuous-data mode or deeply duty cycled burst-data mode of transmission. In even more layman’s terms, this means that data can be collected The transmitter device has been world’s lowest energy consuming while the patient sleeps. This makes under development for a number of RF transmitter reported to date. measuring medical issues like IOP years, however, a paper on the device Additionally, this chip is wirelessly much easier and more efficient. was just published in June this year. powered without having any bulky and Given the exponential rise of interest costly external electronic components — in telemedicine technology due to the that makes the system lightweight and Empowering patients to take coronavirus pandemic, it is no small cost-effective,” he added. control of their IOP surprise that interest in the Purdue transmitter is also increasing. It can The transmitter is now patented as Hansraj Bhamra, PhD, was one of the offer both an effective means of part of the team’s cooperation with the lead researchers on the device while he managing IOP, while also being able Purdue Research Foundation Office was a graduate student at Purdue. He to operate under social distancing of Technology Commercialization. received his doctorate in electrical and conditions. According to the University, they are computer engineering and went on to currently looking for partners to develop work at Apple and Broadcom Limited. The key factor ensuring the the technology further. For more Beyond the academic challenge, his effectiveness of the transmitter device information, contact the office at otcip@ motivation was also to help assist is battery usage. Typically, radio- prf.org with the reference track code amputees and people living with frequency (RF) transmitters are the 2016-IRAZ-67415. glaucoma, which accounts for the broad most power-hungry circuit in wireless applicability of the implant. body sensor nodes and biomedical devices. This is where Dr. Bhamra “The transmitter can be integrated with believes his device leads the pack. a wide number of biomedical systems and can also enable the wireless Contributing Doctor transmission of data, just like WiFi. An opportunity for investment One area which is specific to optometry and development is the implant’s wireless glucose- Hansraj Bhamra received his Ph.D. in electrical and computer monitoring contact lens,” Dr. Bhamra “In previous studies, focus was engineering from Purdue University; said. given to either reducing active or he also holds a master’s degree in leakage power consumption, but engineering from the Indian Institute of Technology, Delhi. He currently “The transmitter collects the pressure not both. In our study we designed works at the research and development data from the sensing chip and and implemented the transmitter for department of Broadcom Limited, a San transmits it wirelessly to a smartphone both low active and low leakage power Francisco, California-based manufacturer application. This is how it enables 24- consumption,” Dr. Bhamra said. of semiconductor and infrastructure software products, as a hardware engineer. hour IOP monitoring — all the patient requires is instruction by a healthcare “Thanks to our work, our transmitter [email protected] professional prior to first time usage,” has an energy efficiency of 7 picojoules he said. per digital-bit, which makes it the

| October 2020 27 INNOVATION | EYE CARE APPS

In fact, smartphones have driven most of the recent innovations in ophthalmology, noted Dr. Akkara in a 2018 paper called Innovative Smartphone Apps for Ophthalmologists.1

He shared that there are some apps (such as the Eye Handbook), which do a variety of things like comprehensive patient vision assessment, ophthalmic calculations, international classification of diseases and more — while many other apps are specialized in one or a few tasks only.

“[There are] apps for vision testing including acuity, contrast, color vision and stereo acuity. There are also apps to test optokinetic nystagmus, to do optometric calculations, to do virtual perimetry and grade various ophthalmic signs,” said Dr. Akkara.

He continued that there are several innovative apps that enable easy, affordable and portable vision testing via smartphone. “Other apps may be useful for a quick reference Eye Screening? (EyeGrader), learning (3D Atlas of Ophthalmology) or smartphone fundus photography (HopeScope, Ullmann There’s an App for that! Indirect & MIIretcam),” explained Dr. by Brooke Herron Akkara.

Apps that assess near and distance ohn Davis Akkara, MD, is an vision testing app). These are currently visual acuity (VA) have been found ophthalmologist at Westend Eye available in the App Stores for Android to be reliable in an emergency JHospital in Cochin, India. But and iPhone. setting, although there is still before he committed to medicine, some standardization needed in he was fascinated by computers and And now, with the COVID-19 pandemic the brightness and contrast of the technology. making access to eye care more difficult smartphones and optotype sizes. worldwide, telemedicine and apps such “Even while in medical school, I as these can contribute to the effort Dr. Akkara said there are also apps that learned mobile software programming to avoid preventable blindness and help patients: There are now several and developed a few apps,” he said. provide continued medical care. Below, apps where can set a medication “During ophthalmology residency Dr. Akkara discusses the different apps schedule to ring an alarm and remind and fellowship, I continued to available to eye care professionals the patient to follow the correct merge my passion for ophthalmology and their patients — as well as their dosing of medications. These are and technology to develop a few potential impact in eye care. especially useful in chronic diseases ophthalmology apps as well.” like glaucoma. There are also apps that stimulate vision in cataract, glaucoma, Since then, he’s developed Riding the tech wave diabetic retinopathy patients, and in numerous smartphone apps for both different types of intraocular lenses ophthalmologists and optometrists to “Smartphones are now an essential part (IOLs). assist with screening, diagnosis and of modern daily life and the medical more. Among them are the 3D Atlas of field is no exception,” began Dr. Akkara. “Patients also get the benefits from Ophthalmology (for stereoscopic atlas of “With the simple phrase, ‘there’s an faster and affordable eye care,” he eye conditions); Eye Grader (for grading app for that,’ many problems of modern said, adding that patients may also find systems in ophthalmology); Eye Know life have been solved — even in eye medication reminder apps very useful. Tamil (a local language helper app for care for doctors and patients.” eye care specialists); and iDoctor JD (a Further, in 2019, Dr. Akkara authored

28 | October 2020 another paper on Smartphone Apps in access to eye care. Dr. Akkara low cost adapters with image clarity for Visually Impaired Persons.2 These suggests some of these apps could help rivalling that from conventional apps can help with daily tasks, with bridge that gap for patients in rural or expensive cameras,” he said, adding talking clocks, calculators and camera underserved communities. that smartphone gonioscopy, corneal functions, but there are also apps that topography, and imaging of endothelial can help patients identify objects, “One of the biggest advantages of these cells have also been demonstrated. recognize people, identify currency, and apps is that they increase healthcare read signs and text. access by improving availability and “As technology progresses and reducing the cost of care. Smartphones becomes more affordable, we should try “Smartphones can also be easily used are becoming very affordable and these to find ways to help each other using as magnifiers and contrast enhancing apps and techniques definitely help to these. Technology should not divide us, low vision aids with free apps,” he said. bridge the gap in access to healthcare, but rather unite us as humanity. “One innovative app is Be My Eyes, in not just eye care,” he shared. which sighted volunteers can help the “We see a lot of disease and ill-health visually impaired in identifying anything And fortunately, for doctors and patients as a consequence of inequitable with their smartphone camera.” alike, the momentum continues to distribution of wealth and technology, build. Dr. Akkara shared that there and much of this can be easily are several interesting innovations improved by careful redistribution The ‘smart’ future of eye care already in use: “Smartphones can be of available resources with no used to take anterior and posterior disadvantage to anyone,” concluded Dr. Worldwide, there is still a huge disparity segment photographs via small and Akkara.

REFERENCES: 1. Akkara JD, Kuriakose A. Innovative smartphone Dr. Akkara’s Top 5 Apps apps for ophthalmologists. Kerala J Ophthalmol. 2018;30:138-44 Most are available in the iPhone and Android App Stores 2. Akkara JD, Kuriakose A. Smartphone apps for visually impaired persons. Kerala J Ophthalmol. 2019;31:242-8 1. Eye HandBook is a free (but iPhone that work as a remote- ad-supported) multipurpose controlled and calibrated VA chart ophthalmic app with multiple with multiple optotype options, vision tests including near and additional charts such as vision, color vision, optokinetic Amsler grid and Duochrome test. nystagmus drum, Amsler grid, The app is free, with the option Contributing Doctor contrast sensitivity and Worth to purchase for more advanced 4-dot test. It also has multiple features. Dr. John Davis Akkara is faculty in optometric calculators such as a the Department of Ophthalmology of glaucoma risk calculator, visual 4. Eye Grader is a free app Sri Ramachandra Medical College, acuity convertor and IOL power developed by Dr. Akkara for Chennai, India. He was formerly a glaucoma consultant at Little Flower calculators. In addition there is clinical grading of several Hospital, Angamaly and Westend Eye ICD coding, forums, videos, eye ophthalmic signs, symptoms and Hospital, Cochin. He completed medical atlas and references for patient findings, including approximately school (MBBS) & ophthalmology residency (MS Ophthalmology) from JIPMER, education. “Truly an essential app 70 grading systems, which Pondicherry; and glaucoma fellowship from for eye care specialists,” said Dr. are searchable and also can Aravind Eye Hospital, Pondicherry. He has Akkara. be browsed by topic. “A few also completed the Ratan Tata Advanced examples include cataract Cataract Fellowship in Sankara Nethralaya, Chennai. Dr. Akkara has presented in state, 2. Peek Acuity is a free app (LOCS), gonioscopy (Spaeth, national and international conferences from Peek Vision that allows for Scheie, Shaffer, RP Centre), bleb and has won awards for smartphone- rapidly distance VA measurement (Moorfields, Indiana) and so on.” based virtual reality perimetry, smartphone using an E chart with built-in ophthalmic photography and virtual reality in ophthalmology. He has publications calibration. “The innovative 5. visualFields easy is free on innovations in ophthalmology, artificial swiping and shaking method iPad-based software that tests intelligence, 3D printing, smartphone slit allows quick and accurate VA suprathreshold visual fields lamp photography, smartphone apps and more. He is passionate about technology measurement and there is also easily. “This technology has and gadgets and does programming, a simulator showing the blurred rapidly evolved in the past few website designing and has created vision experienced at different years to make portable, accurate, ophthalmic smartphone apps such as visual acuities,” he shared. affordable, virtual reality EyeGrader, Eye Know Tamil and 3D Atlas of Ophthalmology. perimetry possible,” said Dr. 3. Eye Chart Pro & Remote Akkara. [email protected] are a pair of apps for iPad and

| October 2020 29 ENLIGHTENMENT | DRY EYE MANAGEMENT

where the lockdowns have been lifted, there appears to be surging Scratching demand. ”What I’m seeing is a breaking of the dam effect,” said Dr. Periman. “Clinics were closed and patients the Surface held back in their dry eye care during the shelter-in-place order. I continued to help patients by quickly Talking Dry Eye with switching to telemedicine. There’s a lot you can do with telemedicine to get people teed up for success. We Dr. Laura Periman by Sam McCommon still offer telemedicine as a way to establish care, gather a great deal of information, start certain therapies e’ve all experienced it at some better understanding and greater and then, now that the clinic is open, point: Red, irritated, itchy eyes patient-doctor access are all arrows in they come in for advanced diagnostics Wthat can really take the wind a physician’s quiver to target dry eye. and treatment. We’re seeing pent up out of your sails. Dry eye is a common demand that’s been unleashed.” condition affecting millions worldwide, To wrap our heads around the and it’s becoming more and more topic, CAKE magazine spoke with So, that’s good news: Patients are common. Increased screen time, air dry eye expert, Dr. Laura Periman, returning in great numbers to get pollution and plenty of other factors a board certified, cornea-trained their dry eye treated. What’s more, such as poor nutrition, personal habits, ophthalmologist, based in Seattle. the lockdowns accelerated the cosmetics and skin care — including She’s recently opened her own development of tools like telemedicine mask use — can contribute to and independent clinic focusing on dry eye, and home treatment devices. exacerbate the problem. so she’s a true guru in the field. Mask-associated dry eye (MADE) It’s something that has certainly affected humankind for its entire Addressing the elephant: dry Interestingly, one side effect of existence, but is becoming more eye and COVID-19 COVID-19 Dr. Periman has noted widespread in modernity. The is an uptick in mask-associated dry demographic of dry eye sufferers is First, we should address the elephant eye — MADE, a term coined by her expanding beyond the classic post- in the room that’s affected all medical colleague and friend Darrell White, menopausal female group to include fields, and everything else for that M.D. Essentially, turbulent air exhaled younger and younger patients. matter: COVID-19. During lockdowns is pushed up through ill-fitting masks in various places, ophthalmic clinic and is directed towards the eyes As such, the condition is certainly visits dropped precipitously as both instead of away from the face. This can on physicians’ and pharmaceutical patients and doctors feared spreading lead to desiccating stresses and fuel companies’ radars. New treatments, the virus. Now, however, in places the inflammatory cascade which can cause or worsen dry eye in vulnerable patients.

Dr. Periman has a solution, however, and it’s relatively simple. The problem comes from ill-fitting masks, so making the masks fit better is the answer. To do this, she suggests lowering the mask down the nose a bit, but so it’s more across the cheeks — and then using one-inch surgical paper tape to secure the mask snugly to the cheeks. Half the tape should be on the mask and the other half should be on the skin.

When removing the tape, do so very carefully to avoid damaging skin. Support the skin with one hand while gently, obliquely removing the tape off with the other to prevent skin injury or A proper fit is important in clothing and masks. bruising.

30 | October 2020 papillary conjunctivitis changes on a patient’s lower palpebral conjunctiva, she’ll do a test dose of anti-allergy in one eye and an artificial tear in the other eye. At 3 minutes, she’ll ask the patient which eye feels better. If the anti-allergy medicine treated eye feels better, voila: Allergies are a component of the overall ocular surface disease picture. Even smoldering, low-grade levels of allergy need to be addressed topically with anti-allergy drops, including the new topical anti-allergy drop Zerviate (Eyevance, Texas, USA).

This new understanding of allergies has also made her appreciate topical steroids even more than before, especially for flare-ups. She said there is definitely a role for short-course New treatments could provide an oasis of relief for dry eye sufferers. steroids, and pointed to steroids specifically for dry eye.

New treatment options for tears and increase tear volume. FLAREX (Alcon, Geneva, Switzerland) dry eye is an eye drop used to treat eye Novaliq (Heidelberg, Germany) inflammation, and has been FDA With the elephant out of the way, we has developed a water-free and approved since the 1980s. It’s valuable can turn our attention to new treatment preservative-free eye drop for dry as a periodic dry eye treatment as developments. And if Dr. Periman’s eye dubbed NovaTears® that may well. Dr. Periman noted that it has an enthusiasm is any indication, these provide significantly longer relief and excellent safety profile and has the developments are exciting indeed. greater spreading while also being efficacy of Pred Forte (prednisolone preservative-free. Dr. Periman tried it acetate; AbbVie, Dublin, Ireland) There are drugs being developed to in her own eyes and was impressed. with the safety profile of FML Forte treat individual aspects of dry eye, The formulation is called CyclASol, Suspension (Allergan, California, USA). including pain and lack of lubricity. For currently in clinical trials, would example, Novartis (Basel, Switzerland) use the EyeSol water-free vehicle to Another steroid in development has a TRPV1 antagonist for treating deliver cyclosporine A, which is water is called Eysuvis, from KALA pain associated with dry eye. Another insoluble and a well-established and Pharmaceutical (Massachusetts, drug underway is Lubricin (Lubris important anti-inflammatory and USA). Eysuvis is currently in phase 3 BioPharma, Framingham, Mass., USA), immunomodulating drug valuable for clinical trial, and is expected to receive an eye drop that may be particularly dry eye. FDA approval in October. When (and useful for patients with autoimmune if) it does, it will be the first steroid disorders. And Azura (Tel Aviv, Israel), Allergies and Dry Eye: New Evidence, specifically indicated for dry eye. is developing a drug to address the New Treatments hyperkeratinization of meibomian gland dysfunction. All of these drugs One topic Dr. Periman focused on Increased physician access are currently in phase 2 clinical trials. is the greater understanding of the and home treatments role of allergies in dry eye, as well Another interesting treatment option as improved treatment options. It’s As mentioned earlier, one positive is neural stimulation. An external particularly important because we now outcome from the COVID-19 crisis vibration neural stimulation device, have scientific evidence explaining the has been the dramatic uptick in iTear100, by Olympic Ophthalmics immunologic bridge between allergic telemedicine and home devices. (Washington, USA), was approved in conjunctivitis and meibomian gland Especially with doctors being able to May 2020 to increase tear production dysfunction. practice telemedicine across state and Dr. Periman told us she has lines, patients have greater physician seen wonderful clinical success As Dr. Periman put it, “When that access than ever before. with this device. A pharmaceutical paper came out my jaw hit the floor. option in development is a nicotinic This made me way more aggressive in “The patient access part is so acetylcholine nasal spray by Oyster treating allergies.” important and it’s such a relief to Point Pharma (New Jersey, USA). It patients,” said Dr. Periman. “You can stimulates the lacrimal functional unit To test for allergies, she has a quick still get access to dry eye experts via to produce physiologically complete and effective method. If she sees telemedicine. I’m hoping the advances

| October 2020 31 ENLIGHTENMENT | DRY EYE MANAGEMENT

pulsed light (IPL) for facial and ocular rosacea. The Lumenis Optima IPL M22 (Yokneam, Israel) is approved Home Modification for Dry Eye in Europe, China and Australia for meibomian gland dysfunction and dry In addition to treatments for dry eye, eye. The U.S. label expansion is in patients can also adapt their home process. The significant majority of or office environment to be friendlier peer reviewed literature demonstrating to their eyes. Some suggestions Dr. the benefits of IPL treatments for dry Periman has for patients include: eye and MGD is with the Optima M22 platform. • Lower your computer monitor. This decreases the surface area of the eye exposed to evaporation Great progress, but there’s stresses. still a long way to go • Get a desktop humidifier, and It’s true that there have been wonderful keep your workstation and room advances in dry eye treatments, and humidity at a minimum of 60 increased focus on the condition will percent. lead to even greater options. But as the condition becomes more prevalent, • Stay well hydrated and practice it will become clear that there’s even good nutrition whenever possible. more to do. • Watch your cosmetic habits: For Refractive procedures like LASIK example, don’t use eyeliner on the we’ve made with telemedicine will not and PRK can lead to dry eye. Plastic eyelid margin if you’re vulnerable be repealed by Congress. With COVID, surgery and neurotoxins for crow’s feet to dry eye. Avoid soap around your there was a bunch of relief that came can also contribute to it. Systemic eyes. Do not use eyelash perms from Congress and reimbursement for medications, antihypertensives and or eyelash extensions. Replace telemedicine in different states, and autoimmune disorders like Sjogren’s your mascara frequently. Avoid so on. It’s been pivotal in creating syndrome and rheumatoid arthritis, can parabens in your eye creams and enhanced access for patients. And they also lead to dry eye. Dr. Periman noted eye cosmetics. love it and appreciate it.” that there are a lot of undiagnosed autoimmune disorders that cause dry • Take omega fatty acid Home devices eye. supplements. There’s enough evidence to support the role of Dr. Periman discussed some new home What this means is that while there omega fatty acids in ocular health. devices that can be valuable tools in have been significant developments Choose brands such as HydroEye combating dry eye. One of them is for dry eye, the problem will still (ScienceBased Health, Spring, NuLids (NuSight Medical, California, exist. Other things are still missing Texas, USA) with excellent clinical USA): a device that helps stimulate in the ophthalmologist’s tool kit. Dr. science demonstrating benefits to and clean the meibomian glands. As Periman said, for example, there has the dry eye patient. Dr. Periman said, “I’m seeing really been incredible progress in advanced exciting clinical results with NuLids diagnostics but more still needs to • Certain vitamins and supplements and patients love it.” be done. Ophthalmologists need the may help, but Dr. Periman ability to do a detailed analysis of indicated she’s seen patients Masks for dry eye treatment can also the inflammation profile of tears. take supplements too far provide significant relief. Masks vary Furthermore, they need more readily and cause toxicity from over from microwaveable designs like the available point-of-care imaging studies supplementation. classic (Bruder, Georgia, USA) to such as confocal microscopy, which USB designs and combination therapy can often solve clinical puzzles such as masks (EyeEco, California, USA). the corneal neuropathic pain with the Dr. Periman emphasized that masks ultrastructural analysis of the corneal that combine modalities of heat and nerves. vibration may help maximize pain relief for dry eyes. And still, there are very challenging Editor’s Note: cases of dry eye. Dr. Periman’s take? A version of this article was LED face masks sold for beauty “That only points to the fact that we first published online at and skincare may be effective for have to keep learning, innovating and www.cakemagazine.org dry eye through a process called discovering for our wonderful patients. on August 31, 2020. photobiomodulation. Currently, there We’re just beginning to scratch the are in-office treatments using intense surface.”

32 | October 2020 ENLIGHTENMENT | DRY EYE TREATMENT Dry Eye, Be Gone! by Hazlin Hassan and Brooke Herron

ry eye can be a literal pain, with “We spend so much time on devices Fight DED with diagnosis symptoms ranging from stinging, that our eyes are going to pay a price Dburning, watering and itching. But — and that price is coming if we don’t Dr. Teh says the latest technology in it can also be a serious disease. If left make an impact on screening for dry dry eye diagnosis and assessment is untreated — or if it becomes severe — eye,” he said. the OCULUS Keratograph 5M (K5M; complications may arise that cause real OCULUS Optikgeräte GmbH; Wetzlar, damage like impaired vision, or in rare “There are many studies that show Germany). He has been using the device cases, vision loss. up to 70% of Asians have meibomian for the last five years. The system gland dysfunction (MGD). That is a integrates a high-resolution camera, Dry eye disease (DED) can result from a high number. In the United States, it’s keratometer and corneal topographer — range of daily activities, like allergies or about 20%,” said Dr. Teh. MGD is a combining corneal topography and dry contact lens use. In addition, increased blockage or some other abnormality of eye analysis in one machine. screen time from smartphones and the meibomian glands resulting in not computers can affect the eyes and enough oil secretion into tears. This “I use the KM5 because it allows me worsen dry eye symptoms. then causes the tear film to evaporate to do everything: I can measure non- too quickly and results in MGD’s invasive Keratograph tear film break-up “We are spending an average of 13 association with DED. time (NIKBUT), look at tear volume, hours a day on our devices — and a lot assess the meibomian glands to see of people are doing more than that. You In his practice, Dr. Teh has a high how well the oil glands are structured work eight hours a day, spend time on number of Asian patients. Following in the upper or the lower lid,” said Dr. social media, play games and watch screening, he’s found that nearly 40% Teh. Netflix — all on the laptop or iPad,” said of his patients had the condition. Jason Teh, an optometrist at In2Eyes “Undiagnosed MGD is going to be a “We can also do stainings — by using Optometry in Melbourne, Australia. Dr. massive problem worldwide in the next fluorescein dye and changing the Teh has 19 years of experience and a five to 10 years,” he said. settings to blue light, we are able to Bachelor’s of Optometry. capture any signs of damaged cells on

| October 2020 33 ENLIGHTENMENT | DRY EYE TREATMENT

the corneal surface. So, many of these “The K5M is a powerful tool for Further, Dr. Teh explained that there are the key diagnostics that we need.” contact lens fitting . . . you can fully aren’t many devices that measure pupil customize the lens just based on function (constriction and recovery) The Keratograph 5M allows optometrists these measurements,” said Dr. Teh. when submitted to light stimulus. “You to assess and record the extent of These measurements include corneal can actually measure recovery time for patients’ DED — using non-invasive topography, pupil size, contact lens pupil function, so that stands out.” methods to take high-resolution images, fitting and NIKBUT. with a wide variety of tests and software analyses, all of which provides patients “The corneal topographer maps the Clear benefits with more insight into their condition. curvature of the eyeball and gives us the measurements of how steep According to Dr. Teh, the patient Dr. Teh says it’s the dry eye assessment and flat it is at different meridians. experience is generally very powerful that really makes the Keratograph 5M With that, the visible iris diameter and very good because the Keratograph stand out among other similar devices. can be measured and that then helps 5M has so many features and functions. Part of this is customization: The dry determine the size of the contact lens He says these make the Keratograph eye assessment can be modified to a needed. 5M “all encompassing” and provide the particular preference, or a set protocol patients with a lot of “wow factor” — from a dry eye society like TFOS (Tear “The pupil size can also be measured especially when discussing the results. Film & Ocular Surface Society) can be and that will help ensure the lens is followed. centered,” continued Dr. Teh. “If the “The K5M is the ‘jack of all trades’ and pupil is big or small, it will be clear or it’s pretty much the master of all. You “Once you select your protocol, it will blurry depending on the optic zone of have so many different things that you take you through each test you need to the contact lens. For example, if the can do with the one device and that’s do,” he shared. Once the patient’s data optic zone is small, but the pupil size what makes it so so valuable,” he said. is captured with the K5M, optometrists is big, then you’re going to get glare can plan the best treatment. These and halos — but if you know the pupil Dr. Teh says of all the equipment he’s results are also summarized in a matches the optic zone of the contact acquired at his practice over the last 10 patient-friendly printout to assist with lens, then the vision outcome is going years, the Keratograph 5M is the most documentation and patient education, to be good.” valuable. “The K5M gives me the best which is a further benefit, said Dr. Teh. value for money. We use it more than “You can put all your findings together The Keratograph 5M can also help with pretty much any other instrument and in a report and show the patient exactly fitting during follow-up — especially it gives us so much information and so what each stands for . . . you can also with hard lenses which are suitable for much value for the price we pay,” he add in your diagnostic suggestions and dye. “You can put the dye into the eye concluded. management plan.” with the contact lens on and you use imaging to check the fit. You can do a video recording of that fit as well,” Dr. More than dry eye Teh explained. “This is one feature that really makes it stand out — how good The Keratograph 5M is not just for the blue light imaging is. diagnosing dry eye either. Contributing Doctor “The other cool thing I like to do, especially with soft lenses, is to Dr. Jason Teh is a member of the as a have a look at the length of time it s as dry tumbl Optometry Australia Association and Eye ewe takes for that lens to dry out, to see ed has been practicing optometry for ? Y whether or not the patient is going more than 19 years. His interest in ou m to have any problems with wearing optometry started from a high school ig h work experience with an optometrist, t contact lense for a long period of time,” h which led him to study two degrees at a v he said. This is done using NIKBUT Melbourne University. This included a year e D while the patient is wearing the contact of research into the causes of myopia. E D During his thesis year, he graduated with . lenses. “You get the patient to blink honors and from there he completed his twice and it will measure how long it Bachelor of Optometry. Dr. Teh started a takes for the tear film to evaporate from myopia management clinic more than 10 the surface of that contact lens. years ago as part of an effort to reduce the impact of short-sightedness in the general community. He believes that the next major “You can even show off how well eye threat to eye health comes in the form of drops work by dropping lubricant in tear film dysfunction, and he now runs a their eye and performing the same busy dry eye group out of three locations with his team of optometrists. test before and after application. So, it guides you in terms of what type [email protected] of tears are better for that particular surface.”

34 | October 2020 CONFERENCE HIGHLIGHTS | WEBINAR COVERAGE

Updates in Controlling and Correcting Myopia Progression

in Children by Chow Ee-Tan

n 2000, low to moderate myopia was in the study equated to approximately minutes/day is likely to slow eye growth. prevalent in 20.2% or 1.243 billion 90 minutes or more of daily outdoor Ipeople around the world. This figure light exposure), the axial growth rate Li Deng, PhD, and her associates at is estimated to increase to 40% or decreased by 0.12 mm/year (about 0.3 the New England College of Optometry 3.82 billion by 2050. Meanwhile, high - 0.4 D slower myopia progression),” (NECO) Department of Vision Science myopia is expected to increase from which was a result of a study in also agreed that participating in more 2.7% (or 163 million) to 9.8% (or 938 Australia. hours of sports and outdoor activities million) in the same time frame. during the school year may protect Meanwhile, the Guangzhou Outdoor against myopia development. Further, the World Health Organization Activity Longitudinal study (GOAL) (WHO) World Report on Vision 2019 showed that 40 min/day of outdoor noted that 2.6 billion have myopia activity decreased myopia onset by 9% Controlling and correcting and of those, 312 million are under after three years. Another interventional pathological myopia 19-years-old. In addition, one billion study in Taiwan revealed that 80 min/ have no access to eye care — as day of intermittent outdoor time could Myopia is found globally across eyeglasses are unaffordable or not decrease myopia onset up to 9% in only ethnicities and its complications accessible. one year. such as myopic maculopathy (MM), glaucoma, retinal detachment (RD) and These statistics were revealed in a “A recent meta-analysis done by cataract can be sight threatening, said CooperVision webinar entitled “Utilizing Shuyu Xiong et al. showed that with Dr. Abesamis-Dichoso. Multifocal Center Distance Soft every additional one hour of outdoor Contact Lens in Myopia Management,” time per week, the risk of myopia Pathological myopia is real and alive. presented by Dr. Carmen Abesamis- onset is reduced by 2% in children A convincing case has been made that Dichoso. and adolescents,” said Dr. Abesamis- the delineation of physiological and Dichoso. pathological myopia is not valid, as Dr. Abesamis-Dichoso, an optometrist the term “physiological” implies that and eye care practitioner at Abesamis This was further demonstrated by the there is a level of myopia which could Eye Clinic in the Philippines, believes Role of Outdoor Activity in Myopia be considered “safe” in comparison to myopia is transforming from benign (ROAM) study, which followed 101 emmetropia. to a disease epidemic. Quoting the children between 10 to 15 years of age, International Myopia Institute (IMI), of whom 41 were myopic and 60 were Using odds ratios, which describe the she defines and classifies myopia with non-myopic, from 42 Brisbane schools. increased risk of a condition over a a proposed set of standards for clinical Aussie kids generally spend more reference of one (this being the risk of and epidemiologic studies. time outside than kids in many other emmetropia), it shows that even 1 D countries, including Asian countries of myopia doubles the risk of MM and She said that high myopia occurs when with a high incidence of myopia. PSCC (posterior subcapsular cataract), the refractive error is -6.00D or more and triples the risk of RD compared to when ocular accommodation is relaxed, According to Stephen Vincent, OD, the emmetrope. At 3D of myopia, the and where pathologic myopia axial PhD, with the Queensland University risk of PSCC triples, with the risk of RD length is 26 mm or longer. of Technology, differences in daily and MM being nine times that of the outdoor light exposure may be one emmetrope. factor underlying the higher prevalence The role of sunlight in of myopia in Singapore. Singaporean “We all know by this time that standard myopia control students are exposed to 61 minutes of regular single vision glasses do not outdoor sun per day compared to 105 work,” said Dr. Abesamis-Dichoso. Sunlight can explain the protective minutes for Australian children. However, recent investigations suggest effect of outdoor activity against that undercorrection may enhance, myopia, said Dr. Abesamis-Dichoso. He concluded that bright light exposure rather than slow down, myopia for 60 minutes or less per day is a risk progression in children, she added. “For every one log unit increase in factor for faster eye growth, whereas average daily light exposure, (which daily outdoor light exposure of 60-90 “Our findings support the hypothesis

| October 2020 35 CONFERENCE HIGHLIGHTS | WEBINAR COVERAGE

that myopes have an abnormal it,” she emphasized. rate of myopia progression over three mechanism for detecting the direction years (but further research is needed).” of optical defocus of the retinal image. Meanwhile, accommodative and [Editor’s Note: See infographic on page We suggest that this results in the binocular vision (BV) conditions 37] stimulation of eye elongation when blur are about nine times more common is present, rather than the expected than ocular disease in patients aged Further, Dr. Abesamis-Dichoso said inhibition of growth when the eye is 6 months to 18 years. Of these, the ideal candidate for multifocal myopic. approximately 20% have a binocular soft contact lenses (MFSCLs) vision condition. should be mature, motivated, with “We also conclude that the popular parental support and myopia with low therapeutic strategy of under-correcting astigmatism, with very limited reusable myopia in children may be not only Slowing the progress of soft multifocal toric options and no unwarranted, but even potentially myopia with MFCL daily disposable multifocal toric option. harmful,” she said. She then described multifocal contact If the child is a suitable contact lens A recent retrospective analysis of a lenses (MFCL) with a 2.0 mm central wearer, the contact lens options can be private optometric practice’s clinical distance zone and 2.0-5.0 mm OK or MFSCLs OrthoK, Toric MFSCLs, data further supports the notion that increasing plus power across a 5.0 or daily disposable MFSCLs. They undercorrection results in greater mm pupil, including: Acuvue Oasys should work with 50% efficacy, she myopia progression compared to (Johnson & Johnson, Florida, USA); concluded. full correction. Authors reported a CooperVision MiSight (California, USA); significant positive correlation, with CooperVision Biofinity; and Visioneering greater amounts of undercorrection Technologies NaturalVue (Georgia, resulting in greater myopic progression. USA).

Another option is orthokeratology (also Dr. Abesamis-Dichoso detailed a study known as Ortho-K, OK or Overnight that found in 70% of the children, Editor’s Note: Vision Correction), which refers to the myopia progression was reduced by use of gas-permeable contact lenses 30% or more in the eye wearing dual The CooperVision webinar took that temporarily reshape the cornea to focus (DF) lens, relative to that wearing place on August 15, 2020. Reporting for this story is reduce refractive errors such as myopia, the single vision distance (SVD) lens from information obtained hyperopia and astigmatism. in period one (10 months). Similar from that webinar. reductions in myopia progression and According to Dr. Abesamis-Dichoso, axial eye elongation were also observed overnight orthokeratology has shown with DF lens wear during period two to be effective in slowing myopia (10 months further). Visual acuity and progression over a 12-year follow-up contrast sensitivity with DF lenses were period and demonstrated a clinically not significantly different than with SVD acceptable safety profile. lenses. Accommodation to a target at 40 cm was driven through the central The risk of microbial keratitis (MK) with distance-correction zone of the DF lens. Contributing Doctor overnight orthokeratology was similar to other overnight modalities. The risk of “Soft multifocal contact lenses with Dr. Carmen Abesamis-Dichoso is a MK for daily disposable contact lenses a distance center design may slow Fellow of the American Academy is 2 in 10,000 wearers per year; for the average growth of the myopic of Optometry and the Philippine monthly disposable contact lenses, the eye, and some studies suggest College of Optometrists. She received her Doctor of Optometry rate is 12 in 10,000. that the treatment effect for axial from the Central Colleges of the elongation continues to accrue beyond Philippines in 1989, and earned her Dr. Abesamis-Dichoso also discussed the first year of treatment,” she said. Master of Arts in Teaching from the Central Colleges of the Philippines in 2001. Her the efficacy of various strategies to specialties include special contact lens control myopia. She then covered an August 2020 design for keratoconus, children and high report published in JAMA that asked: astigmatism; and visual assessment of “The most efficient myopia control Can soft multifocal contact lenses with the mentally challenged, autistic, ADHD, cerebral palsy and learning disabilities. strategies are atropine, Ortho-K, high add power slow myopia progression In addition, Dr. Abesamis-Dichoso has multifocal contact lenses, prismatic in children more than medium add been an orthokeratology practitioner in bifocal lenses, peripheral addition power or single-vision contact lenses? the Philippines and has been actively lenses, and time spent outdoors. practicing myopia management and control Since 1998, she has been self-employed in The clinical trial found “that in children private practice at Medical Plaza Makati. “Refractive surgery is NOT effective, as with myopia, treatment with high add well as single vision lenses and contact multifocal contact lenses — compared [email protected] lenses, because these interventions only with medium add multifocal and single- correct myopia — instead of controlling vision contact lenses — reduced the

36 | October 2020 | October 2020 37 CONFERENCE HIGHLIGHTS | OIS COVERAGE

In the area of imaging, Ra’anan Gefen, the managing director of AdOM Advanced Optical Technologies, an Israeli med-tech company, presented a singular device that comprehensively diagnoses DED. The Tear Film Imager (TFI) is currently deemed as the only device that measures muco-aqueous and lipid sublayers simultaneously in nanometer resolution. “A single OIS Dry Eye 40-second automatic non-invasive test provides objective and quantified Innovation Showcase parameters,” he said. The technology was developed as a Making Great Strides in Therapeutics result of the understanding that mucus is a barrier for topical ophthalmic drug by Joanna Lee and Technology delivery. Besides its ability to capture measurements in 40 seconds, it has a high frame of more than 10 hertz to he latest innovations in drugs and COVID-19 pandemic. “Because their capture tear film dynamics (the first devices that ease the sting of dry quality of life is affected, they’re more in the market to do so), with artificial Teye increase opportunities for likely to come in,” he said. intelligence capabilities to analyze profit and are pioneering a continuum captured images. of care. With much room to make a difference, the Dry Eye Innovation Showcase (by Dry eye disease (DED) is sometimes Ophthalmology Innovation Source; OIS) The role of therapeutics taken as seriously as chapped lips. Yet, featured eight startups and gave the while 42% of eye care patients (or up to audience a glimpse into the exciting Stepping in to combat the mucus barrier 80 million Americans) have complained developments in this growing area of for topical ophthalmic drug delivery is of symptoms that indicate DED, only treatment in ophthalmology. Kala Pharmaceuticals (Massachusetts, 16 million were diagnosed with DED — USA) with its AMPPLIFY® Technology and only 1.6 million are being treated. drug delivery system. Its Chief Medical This means that only 5-6% of the U.S. What the market offers Officer Dr. Kim Brazzell explained population gets any DED treatment, how AMPPLIFY delivers drugs using representing a great opportunity for The first presentation showcased nanoparticles with its proprietary coating DED therapeutics. “We’re in the infancy Novaliq’s unique water-free technology to avoid interaction of the drug particles of this,” said Dr. Paul Karpecki, director EyeSol®, which overcomes water- with the mucus. of cornea services and external disease based limitations in eye drops. Out of at the Kentucky Eye Institute, as he this technology, Novaliq (Heidelberg, “In the eye, it avoids adhesion to the moderated the session. Germany) was able to develop eye’s tear film mucins, thus enabling CyclASol®. Its Vice President of rapid penetration through the tear film Not only that, but Dr. Karpecki also Preclinical and Clinical Development and enhancing diffusion in the ocular said what was thought of as an “elderly Dr. Sonja Krosser revealed CyclASol® tissues,” Dr. Brazzell said. Significant disease” is now changing due to factors has been able to improve cornea improvements were seen in both signs like increased time spent on digital damage significantly over Restasis™ by and symptoms in the same population devices. The Beaver Dam Offspring reducing blurred vision and frequency during the four trials of this system Study (BOSS) showed that the of dryness. One highlight was that (primary for phase 2, STRIDE 1, STRIDE prevalence of dry eye in children now the trial’s subjects reported reading 2 and secondary for STRIDE 3). Also, matches that of their parents. Women speed improvement with corneal less than 1% reported any IOP elevation, over the age of 65 suffer from DED staining reduction. The technology’s with no serious adverse events observed. twice as much as men. However, there increased residual time on the eye’s doesn’t seem to be a large statistical surface, from minutes to hours, also has AMPPLIFY is targeted for a Q4 2020 difference between men and women positive effects on its bioavailability. launch with the potential to become aged 21-34 when it comes to DED. CyclASol may just fill the gap for the the first-line therapy for the short- 60% of patients who abandon their term treatment of DED, including Dr. Karpecki also revealed that many treatment due to discomfort. “Its the treatment of dry eye flares, which specialty clinics that treat DED have excellent tolerability profile is key for occur with the vast majority of dry eye been doing well with 100% return compliance,” she said. patients. to profitability, especially during the

38 | October 2020 OptimEyes Technologies (Ontario, (vibration at certain frequencies to dry eye treatment. This potentially Canada) sees potential in its patented induce liquefaction and mobilization of unique mechanism is a corneal platform technology using a high dose the oil). “Finally, there’s an activation receptor modulator. OCU001’s multiple of cyclosporine. The Micelle technology of the lacrimal functional unit through preclinical trials (animal models) have comprises small polymeric spheres neuromodulation to induce expression demonstrated normal tear secretions, that are able to encapsulate drugs in from the meibomian glands of the improved corneal sensitivity and their core. “Unique to our formulation, oil,” he explained. These would be corneal surface health. Its phase 1 the surface of Micelles are adhesive, conducted through the device worn over study has shown safety intolerance allowing them to bind to the ocular patients’ closed eyelids. levels with a successful development surface,” said OptimEyes’s Chief through its phase 2a proof of concept Executive Officer Dr. Frances Lasowski. The ELM has a strong patent portfolio, trial, with no serious adverse events or The value Micelle proposes to bring he said. EyeDetec has also to date tolerability issues — and with dry eye is that it significantly reduces the accomplished $3 million in convertible relief experienced within two weeks. dosing needed with enhanced efficacy. notes with several products. The most Mr. Shine said Ocunova (Pennsylvania, In animal trials comparing Micelle notable is the EyeGiene® Insta- USA) is currently seeking investors for (0.075% cyclosporine A) with Restasis Warmth™ product, which is a reusable OCU001 in order to complete its phase (0.05% cyclosporine A), Micelle’s dose eye mask with single-use warming 2b clinical trials. of once every three days was equal to disposable vapors. The product has Restasis’ twice-daily dose. It was also been validated clinically by a Singapore shown to help tear volume and staining Eye Research Institute (SERI) Panel take home message return to baseline. published study, and is a U.S. FDA Class 1 exempt product with early sales The presentations were followed by Addressing dry eye from a different in the United States. the Dry Eye Outlook panel featuring angle, Tarsus Pharmaceuticals’ Chief Dr. Karpecki and an esteemed and Executive Officer Dr. Bobak Azamian experienced panel of physicians, announced the development of the What technology contributes namely Dr. Whitney Hauser, Dr. first drug for Demodex blepharitis. Marguerite McDonald, Dr. Joseph In uncovering this disease (which Neurostimulation influences key Tauber and Dr. William Tattler. They also causes dry eye), Dr. Azamian aspects of dry eye. Enter the discussed the reasons behind the small highlighted the key role that collarettes iTEAR100 Neurostimulator™ from numbers (3-5%) being treated for DED; play in Demodex infestations. Dr. Laura Periman, who is the founder collarettes in blepharitis; the difference Collarettes are mite waste products and director of Dry Eye Services & between dry eye disease and meibomian and eggs, a pathognomonic sign of Clinical Research at Periman Eye gland dysfunction; the use of steroids the infestation. It is found in 100% Institute (Washington, USA). The for treating dry eye; the current of Demodex blepharitis patients’ electromechanical neurostimulator opportunity to specialize in diabetic lashes. Dr. Azamian added that device is indicated for temporary use dry eyes treatments; and the value of blepharitis is a large, unserved market for up to 30 days to increase tear treating with on-label therapeutics. in ophthalmology. He said that Tarsus production. Dr. Periman said “the Pharmaceuticals (California, USA) has holy grail is the number of meibomian “There are so many causes of completed four phase 2 clinical trials glands yielding liquid secretions (or meibomian gland dysfunction (MGD) including randomized control trials MGYLS in literature),” where the and dry eye, so to find one single with very strong and consistent results. iTEAR100 was able to induce a higher treatment is pretty unlikely. I think Phase 3 trials are underway and phase yield of the clear liquid fluid in test there will always be a poly-therapy 2 trials are in the pipeline for 2021. subjects. In their 6-month trial, there concept. As new products come around, was also a reported decrease in corneal we’ll find new ways for them to be EyeDetec Medical (California, USA) staining. After the neurostimulation, symbiotic together,” Dr. Hauser said. President and Chief Executive Officer although patients were advised to Dr. Barry Linder explained that dry maintain their treatment regimen, 44% eye is a lipid problem — and not so reported being able to decrease their much a lack of tears. “Lipids prevent dependence on artificial tears, and a evaporation from the tear film, and quarter of them were able to get off that’s critical,” he said. Based on this, artificial tears altogether. Editor’s Note: they have introduced the Eye Lipid The OIS @Dry Eye Innovation Mobilizer (ELM), a medical device that Another niche segment with potential is Showcase was held on 20th August aims to improve the eye’s oil layer and in the diabetic dry eye market. Startup 2020, 1-4 PM EDT. Reporting for thus, decrease tear evaporation and Ocunova’s Chief Executive Officer this story also took place during the event. A version of this article normalize the ocular surface. Michael Shine presented on how his was first published online at company’s product OCU001 has been www.cakemagazine.org Combining several mechanisms, the shown to improve corneal sensitivity, on August 21, 2020. ELM would give heat to lower the increase tear production and rapidly viscosity of the oil. Next, it induces improve dry eye symptoms. OCU001, resonant frequency stimulation he said, is a novel, patented ocular

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