Category: Specialists-Ophthalmology

Modern medicine works by finding evidence to support one or more differential diagnosis at a particular point in time. Sometimes the evidence can come from seemingly unrelated parts of our body. The eye is unique in being the only organ in our body that allows a direct visualisation of its nerve and blood vessels. This offers a peephole view of the state of our health. As such, an eye test is a golden opportunity not to be missed, to gauge our overall physical wellbeing.

Starting from the eyelid and the internal content of the eyeball, all the way to the layers of its walls as well as the six muscles responsible for eye movements, all are closely connected to the rest of our body via their blood supply and innervations. One could say the eye is the “crystal ball” that can foretell our health, providing early clues that should be acted on with appropriate follow-up tests and actions, not just for sight, but also for life-preservation. Several recent examples come to my mind.

First is a very fit patient who had a persistent blurring of vision when reading in one eye and no obvious general health issues. I made a diagnosis of macula swelling secondary to blockage of a branch retina vein at the back of the eye, supported by a thorough eye examination and eye scans. Treatment with eye injections and laser was successful in restoring eyesight. Closing the case after eyesight restoration would be like missing the forest for the trees, as it is usually the underlying cardiovascular health that is the root cause of the eye disease. In fact, in a 2016 meta-analysis endorsed by the American Heart Association and American Stroke association, blockage of the retina vein was found to be associated with a 120 per cent to 450 per cent increase in the risk of stroke, depending on age.

The bigger picture

Recognising the possible bigger picture from a single problem of blurring of eyesight can indeed prompt health-seeking behaviour and ultimately save your life. In fact, my patient is contemplating a career switch from a very stressful job that is felt to be contributing to episodic blood pressure spikes, which almost certainly caused the vein occlusion in the eye.

Another is a patient with a complex intraocular lens problem who also suffered from intractable diabetes and severe diabetic eye disease. A previous cataract surgery in a neighbouring country many years ago could not stand the test of time and the inserted artificial lens implant had become wobbly, to the point of causing terrible visual distortions with every movement. After a rather “heroic” eye surgery lasting several hours, we treated both the dislocated lens implant and detached retina, but subsequent recovery of sight seemed slower than expected.

As a result of the severe diabetic eye disease, in this case, the optic nerve is no longer able to provide clues to possible brain diseases. However, due to complaints of headache and my impression that there could be more to the case, I ordered a brain magnetic resonance imaging (MRI). The result was a sizeable brain tumour that fortunately was still operable, and the final outcome of the case was thankfully a happy ending.

Many patients ask me why their eyes look “smaller” and their eye colour seems to become lighter as they age. The answer is a ring of deposit of oily (lipid) material around the cornea, which is the perceived “black of eye”. The scientific parlance is arcus senilis (pardon the language please) and may indicate a rise in the blood cholesterol level of the body, so it is highly recommended to undergo tests and treatment to manage the cholesterol level.

More than meets the eye

And if becoming senile and demented is a concern, new research also indicated that studying the retina blood vessels may give clues to early Alzheimer’s disease, although diagnosis still needs to be supplemented by neurological tests and brain imaging.

Dry eye disease can be associated with an underlying thyroid problem, and new research has also indicated an association with a lack of Vitamin D which is not rare even in sunny Singapore. I have sent many patients, some even pre-operatively before their planned cataract or laser refractive surgery for blood tests for the above, if suspicion index is high.

Sometimes these tests do turn out to be positive. Proper treatment can then improve their eye symptoms such as eye tiredness and irritation, and improve their general wellbeing too.

I always make it a point to inform young (and sometimes older) patients who sign up for Lasik surgeries which rid them of refractive errors like myopia and astigmatism, if I find any tell-tale signs suspicious of glaucoma, at the risk of sounding like nagging.

One of the associated causes for glaucoma is snoring (sleep apnoea). This may sound innocent enough, but if the end result of continuous neglect is the possibility of complete blindness, my sincere advice is to please get the snoring treated, by the ear nose and throat specialist, as believe me, blindness from glaucoma is real, irreversible and very terrible.

The English poet William Blake once wrote in his famous Auguries of Innocence: To see a world in a grain of sand, and heaven in a wild flower. So too, a quick check of the eyes can reveal more than, well, meets the eye. It may not be possible to hold infinity in the palm of the hand, but here’s wishing that we safely go through the world!

As Singapore emerges from the “circuit breaker”, a measured approach and long-term plan for eye care to better prepare for possible future outbreaks should be considered

SGSecure, a national campaign launched in Singapore four years ago for crisis preparedness has been a success in informing residents of the need to be vigilant against terrorist attacks and other civic emergencies. It has a catchy tagline of “Our eyes are our first defence”, with eyeball mascots keeping an eye out for signs of trouble. I cannot agree more, since our sense of sight comprises 80 per cent of our senses.

2020, the year for good vision, has quickly degenerated into the worst public health and financial crisis in a generation, no thanks to Covid-19. As the world hunkers down to avoid what seems to be a threat worse than terrorism, local essential services like healthcare, transport, food supply and infrastructure have soldiered on these two months, including my specialist eye clinic, albeit on a much smaller scale.

Eye diseases are rarely life-threatening, even though they can blind one and affect one’s independence and livelihood. Yet the trickle of patients with eye problems, significant enough to leave home to see a doctor for, has told a sobering story of how prevention is truly many times better than cure. Apart from symptoms like seeing floaters and flashes which may be due to unavoidable retina tears that can cause detachment, most other acute eye diseases are arguably avoidable, either by early detection and preventive treatment, or careful management of general health problems that may give rise to eye diseases as a complication.

Flattening the curve
Very few would have predicted that a viral pandemic could bring human activities to such an abrupt halt. Deriving Singapore’s coping strategies from our Sars-hardened political leaders, public health and infectious diseases experts, themselves on a steep learning curve, we do our best to flatten the Covid-19 curve by staying home as much as possible.

Meanwhile, life goes on, and the usual urgent and emergent health problems happen as they normally would, with some exceptions such as reduction in influenza and air pollution-related allergies. On the other hand, as a result of the stay-home campaigns, health-seeking behaviours, other than pandemic-related, are altered and delayed by the healthcare bottlenecks worldwide. As such, there are emerging signs of increased disease severity at presentation in affected specialties, with possibly higher morbidity and mortality.

Even though I fully agree with and have operated by the Ministry of Health’s guidelines on appointments and social distancing during the past crucial weeks, my heart aches when I see otherwise able-bodied patients lose their vision. Chronic diseases like cataracts can sometimes progress faster than what conservative treatment plans for. This has resulted in some patients going from doctor to doctor, seeking surgical relief for functional restoration.

Furthermore, delays in seeking medical attention can cause one’s vision to be permanently damaged from common eye diseases like glaucoma, macular degeneration and diabetic retinopathy, all of which are usually symptomless in the early to moderate stages, where commencement of treatment to preserve sight is effective and strongly advised. In the worst scenarios, patients are unaware until they reach advanced stages of these eye diseases. By then, extensive treatment is indicated, unfortunately often unsuccessful in fully restoring vision. The consequent vision loss can render one unable to adequately manage activities of daily living and to work. It is my sincere wish that the eye care profession can satisfactorily manage the backlog of cases in the coming weeks.

As Singapore emerges from the “circuit breaker” and gradually resumes life as we knew it, my personal opinion is that a measured approach and long-term plan for eye care to better prepare for possible future outbreaks be considered. Ongoing management of acute cases aside, and while safe distancing and all applicable infection control measures are followed for protection of patients and doctors, emphasis should be on eye treatment to restore function as soon as possible for affected patients, so that breadwinners and families can get on with their lives.

Further to that, monitoring of previously diagnosed chronic eye diseases, particularly unstable cases, and eye screening for patients with risk factors should not be long-delayed, so that treatment outcome can be optimised. Efficient use of downtime As food for thought, in Hong Kong and South Korea where pandemic measures are reportedly balanced and infection control generally good, ophthalmologists, particularly those in non-hospital or privately-run settings, had continued to provide “compartmentalised” services for eye care including cataract and refractive laser surgeries.

Such practices, to my knowledge, had reportedly not contributed to a spread of Covid-19, is openly accepted locally and deemed an efficient use of enforced downtime, particularly by patients seeking laser refractive correction, who are typically young adults and more resilient to the pandemic. In other countries, Covid-19 swab tests are carried out as a screening prior to surgeries. In Hong Kong, eye specialists in different sectors seem to close ranks, with counterparts in the private sector proactively contributing to the care of public sector patients.

While practices differ from place to place, I opine that a universal principle should be to improve clinic infection control and time-efficiency so that eye service quality is not compromised. While we wait for sustained stabilization of the pandemic, clinical research, particularly commercial and unrelated to the pandemic, should continue to be scaled back. Certainly, in my practice, tests and procedures that are potentially aerosol-generating such as the airpuff eye pressure test, and that are invasive or prolonged, are currently avoided in favour of those that can achieve similar aims without the downsides.

Similar to how the pandemic forces us to hasten trends at the workplace, in retail and information technology, I believe in time to come, it will shape and perpetuate practice trends in healthcare and ophthalmology too. These trends may be the adoption of telemedicine, increasing use of non-invasive and contact-less diagnostic devices and embracing newer surgical approaches to reduce risks and improve long-term post-operative results, like using laser cataract and refractive laser lenticule techniques.

One thing is for sure, Zoom and webinars have resulted in unprecedentedly large participation in both public education and professional meetings I attended in the past two months, a trend that hopefully will stay for good. As for our first defence against the pandemic in the coming weeks, in addition to face masks, may I please suggest the anti-terrorist mentality of including eye protection, particularly in crowded places, since catching the virus through our eyes is not impossible – be it a wraparound eye shield, face shield or large-framed, close-fitting spectacles, all to be washed regularly. After all, Covid-19 is the most lethal terrorist to date!

One of the most common applications for lasers in the treatment of eye problems is in refractive correction. Due to its high safety and efficacy, laser vision correction for refractive errors has today become a mainstream approach. Providing freedom from glasses and contact lenses, it is sought after not just for convenience and cosmetic effect, but also for practical reasons, such as facilitating participation in sports, enhancing one’s career, and lifestyle pursuits. In many cases, quality of life is significantly improved following successful laser vision correction.

Compared to the first generation of laser vision correction treatments, such as the flapless Photorefractive Keratectomy (PRK) which is associated with post-op pain, longer recovery, and side effects of haze, the newer treatments, such as the flap-based Laser-assisted In Situ Keratomileusis (LASIK), are vastly more popular as they result in much shorter downtime and a higher satisfaction rate. While some patients may experience some degree of dry eyes, particularly in the treatment of higher eye power, they generally recover with proper post-operative care.

Third generation technology, such as the still-maturing Small Incision Lenticule Extraction (SMILE), a keyhole operation combining the flaplessness of PRK with the quick recovery of LASIK, can deliver even more stable results. Any small chance of eye power regression and cornea weakening (ectasia) can also now be prevented by corneal collagen cross-linking (XTRA).

Swiss Ziemer LDV™ Z8 Technology
A recent addition to the armamentarium in the refractive surgery world is the highly innovative and mobile FEMTO LDV™ Z8 Laser by Ziemer, an advanced technology that has brought a new level of accuracy, flexibility, speed, and mobility to laser eye surgeries. With its low energy (the lowest amongst all femtosecond lasers), it comes on the back of a highly respectable and continuous lineage. As an established FDA-approved femtosecond laser purpose-built for LASIK and corneal and lens surgeries, it has its roots in versions Z2, Z4, and Z6. The unique LASIK performed on the Ziemer platform is called Z-LASIK. Distinct from other makes of femtosecond lasers, the proprietary FEMTO LDV Z8 uses extremely fast, short pulses of low range pulsed light, which gives rise to a faster creation of the corneal flap (the first step of the Z-LASIK procedure) – within just 30 seconds.

The nanojoule laser allows for a gentle approach that produces an extremely smooth interface, reducing the stress on corneal tissue and post-treatment inflammation. As a result, patients can expect more rapid healing and improved vision in a shorter time frame. The laser’s small footprint and mobility also means that patients are not required to shift during different steps of the treatment, improving patient comfort and streamlining the surgical process. The flap creation is then followed by excimer laser treatment in the second step of LASIK (SMSC uses a proven NASA excimer technology, iDESIGN 2.0 VISX STAR S4, including wavefront-guided LASIK treatment).

What is interesting is that the FEMTO LDV™ Z8 does not just deliver bladeless all-laser LASIK for the treatment of refractive errors such as myopia, hyperopia, astigmatism, and presbyopia with high precision. Its adjustable 3D LASIK flap configuration is also versatile and customisable, like the Z6, with the additional advantage of an Optical Coherence Tomography (OCT) to visualise the Bowman membrane and previous LASIK interfaces, a feature of Z8 that enables finer precision work, such as LASIK retreatments or thinflap femtosecond LASIK (femtosecond sub-Bowman’s keratomileusis).

In lens surgeries, the Z8 laser delivers documented excellent results in Femtosecond-assisted Cataract Extraction Surgery. With its low energy levels, the
laser cuts are fine and precise, allowing for safe surgeries even in complex lens exchange and cataract operations. The mobility of the laser unit allows it to be positioned in the operating theatre right next to the patient, doing away with patient movement between equipment changes, creating a more comfortable experience. The Z8 is the only laser that is feasible when bilateral sequential femtosecond-laser assisted cataract surgery is opted for.

In addition to the above indications, the Z8 is able to perform femtosecond arcuate keratotomy for the treatment of astigmatism using a non-invasive method. Furthermore, Ziemer is on the cusp of releasing its Z-lenticule extraction treatment (yet to be formally named), its own version of SMILE, with added ability for centration, projected improvement in accuracy, and precision. Anticipated in the first quarter of 2020, it will be an attractive option for laser vision correction candidates seeking a flapless alternative.

Ziemer Z8 + Galilei G6
The breakthrough Z8 femtosecond laser can coordinate with the FDA-approved Galilei G6 scanner to create a complete Ziemer ecosystem. The Galilei G6, built on the G4 model, is a dual-Scheimpflug imaging/scanning device that captures up to 300,000 spots on the cornea on both its front and back surfaces and incorporates an optical biometer and Artificial Intelligence assessment technologies. It is precise for assessments for LASIK and SMILE/Zlenticule and for lens implant treatments like the Implantable contact lens (ICL), lens exchange, and cataract surgeries. The unique combination of the Galilei G6 scanner and Ziemer Z8 laser streamlines the application of pre-operative measurements, thereby improving LASIK and SMILE/Z-lenticule as well as ICL, lens exchange, and cataract surgery pre-planning, providing a clearer picture to achieve a safe and great visual outcome.

The Singapore Medical Specialists Centre is proud to be the first in Singapore to have the Ziemer Z8 combined with the Galilei G6. With OCT guidance for LASIK, we are confident we can enhance your vision with increased precision.

AT the dawn of a year and decade, it is fitting to review and renew our goals. 2020 holds special meaning for everyone who appreciates the sense of sight and especially for me as an eye specialist. “20/20 vision” is medical parlance for normal or optimal visual sharpness: what a healthy eye should be able to see clearly, at 20 feet. “Vision 2020: The Right to Sight” is also the name of a World Health Organization (WHO) project that was launched in 1999 as part of an ongoing project commenced 30 years ago, with the aim of eliminating avoidable blindness globally by 2020.

A global guidance and blueprint for eye care systems, Vision 2020 started with advocacy for intervention against eye diseases such as cataract, glaucoma, diabetes, Vitamin A deficiency and trachoma (parasitic river blindness prevalent in Africa) as its first priorities. To sum up Vision 2020, WHO published its comprehensive World Report on Vision last year, freely available on the Internet. Although unmet needs still exist, the project has seen unprecedented progress and is deemed successful by most yardsticks. There has been a very significant reduction in cases of eye infections and blindness from Vitamin A deficiency, as well as the ongoing reduction in prevalence of blindness among adults, including treatable causes.

Nevertheless, continuous focus is necessary as these results can’t keep pace with the growth of an ageing population. The report includes the global magnitude of the issues, successes, what remains to be done, recommended strategies and paths charted for the future. The causes of vision impairment and their impact on financial burden are of particular interest to me. The figures are staggering: at least 2.2 billion people have vision impairment globally. At least one billion of these (an underestimation according to the report) could have been prevented or are unaddressed, with 123.7 million suffering from unaddressed refractive errors.

Cataract comes in second at 65.2 million. These eye conditions are projected to increase due to population ageing, as well as environmental and lifestyle changes. From the report, the cost of the coverage gap for global unaddressed refractive errors and cataract was estimated to be US$14.3 billion. In the world, there are an estimated 2.6 billion people with myopia (of which 312 million are under 19 years old) and 1.8 billion with presbyopia. These contributed to losses in annual global productivity estimated to be US$244 billion and US$25.4 billion, respectively. The prevalence of myopia is the highest in East, South and Southeast Asia. It was reported in these regions that the economic burden of uncorrected myopia was more than double that of other regions and equivalent to one per cent of gross domestic product (GDP).

A simple calculation should convince one of the highly cost-effective outcomes for addressing treatment of myopia, presbyopia and cataract – my three main areas of practice in ophthalmology – in any health care system. There are several points in the report that strike a pertinent yet sensitive note. First, the issue of funding for management of the commonest eye condition, that is, refractive errors, which in many countries are mostly out-of pocket. These include the costs of spectacles, deemed an assistive device, as well as contact lenses and refractive surgeries such as LASIK. Second, the potential role for public-private partnerships to improve eye care services. What is new for this decade is the focus of “integrated people-centred eye care” as a continuum of health intervention.

This is a new addition to the WHO project’s action plan to now include integration of eye care into health care systems, ideally across all sectors, and, for this, four important strategies are proposed. These are to empower and engage people and communities, reorientate model of care, coordinate services within and across sectors, and create an enabling environment. In my mind, these are applicable to both policymakers and the public. Integration of eye care into health care is here to stay. For the general public, it should translate to ensuring good eye care and visual habits from the groundup, starting in the family, schools, public institutions, at work and at leisure.

It also means having eye protection in sports and in relevant occupations and attending eye screenings regularly even when the eyes feel fine, as some eye diseases are silent in the initial stages where they can be controlled and potentially reversed. Ensuring good general health and lifestyle is key in maintaining good eye health. Our eye clinic also welcomes the new decade with an addition of the services provided. Incorporating a Refractive and Cataract Surgery service  on site has long been our aim. We look forward to deliver safe, effective and integrated eye care with the addition of the trusted Johnson and Johnson Star S4 iLASIK excimer laser with FDA approved wavefront guided treatment via its latest iDesign 2.0 and the Swiss-made Ziemer Z8 femtolaser for OCT-guided thin flap LASIK surgery, being the first in Singapore, as well as for laser cataract surgery.

These will help address the most common eye conditions in the world – namely myopia, presbyopia and cataract – in an efficient and affordable manner.
The Ziemer Z8 also looks forward to providing further innovations in flapless refractive lenticule treatment for myopia in the near future. Eye screening enabled with artificial intelligence for front-of-eye diseases by dual-Scheimpflug imaging and back-of-eye diseases by digital angiography and fundal camera remains our go-to option, a sign of the times.

Dr Daphne Han
Senior Consultant Ophthalmologist
MBBS (Melbourne), MMed, MRCS, FRCS (Edinburgh), FAMS

THE BUSINESS TIMES WEEKEND JANUARY 11, 2020