The 9th Asia Cornea Society in conjunction with The 7th INASCRS Biennial Scientific Meeting 2024

Abstract Title
Efficacy of Perioperative Music Interventions on Hemodynamic Measures of Pain and Anxiety Among Patients Undergoing Cataract Surgery: A Meta-Analysis

Introduction & Objectives
Cataract surgery can cause pain and anxiety. This can elevate the patient's hemodynamics, which increases the risk of complications. Music intervention can adjunct topical anesthesia to relieve the patient's pain and anxiety accounting for its stable analgesic and anxiolytic ability, affordability, and safety. This study serves as the first meta-analysis to summarize the efficacy of perioperative music interventions in the hemodynamic parameters of pain and anxiety among cataract surgery patients.

Methods
Nine databases were systematically searched using relevant keywords, wildcards, and Boolean operators until April 27th, 2024. Eligibility criteria include RCTs with (1) a low risk of bias assessed using RoB 2.0; (2) a music group and a control group; and (3) outcome (systolic blood pressure (SBP) and Heart Rate (HR)) reported during cataract surgery's preoperative/earlier phase (EP) (for the music group: after music intervention has been given) and postoperative/later phase (LP). Fixed-effect models were used for the meta-analysis with 95% CI. We imposed no language restrictions.

Results
A total of 115 reports from search results went through a rigorous selection, resulting in four RCTs (563 participants) that were included in the meta-analysis. A fixed-effect meta-analysis showed that SBP (Mean Difference (MD)=-3.24, 95%CI[-6.10, -0.37]) and HR (MD=-2.46, 95%CI[-4.49, -0.43]) among patients in the music group were significantly lower than the control group during the EP. Similar results were also shown for SBP (MD=-6.26, 95%CI[-10.47, -2.05]) and HR (MD=-3.07, 95%CI[-5.03, -1.11]) during the LP.

Conclusion
This finding suggested that music is efficacious in lowering SBP and HR during surgery's EP and LP.

Keyword
Music, Cataract, Hemodynamic

Abstract Title
Characteristics of Senile Cataract Patients in Sawan I Primary Health Care

Introduction & Objectives
Cataract continues to be the leading cause of blindness worldwide, particularly in developing countries. The risk of an individual to develop cataract increases in every decade of their life starting from the age of 40. Cataract affects not only patients' visual function but also disrupts their course of life. Identification of cataract patient characteristics and risk factors is important to implement steps to prevent senile cataracts especially in primary health care settings like in public health care (PHC) facilities.

Methods
This cross-sectional descriptive research was conducted by collecting secondary data sourcing from medical records of senile cataract patients who met the inclusion criteria at the Sawan I Community Health Center from November 2022 to March 2023.

Results
The result of this study shows that the prevalence of senile cataract patients at the Sawan I PHC during the research period is 47 patients with the most dominant age group being 50-59 and 60-69 age groups with the same number of patients, 14 people (29.8%) in each group. 29 patients were female (61.7%). Unilateral cataracts in 13 patients (27.7%) and bilateral cataracts in 34 patients (72.3%). 5 patients (10.6%) have a history of refractive errors, 4 patients (8.5%) have a history of diabetes mellitus, 17 patients (36.2%) have history of hypertension, and 6 patients (12.8%) have a history of hypercholesterolemia.

Conclusion
The growing prevalence of senile cataract should increase the awareness of planning a better health service strategy in early detection and treatment.

Keyword
cataract, characteristic, PHC

Abstract Title
Ocular Cicatricial Pemphigoid in An Elderly Filipino Man: A Case Report and Literature Review

Introduction & Objectives
Ocular cicatricial pemphigoid (OCP) is a rare form of blinding cicatrizing conjunctivitis among Filipinos. The authors aim to report the first direct immunofluorescence assay proven OCP in a Filipino healthy elderly male.

Methods
Case report and review of related literature

Results
A non-hypertensive, non-diabetic male patient in his late 60s consulted for chronic progressive blurring of vision of both eyes (right>left) associated with eye redness and the development of whitish eye opacity and inwardly misdirected eyelashes. He also had relapsing-remitting blistering lesions on the face, right foot, and oral mucosa after the onset of ocular symptoms. On examination, the visual acuity on the right eye was best corrected to counting fingers at 1 foot and on the left eye was best corrected to 20/20. On further examination, the right eye showed complete obliteration of the inferior fornix with conjunctivalization of the entire cornea and lower eyelid entropion. The left eye showed a clear cornea with 360 degrees pannus formation associated with eyelid entropion and symblepharon formation. The suspicion of OCP was confirmed with direct immunofluorescence assay (DFA), and he was subsequently managed with oral dapsone and topical steroids.

Conclusion
OCP is a rare autoimmune and blinding disease. Early diagnosis and prompt treatment are vital to prevent ocular complications that may permanently affect the quality of life of patients. DFA remains the gold-standard for diagnosis. Systemic immunosuppression is the mainstay of treatment. Adjunctive supportive topical may be given to alleviate ocular discomfort. A multidisciplinary approach is essential to provide holistic care to each patient.

Keyword
Ocular Cicatricial Pemphigoid, Mucous Membrane Pemphigoid, FIlipino

Abstract Title
Advanced Corneal Surgery: Exploring Layer-by-Layer Manual Dissection in Cases Unsuitable for Deep Anterior Lamellar Keratoplasty (DALK)

Introduction & Objectives
Corneal opacities in pediatric patients pose significant challenges due to the complex nature of surgical intervention and the necessity for precise depth management. This study highlights layer-by-layer manual dissection technique of DALK in children.

Methods
A case series of two pediatric patients underwent DALK. Patient A (11-year-old) with unilateral Congenital Corneal Opacities given difficulties in determining the exact depth of the lesions beforehand, and Patient B (10-year-old) with unilateral acute hydrops on keratoconus; making the Big Bubble method improbable. Both underwent layer-by-layer manual dissection, with corneal trephination sizes 7.5 mm (Patient A) and 8.25 mm (Patient B). This technique provides flexibility in managing varying opacity depths, with the potential to convert to penetrating keratoplasty (PKP) intraoperatively if deeper layers were affected.

Results
Both patients tolerated the DALK procedures well, with no intraoperative complications requiring conversion to PKP. Postoperative follow-up showed significant improvement in corneal clarity. Patient A's visual function remained the same as pre-operative, while Patient B's improved significantly. Both showed stable grafts with no signs of rejection six months post-surgery. The layer-by-layer approach allowed for careful removal of opacities, maintaining corneal integrity, and minimizing the risk of perforation.

Conclusion
Layer-by-layer manual dissection in DALK is a viable alternative in managing pediatric corneal opacities without pre-determining lesion depth. This method provides flexibility in addressing varying opacity depths, minimizes risk of endothelial damage, and allows the option to convert to PKP if necessary. Further studies with larger sample sizes are recommended to elucidate these findings, opting for surgical protocols.

Keyword
Layer-by-layer manual dissection, DALK, Pediatric Corneal Opacities

Abstract Title
Outcome of Accelerated Corneal Cross-Linking with 0.25% Riboflavin in Progressive Keratoconus Patients: A Retrospective Study in Taiwan

Introduction & Objectives
To present the one-year outcomes of accelerated corneal collagen cross-linking (CXL) with 0.25% riboflavin in the management of progressive keratoconus in the Taiwanese population.

Methods
A retrospective analysis was performed on twenty-four patients (32 eyes) diagnosed with progressive keratoconus treated at Shin-Kong Wu Ho-Su Memorial Hospital. Exclusion criteria included corneas with a stromal thickness of less than 400 μm. A 15-minute soak with 0.25% riboflavin was followed by UVA light exposure at 18 mW/cm2 for 5 minutes, achieving a total energy of 5.4 J/cm2. Corrected distance visual acuity, corneal topography, subjective refraction, endothelial cell density, corneal thickness were evaluated at baseline, 1, 3, 6, and 12 months postoperatively. The primary efficacy criterion was the changes in maximum keratometry (Kmax) at the 12-month follow-up.

Results
The mean Kmax decreased from 61.74 ± 9.9 D to 60.05 ± 9.1 D at one-year follow-up (P = 0.002). Central corneal pachymetry decreased significantly from 464.16 ± 28.6 μm to 442.73 ± 87.6 μm (P < 0.001) at one year. The mean demarcation line depth was 375.91 ± 53.4 μm at one-month follow-up. Mean corrected distance visual acuity, manifest refraction and endothelial cell density remained unchanged.

Conclusion
This study is among the first to document the outcomes of CXL in Taiwanese patients. Our findings support accelerated CXL with 0.25% riboflavin as a safe and effective intervention for patients with progressive keratoconus, contributing valuable data to the global understanding and management.

Keyword
CXL, Corneal Cross-Linking, keratoconus, 0.25% riboflavin, Taiwan

Abstract Title
Endothelial Cell Loss After Preparation of Grafts for Endothelial Keratoplasty at Lions Eye Bank of Western Australia

Introduction & Objectives
The purpose of this study was to determine the rate of endothelial cell loss following donor tissue preparation for Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK).

Methods
Endothelial cell density (ECD) was calculated on the day of corneal transfer to thinning medium and DSAEK or DMEK tissue was prepared 1 day later. DSAEK’s were prepared using the Moria microkeratome and DMEK’s were manually stripped by Eye Bank staff using the scuba technique. A second evaluation of ECD was performed 2 days after graft preparation.

Results
There was a decrease in ECD from 2756 ± 470 to 2561 ± 482 cells/mm2 and from 2460 ± 547.5 to 2258 ± 556 cells/mm2 after DSAEK and DMEK preparation respectively. ECD did not differ significantly before and after graft preparation. The average daily loss of endothelial cells after DSAEK (56 cells/mm2) and DMEK (66 cells/mm2) preparation were not significantly different.

Conclusion
We observed similar rates of cell loss in DSAEK and DMEK preparations. Despite some loss of cells following graft preparation, ECD was not significantly lower when compared to initial ECD evaluations prior to graft preparation.

Keyword
endothelial cell loss, ECD, endothelial keratoplasty, corneal evaluation, cornea

Abstract Title
Factors Affecting Visual Outcome After Small Lenticule Extraction Pro (VISUMAX 800): First-Year Experience in Indonesia

Introduction & Objectives
This study aimed to report the visual outcome after small incision lenticule extraction (SMILE) along with factors that could affect it in the early experience of treating eyes with VISUMAX 800 (Carl Zeiss Meditec AG) in our eye center.

Methods
This is a retrospective study with cross-sectional design of eyes underwent SMILE Pro® using VISUMAX 800 in JEC @Kedoya Eye Hospital Jakarta, Indonesia. Patients 40 years old or younger with the corrected distance visual acuity (CDVA) of >20/25, manifest refractive spherical equivalent (SE) ≤10.0 diopters (D), cylinder refraction <5.0 D were included. Follow up was conducted at 1 day and 1 month postoperatively to evaluate visual outcome. All statistical analyses were performed using the SPSS v. 26.0 software (IBM Corp.) based on data normality.

Results
A total of 258 eyes from 132 patients were analyzed. 94% of eyes achieve 20/20 1-month post operatively. 81% of high myopic eye achieve 20/20 following by 97% and 99% in moderate and low myopic eyes, respectively. Spherical equivalent rate (SER) (r 0.273; p <0.01), optic zone (OZ) (r 0.260; p <0.01), cap thickness (r 0.209; p <0.01), and residual stromal thickness (RST) (r 0.256; p <0.01) have significant weak correlation with visual acuity 1-month after surgery. There is increasing risk to get visual acuity <1.0 in right eyes (OR 3.101; p <0.045), eyes with high myopia (OR 9.964; p <0.01), ≤100um cap thickness (OR 4.578; p 0.006), ≤6mm OZ (OR 10.556; p <0.01), and <300um RST (OR 9.100; p <0.01) 1-month post operatively.

Conclusion
SMILE Pro® give promising visual outcome in early post operative period. Low-moderate myopia give better visual outcome than high myopia patient. Small OZ, thin cap thickness, and low RST could increase risk for not getting a maximum visual outcome after SMILE. Study with prospective design and longer follow up time which included comprehensive variables were needed to fully understand factors affecting VA after SMILE.

Keyword
Small incision lenticule extraction, Smile pro, visual outcome

Abstract Title
Reverse Bioptics as the Preferred Treatment of Myopia Regression After Photorefractive Keratectomy: A Case Report

Introduction & Objectives
Myopia regression can happen as the side effects after Photorefractive Keratectomy (PRK). It mostly results from epithelial hyperplasia and stromal remodelling. Reverse bioptics is one of the treatment options in this cases.

Methods
A 29 years old woman presented to the hospital with complaint of blurred vision in both eyes. At the age of 19, patient had been using spectacles of right eye (RE) S-9.0 D and left eye (LE) S-10.0 D, then she undergo PRK procedure and achieved clear vision. One year after PRK, her vision regressed. Uncorrected visual acuity (VA) of each eye were counting fingers. Best corrected visual acuity (BCVA) of RE 6/8.5 and LE 6/7.5 using S-7.50 spectacles. Anterior and posterior segment examinations of both eyes were within normal limit. Corneal topography demonstrates central corneal flattening. Patient’s examinations using Oculus Pentacam, showed axial length (AL) of RE 29.806mm, LE 29.306mm. RE K1 were 38.0 D, K2 39.5 D. LE K1 were 38.3 D, K2 38.9 D. Anterior chamber depth (ACD) of RE 2.99mm, LE 2.97mm. Central corneal thickness (CCT) of RE 399μm and LE 397μm. Cell density of RE 2811cell/mm3 and LE 2770cell/mm3. Considering corneal biomechanics alterations in this patient, reverse bioptics of Refractive Lens Exchange (RLE) was chosen. Intraocular lens (IOL) was calculated using Haigis formula and Aspheric Monofocal IOL with negative spherical aberration were chosen.

Results
On postoperative examination, both eyes uncorrected VA improved to RE 6/6 and LE 6/7.5.

Conclusion
Reverse bioptics can be done for patient who had myopia regression after PRK.

Keyword
Photorefractive Keratectomy, Myopia Regression, Reverse Bioptics

Abstract Title
Short Yamane Technique for Short Eyes: A Challenge in Managing Microphthalmia with Microcornea

Introduction & Objectives
Microcornea is a rare abnormality with a corneal diameter of less than 10 mm.1,2 This condition can be isolated or accompanied by other eye abnormalities, such as congenital cataract and microphthalmia with short axial eye length (less than 21 mm).2,3 One of the options for Intra-Ocular Lens (IOL) insertion after cataract extraction was the modified Intrascleral Haptic Fixation (ISHF) Yamane Technique.

Methods
Case Illustration: A 26-year-old woman with microphthalmia and microcornea came to our hospital with discomfort in the eye. She had a history of congenital cataracts and underwent surgery when she was two years old. On examining the right and left eyes, the visual acuity was 0.5/60 and 1/60, a corneal diameter of 9 mm in both eyes, a deep anterior chamber, and an aphakic lens in both eyes. We planned to perform a secondary implant Yamane intrascleral fixation with some modification.

Results
Managing aphakic eyes in microphthalmia and microcornea often requires adjusted surgical technique. We modified the Yamane Technique by trimming the IOL haptic 2 mm before making a bulb, called a "short" Yamane Technique. Another challenge to this case is that only some IOL products accommodate the high IOL power required. Follow-up day one, eye examination revealed minimal conjunctival injection, increased visual acuity in the right eye to 6/30, and IOL in a central position.

Conclusion
A careful approach and modified surgical technique are crucial to improving the visual outcome in this case. Therefore, secondary IOL implantation is still a challenge in this condition.

Keyword
microcornea, microphthalmia, secondary intraocular lens, aphakic eyes, Yamane technique

Abstract Title
Clinical Profile and Outcomes of Ocular Surface Squamous Neoplasia at the Philippines General Hospital: A Retrospective Study

Introduction & Objectives
This was the first study to investigate OSSN among Filipinos. It aimed to evaluate the demographics, clinical characteristics, treatments, and outcomes of patients with ocular surface squamous neoplasia (OSSN) at the Philippine General Hospital.

Methods
This was a single-center, 10-year retrospective, cross sectional case series on 18 cases of OSSN seen between January 2012 to June 2023. The patient’s demographics, presenting symptoms, tumor characteristics, histopathologic diagnosis, treatment, outcomes, and duration of follow-up were reviewed.

Results
Out of 33 identified cases of OSSN, only 18 were eligible for inclusion in the study. Mean age was 60.78 years (range 31 to 80), with male predominance (66.67%). The left eye was most commonly affected (61.11%) with most presenting with fleshy mass (83.33%). Most tumors were located nasally (66.67%) and were predominantly papilliform (44.44%) in morphology with associated hyperpigmentation (38.89%). Squamous cell carcinoma (SCCA) was the most common histopathologic diagnosis (72.22%). The main primary treatment was surgical excision (94%) with or without adjunctive therapy, with only 1 patient undergoing first-line topical chemotherapy. Only 3 recurrences (16.67%) were noted with a median follow-up of 7.5 months. A statistically significant recurrence-free odds leaning towards the utilization of cryotherapy was noted.

Conclusion
OSSN seen at the Philippine General Hospital presented as a limbal papilliform mass, most commonly affecting elderly males. Surgical excision with adjuvant cryotherapy and/or chemotherapy was the preferred mode of treatment.

Keyword
Ocular surface squamous neoplasia, OSSN, malignancy, squamous cell carcinoma, conjunctival intraepithelial neoplasia

Abstract Title
Outcomes of Cross-Linked Bowman-Stromal Inlay for Progressive Keratoconus

Introduction & Objectives
Background: Keratoconus is a progressive ectatic disorder of the cornea with various treatment options to improve corneal structural integrity, including corneal collagen crosslinking (CXL), keratoplasty, intracorneal ring segments (ICRS), and stromal augmentation procedures. While CXL has limitations in thinner and steeper corneas, stromal augmentation techniques like Bowman-Stromal Inlay (BSI) have gained popularity. Objective: This study evaluates the initial results and safety profile of using crosslinked Bowman-Stromal Inlays (X-BSI) in keratoconus patients, aiming to enhance corneal strength and volume while minimizing rejection risks.

Methods
Retrospective, non-randomized, interventional study included 25 eyes (23 patients) diagnosed with keratoconus. All patients underwent a customized Bowman-Stromal Inlay (cBSI) procedure, where the inlay was additionally crosslinked using UV-A in three cycles of high-energy accelerated CXL. Retrospective data were collected from electronic medical records (EMR), including pre- and post-intervention tomography. Slit lamp photographs were also analyzed to monitor for any complications. The key parameters assessed included corneal topography, visual acuity, and adverse events.

Results
23 patients (18 males and 5 females) underwent X-BSI with mean follow-up duration of 10.52 ± 3.1 months. Post-operatively, mild haze was observed in a few cases, which resolved spontaneously. No cases of inlay melt, scarring, or opacification were noted during the follow-up period. Significant improvements were observed in several parameters: Kmax: Decreased (p=0.03) Kmean anterior: Decreased (p=0.04) Pachymetry: Increased (p=0.0001) Q value: Improved significantly

Conclusion
Cross-linked Bowman-Stromal Inlay (X-BSI) appears to be safe and well-tolerated by patients. The procedure resulted in significant improvements in tomographic parameters, demonstrating its effectiveness in stabilizing keratoconus, enhancing corneal thickness, and improving corneal shape.

Keyword
Stromal Augmentation; Progressive Keratoconus; Bowman Layer transplant; BS Inlay; Corneal Inlay

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