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

Abstract Title
A Case of Pterygium in the Isolated Island of Shikinejima Diagnosed Remotely and Treated on the Mainland in Japan

Introduction & Objectives
The Japanese island of Shikinejima has a population of 580 residents, with no eye specialists and only general practitioners and nurses. Located 170 km from the mainland, their eye care needs are not fulfilled.

Methods
A 74-year old Japanese female presented with hyperaemia and a foreign body sensation on the nasal side of her left eye, on the island. A general practitioner used a smartphone-based portable slit-lamp with image filing and telemedicine functions, the Smart Eye Camera (SEC), to record a video of the anterior segment. Through the telemedicine function, remote diagnosis was performed by a mainland ophthalmologist. Then the patient was examined at Keiai Yokohama Eye Clinic.

Results
The mainland ophthalmologist concluded a pterygium on the left eye and the indication for surgery. Once the patient was referred to Keiai Yokohama Eye Clinic for further examination, the findings were the following: LV = 1.0 × IOL (1.2 × C-0.50D Ax120), left IOP 13 mmHg, keratoconus value CYL-2.50D Ax7, no corneal ulcer, no epithelial damage, no conjunctival papillae, and no abnormal fundus findings. After the surgery, the patient returned to Miyakejima island. Using the SEC, the patient was followed up on, and no complications were observed. The patient presented with no complaints and had nor recurrence in the 3 months after the surgical intervention.

Conclusion
Remote islands in Japan lack eye specialists. Using a new smartphone-based portable slit-lamp with telemedicine, we diagnosed and treated a pterygium case on Shikinejima island.

Keyword
telemedicine, pterygium, cornea

Abstract Title
Comprehensive Network Meta-Analysis of Astigmatism Correction Techniques: Evaluating Outcomes of FSAK, Toric IOL, LRI, Mechanized Keratotomy, and SMILE

Introduction & Objectives
Astigmatism, with 14.9% prevalent refractive error worldwide, remains challenging. This meta-analysis provides a comprehensive synthesis comparing Femtosecond Laser-Assisted Astigmatic Keratotomy (FSAK), Toric Intraocular Lens (IOL) implantation, Limbal Relaxing Incisions (LRI), Astigmatism Keratotomy (AK), and Small Incision Lenticule Extraction (SMILE).

Methods
Quality assessment was done using the RoB 2.0 and ROBINS-I while analysis was performed using RStudio.

Results
Search across seven databases identified 17 low-risk and 5 moderate-risk of bias articles. LRI showed superiority in decreasing angle of error and improving Corrected Distance Visual Acuity (CDVA) [Mean: 0.19; 95% CI: -3.80;4.19; MD: -3.50; 95% CI: -4.73; -2.27]. LASIK showed superiority in correction index, target-induced astigmatism, and Uncorrected Distance Visual Acuity (UDVA) [MD: 0.88; 95% CI: 0.79; 0.98; MD: 1.34; 95% CI: 1.12;1.56; MD: -0.84; 95% CI: -0.92;-0.76] with best keratometric result shown by AK [Mean: -0.39; 95% CI: -0.70; -0.08]. FLACS+FS-AK has the lowest magnitude of error and highest refractive cylinder [MD: -50.00; 95% CI: -75.41;-24.59; MD: -1.17; 95% CI: -1.58;-0.76]. Surgical-induced astigmatism was lowest in axis incision [MD: 8.40; 95% CI: 7.32;9.48].

Conclusion
LASIK has shown to be the best astigmatism correction technique with its ability to improve correction index, target-induced astigmatism, and UDVA significantly. Meanwhile, LRI can improve the angle of error and CDVA.

Keyword
astigmatism, cornea, correction technique, efficacy, refractive surgery

Abstract Title
Comparison of Corneal Endothelial Changes After Small Incision Cataract Surgery and Phacoemulsification

Introduction & Objectives
Corneal endothelial cells are monolayer polygonal cells that function to control ion pumps for storm hydration. These cells cannot replicate and their numbers can be reduced due to trauma during cataract surgery. This literature review aims to compare changes in endothelial cells in small incision cataract surgery and phacoemulsification.

Methods
An Article search was conducted in four electronic journal databases (Google Scholar, PubMed, ScienceDirect, and Medline) to find scientific articles on the comparison corneal endothelial changes after small incision cataract surgery and phacoemulsification published within the last 10 years (2014-2024), without language restriction, with criteria inclusion as follows: 1) respondents with uncomplicated senile cataract;2) an explanation of the corneal endothelial changes after cataract surgery; and 3) description the effect of cataract surgery to the central corneal thickness (CCT), endothelial cell density (ECD), and visual acuity (VA).

Results
In total, there were five studies used in this literature review. Some studies suggest that small incision cataract surgery provided lower postoperative ECD loss and CCT changes compared with phacoemulsification. In contrast, other studies found both surgery techniques have similar visual outcomes. An increase in post-operative CCT is insignificant following surgery. Postoperative ECD loss in phacoemulsification techniques is related to age, hard nuclear cataracts, and effective phacoemulsification time.

Conclusion
This literature review has answered that SICS provided less corneal endothelial changes compared to phacoemulsification.

Keyword
Corneal Endothelial, ECD, CCT, SICS, Phacoemulsification

Abstract Title
Characteristics of Patients Underwent ReLEx SMILE Surgery in Bali Mandara Eye Hospital Denpasar from January to December 2022 : A Descriptive Retrospective Study

Introduction & Objectives
ReLEx SMILE (Small Incision Lenticule Extraction) is a minimally invasive refractive surgery that was first introduced in 2011 as an alternative to LASIK (Laser-Assisted in situ Keratomileusis) and PRK (Photorefractive Keratectomy) procedures. ReLEx SMILE uses a femtosecond laser to create a small incision in the cornea and remove a lenticule of tissue to reshape the cornea and correct vision. The aim of this study was to describe the characteristic and visual outcome of patients underwent Relex Smile Surgery in Bali Mandara Eye Hospital Denpasar from January to December 2022.

Methods
A descriptive retrospective study was conducted in March-April 2023 using medical records of patients underwent ReLEx Smile Surgery in Bali Mandara Eye Hospital Denpasar from January to December 2022.

Results
Results: There were 336 patients (655 eyes) underwent ReLEx SMILE surgery, most of them were male (59.5%), age 15-20 years old (55.36%) and followed by those in the range of age 21-25 years old (21.43%). Most of the cases were bilateral with decrease of impaired visual acuity 6/60-<6/18 (51%), with average spherical equivalent -5.00 ± 2.82 diopters, degree of myopia is mostly medium (36%), mean keratometry is 43.38 ± 1.46, the average of (CCT) 555.15 ± 35.32, and followed by post operation symptoms mostly with no symptoms (73.51%). The post operative visual acuity showed a favorable results with normal eyes were found in 98.62%

Conclusion
Conclusion: ReLEx SMILE surgery is commonly performed in young productive age patients. While most of the patients came with high expectation of having a normal 6/6 visual acuity

Keyword
Characteristics, ReLEx SMILE, Refractive Surgery

Abstract Title
Investigating the Effects of Varied Lenticular Profiling on Corneal Nerve Regeneration

Introduction & Objectives
Purpose: This study aims to assess the impact of lenticular profiles in various laser-assisted lenticular extraction surgeries (LALEX) on corneal nerve regeneration and its impact on outcomes.

Methods
Methods: In-vivo confocal microscopy was done to evaluate corneal nerve changes in eyes undergoing LALEX with ELITA SILK, SCHWIND ATOS(SS), and VISUMAX 500 SMILE procedures (n=50 each). Corneal nerve fiber density (CNFD) and corneal nerve fiber length (CNFL) were assessed using CC Metrics software. Changes in parameters from pre to postoperative stages were compared.

Results
Results: Preoperative CNFD and CNFL were similar in all 3 groups. Change in CNFD and CNFD was significantly less in SILK and SS groups compared to SMILE at 1, 3 and 6 months postoperatively.

Conclusion
Conclusion: The SILK and SS groups showed a reduced change in CNFD and CNFL, indicating less nerve damage and faster nerve regeneration. This suggests that these procedures may lead to quicker recovery of ocular surface balance and reduction in dry eye symptoms.

Keyword
Laser Assisted Lenticular Extraction procedures in different platforms - VISUMAX 500 SMILE, ELITA SILK and SCHWIND ATOS

Abstract Title
Peripheral Ulcerative Keratitis: A Case Report Highlighting Diagnostic Challenges and Multidisciplinary Management

Introduction & Objectives
Introduction: Peripheral ulcerative keratitis (PUK) is a severe inflammatory condition affecting the peripheral cornea, often associated with local or systemic inflammatory disorders. This condition involves a complex interaction among host autoimmunity, the anatomy and physiology of the peripheral cornea, and environmental factors. objectives: to present a case with peripheral ulcerative keratitis

Methods
A 47-year-old woman reported experiencing recurrent redness, pain, tearing, and photophobia in both eyes, particularly in the left eye, over the past year. Upon examination, her visual acuity was 1.0 in the right eye and 0.5 in the left eye with a fixed pinhole. Anterior segment examination of the left eye revealed mild ciliary injection, corneal edema, and peripheral ulcers with thinning extending from the 1 to 5 o'clock positions, along with a pseudopterygium in the superotemporal region. The diagnosis included peripheral ulcerative keratitis in the left eye and bilateral pseudopterygium. During the operation, a corneal perforation and scleral thinning in the superotemporal region were discovered. A 360° conjunctival resection was performed and the scleral patch graft was secured. The patient was given methylprednisolone, antibiotic eye drops and artificial tears.

Results
At the 14-day follow-up, her vision had improved to 0.63. Unfortunately, an autoimmune panel had not been conducted to confirm the diagnosis. After the procedure, the patient was referred to a rheumatoid specialist and began receiving immunosuppressive therapy.

Conclusion
Peripheral ulcerative keratitis is a severe inflammatory disorder of the peripheral cornea necessitating comprehensive diagnostic evaluation and a stepwise management approach.

Keyword
Peripheral ulcerative keratitis, autoimmune disease, management.

Abstract Title
Comparison of Early Refractive and Visual Outcomes Between Same-Day Versus Scheduled Small Incision Lenticule Extraction in Myopic Patients

Introduction & Objectives
To compare the early visual and refractive outcomes of same-day and scheduled small incision lenticule extraction (SMILE) for myopia.

Methods
This was a single center, retrospective study of SMILE patients who underwent same-day screening and surgery (SD) as well as those who had separate-day screening and surgery (SCH). Included were myopic patients with preoperative corrected distance visual acuity (CDVA) of 20/20 or better and one month postoperative data available for analysis. Standard graphs for reporting visual and refractive outcomes were used for analysis. Efficacy, predictability, and safety were compared between groups using unpaired T-test.

Results
Included were 196 eyes comprising 74 SD eyes and 122 SCH eyes. At one month, uncorrected distance visual acuity (UDVA), CDVA, and spherical equivalent (SE) were better in the SCH group (LogMAR 0.02, LogMAR 0.00, -0.12 D) compared to the SD group (LogMAR 0.04, LogMAR 0.02, -0.01 D) (P<0.05), although not clinically significant. The SD group had 61% of eyes with UDVA of 20/20 or better while 75% of the SCH group had UDVA of 20/20 or better. Both groups have comparable predictability with SE within ±0.50D in 92% and within ±1.00D in 99% of eyes in SD group; and SE within ±0.50 in 97% and within ±1.00D in 99% of eyes in SCH group. Two eyes lost two lines in the SD group versus none in the SCH group.

Conclusion
Early outcomes for same-day and scheduled SMILE showed similar efficacy and predictability but with a slightly better safety profile in scheduled SMILE.

Keyword
Small incision lenticule extraction, visual outcomes, refractive outcomes, same-day SMILE, scheduled SMILE, myopia

Abstract Title
Black Cataract in Microcornea and Coloboma: So Many Things to Do in Such A Small Space

Introduction & Objectives
Ocular colobomas are malformations of the eye and are associated with microcornea and early cataractous changes. Black cataract is one of common manifestations of cataract in association with coloboma. Cataract surgery in eyes with microcornea and coloboma requires extra care. Choosing the appropriate operative technique was crucial for the patient's post-operative outcome.

Methods
To present a case report.

Results
A woman, 53 years old, was present to the Cataract and Refractive Surgery unit of Cicendo National Eye Hospital with a chief complaint of blurry right eye. The patient was diagnosed with mature cataract, microcornea, iris, and chorioretinal coloboma in the right eye (RE), phthisis bulbi in the left eye (LE), dysgenesis of the right anterior segment and nystagmus in the right and left eye, and moderate hearing impairment. The patient, as previously planned, underwent phacoemulsification, thus converting to intracapsular cataract extraction (ICCE) of the right eye. Improved visual acuity is attained post-surgery, despite the patient's aphakic condition. Subsequent use of corrective glasses is implemented to augment and optimize visual perception.

Conclusion
The treatment of black cataracts in individuals with microcornea and coloboma poses a significant challenge. The ICCE technique is a viable substitute in situations where intraoperative difficulties occur, such as constriction of the iris, dislocation of the lens, complications during capsulotomy, and difficulties in intraocular manipulation because of a limited anterior chamber. A notable enhancement was observed in the visual acuity post-surgery.

Keyword
Coloboma, Hard Cataract, ICCE, Microcornea

Abstract Title
Modified Re-SMILE Rescues for Large Retained Central Lenticule After A Previous Failed SMILE

Introduction & Objectives
To report a unique case of central retained lenticule after a failed small incision lenticule extraction (SMILE) managed successfully by modified SMILE using Flap and Circle Junctional cut software (Carl Zeiss Meditec AG).

Methods
A case report

Results
A case of a 30-year-old male undergoing SMILE surgery is presented. While the left eye procedure was uneventful, a suction loss occurred during the lamellar plane cut in the right eye. A rescued re-treatment of SMILE was planned, attempting to wrap the initial lamellar plane into a new lenticule. However, a false layer separation occurred and only partial lenticule removal was achieved, resulting in a central retained lenticular adhesion to cap. Postoperative uncorrected visual acuity (UCVA) was low to 20/400 with residual refraction of -12D. Six months postoperatively, a successful operation removed a new lenticule containing the original residual lenticule beneath the original cap by new Flap and Circle procedure. UCVA returned to 20/20 post-second operation.

Conclusion
Large central residual lenticule, though rare, can occur during SMILE surgery. Immediate subsequent new lenticule creation may lead false layer entrance and increased the risk of large retained lenticule. Creating a new lenticule using Flap & CIRCLE Junctional Cut software a few months postoperatively may offer a solution to such complications.

Keyword
SMILE, CIRCLE, retained lenticule

Abstract Title
Difference in Quality of Vision Outcome between Extended Depth of Focus and Monovision Intraocular Lens in Cataract Patients: A Systematic Review

Introduction & Objectives
In recent years, cataract patients have sought for the ideal intraocular lens (IOL) that enhances near vision quality with minimal post-implantation visual complications and spectacle dependency. Several developments to mitigate these challenges include the use of extended depth of focus (EDOF) IOL or the application of pseudophakic monovision IOL implantation technique. Our study aims to compare the visual performance and spectacle independence after implantation of bilateral emmetropic EDOF IOLs and monovision IOLs after cataract surgery.

Methods
Comprehensive literature search was conducted using PubMed, Cochrane, Scopus, and Proquest, resulting in 163 articles. Studies were manually reviewed based on inclusion and exclusion criteria, and 4 articles were selected for the systematic review.

Results
Three studies utilized monovision EDOF IOLs and one study used monovision monofocal IOLs as the intervention group, with all being compared to bilateral EDOF IOLs at emmetropic power. In total, 422 patients received EDOF lenses without monovision, and 258 patients received IOLs with monovision (-0.5D to -0.75D). Outcomes were analyzed at 3 to 6 months postoperatively. Monovision significantly improved binocular UNVA (p<0.03) in all studies and UIVA in two prospective cohorts (p<0.05), with no observed difference in UDVA. Spectacle independence was high in both groups across three studies, with near (p=0.01) and intermediate (p=0.039) significantly higher in the monovision group (±80-100%) compared to EDOF (±28-98%).

Conclusion
Monovision technique was superior to the bilateral emmetropic EDOF implantations method in achieving better near and intermediate VA, as well as in providing greater spectacle independence.

Keyword
Cataract, EDOF IOL, Monovision IOL

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