Dear MSO Members,
 
As we approach the end of the year, we would like to thank each one of you for being a part of this society and for your continuous contributions to the field of Ophthalmology. It has been a fruitful year for the society. The formation of the Young Ophthalmologists Sub-Committee is an exciting addition to the society, this year. We now have these younger minds with fresh new ideas contributing actively to the society especially in the production of the MSO newsletter.

Latest in the line of events in 2019, would be the World Sight Day 2019. World Sight Day is an internationally recognized day for vision that is celebrated on the 2nd Thursday of October each year. Events are held all over the world on this day, to highlight the importance of vision. This year, the Malaysian Ophthalmology fraternity commemorated this significant day by having a grand celebratory event at Dewan Seri Melati, Perbadanan Putrajaya which was proudly hosted by Putrajaya Hospital. The event was officiated by our Deputy Prime Minister, YAB Datuk Seri Wan Azizah Wan Ismail who was an Ophthalmologist herself, in the presence of the Minister of Health, YB Datuk Seri Dr Dzulkefly Ahmad and many other officials. A free eye screening programme was also successfully conducted on the same day. The celebration ended with the much awaited Ophthalmology night which was organized by Hospital Kuala Lumpur, where members of the Ophthalmology family came together to have a delightful evening of friends, food and fun. On behalf of the MSO committee, we would like to congratulate all those involved in making this event a great success.

As we welcome the next year, one must realize the perfection that awaits. As cliché as it may sound, 2020 after all denotes perfection to us. Many exciting events have already been lined up. As a grand start to 2020, the 35th Singapore-Malaysia Joint Meeting in Ophthalmology in conjunction with the 1st Asia-Pacific Ocular Imaging Society Conference is planned to be held from 17th-19th of January 2020 in Singapore. I would like to highlight the Global Young Ophthalmologists Symposium which is specially planned for the younger members of the fraternity. We encourage the active participation of our young ophthalmologists in this event. It will be an excellent opportunity to network and gain valuable knowledge.

ARTICLES

SUB-SPECIALTY FOCUS: THE JOURNEY OF OPHTHALMOLOGY FELLOWSHIP - PART 1

Dr Shelina Oli Mohamed
Consultant Ophthalmologist
Medical Retina & Uveitis Sub-specialist
Hospital Shah Alam, Selangor

Relentless journey the medical field is. Just when the arduous journey in masters ends and there is finally some breathing space to practice Ophthalmology on your own, another chapter unfolds—Sub-specialty in Ophthalmology! And suddenly, you begin scrutinizing and dissecting in more detail the subject you are ever so passionate about. Ophthalmology: the learning never ends.

In this part 1 of a 3-part series on getting the most out of the sub-specialty training, we will hear from Dr Shelina Oli Mohamed regarding the sub-specialty training program here in Malaysia. Apart from being an expert Medical Retina sub-specialist practising in Hospital Shah Alam and a renowned international speaker in her field, Dr Shelina is also the secretary of the Ophthalmology Sub-specialty Selection & Training Program for the Ministry of Health candidates.

1. How many ophthalmology sub-specialists are there in the Ministry of Health Malaysia currently and what is the demand for sub-specialists in Malaysia?

There are currently about 55 sub-specialists in various fields and the most being in the field of vitreo-retina and glaucoma.

The need for sub-specialists in the government sector is great. Ideally, our aim is to have at least one sub-specialist in each state of Malaysia especially in demanding fields such as vitreo-retina. In this way, we can reduce the waiting time for sub-specialist consultation and the burden of patients crowding one major center at any given time.

2. How many ophthalmology sub-specialty categories are there and which is the most popular among candidates and why?

Currently, there are 9 sub-specialty categories candidates can apply to:-

• Glaucoma
• Paediatrics and Strabismus
• Cornea and External Eye Diseases
• Medical Retina & Uveitis
• Vitreo-retina
• Neuro-ophthalmology
• Oculoplastic surgery
• Public Health Ophthalmology
• Comprehensive Ophthalmology

Year in year out, popular choices include vitreo-retina and medical retina while neuro-ophthalmology is the least preferred option.

MYOPIA: IS IT A PROBLEM? AND HOW TO CONTROL PROGRESSION

The Myopia Epidemic: Magnitude of the condition

It is estimated that 1.4 billion people worldwide (22.9% of world population) are myopic and 163 million are categorized as having high myopia.¹ Myopia has become an epidemic in certain East Asian cities; i.e. Singapore, Hong Kong and Guangzhou (China); with around 1 in 2 people being affected.² The prevalence is highest among young adults where 80-90% of those aged 17-18 years suffer from myopia. Published reports on myopia prevalence in Malaysia shows a relatively lower rate at 9.8% in children 7 years of age which increases to 34.4% by the age of 15 years.³

Why is it a problem?

Myopia, particularly high myopia (defined as spherical equivalent of greater or equal to -6.00D or axial length >26.5mm) is associated with vision-threatening conditions, of which some are irreversible, leading to pathological myopia. These include myopic macular degeneration, myopic choroidal neovascularization, rhegmatogenous retinal detachment, glaucoma and cataract.

What are the risk factors for myopia?

Overwhelming evidence has shown that sustained, intense near-work is significantly linked to the onset of myopia in children and possibly progression of myopia, particularly in young adult-onset myopia. These activities include continuous long durations of intense studying or reading, as well as prolonged screen-time with mobile gadgets, TV and videogames.

Outdoor time is a protective factor

Light-induced release of dopamine has now been confirmed to inhibit axial elongation and is generally accepted as the mechanism of myopia protection. Numerous studies have consistently shown that children who spend more time outdoors are less likely to be or become myopic.⁵ Causal association has been proven by 2 large randomized clinical trials,^6,7 where increased time outdoors had significantly reduced myopia incidence in children aged between 6 and 11 years old.

ABSENCE OF CAPSULAR SUPPORT: THE ALTERNATIVES FOR ACIOL

Intraocular lens (IOL) implantation in the eye that lack capsular support remains a great challenge for cataract surgeons. Till the past decade, there were only two choices - insert an angle supported anterior chamber lens or suture a PMMA lens to the sclera via a large corneo-scleral wound. Although the open loop ACIOLs have good track record of safety and visual outcome, many surgeons are shying away from this option due to its potential complications to the cornea, iris and angle in the long run. Lately, many new techniques have been described on the fixation of posterior chamber IOL with their own set of nuances. All these techniques aim to place the IOL in a more physiological position via smaller incisions and minimal manipulation of surrounding ocular tissues.

The Glued IOL Technique

In 2007, Dr Amar Agarwal introduced the glued IOL technique, which is a sutureless, fibrin glue–assisted PCIOL implantation with intrascleral tunnel fixation. In this technique, a 3-piece foldable IOL injected into the eye and the haptics exteriorized through a scleral opening; the haptics are then buried inside a scleral tunnel with the scleral flaps glued. A recent five-year review by the Agarwal group promised good visual outcome with no optic-haptic related complications. However, there are concerns about the long-term stability and the centration of the scleral-fixated IOLs.

The Yamane Technique of flanged intrascleral IOL fixation

This novel double-needle technique for flanged intrascleral posterior chamber IOL fixation was first described by Yamane at the 2016 ASCRS meeting in New Orleans. The Yamane technique involves externalizing the haptics of the 3-piece IOL using two needles, and then using cautery to form a mushroom-shaped tip at the end of each haptic. As the needles are externalized, the haptics are drawn through the trans-scleral tunnel, with the leading edge temporarily externalized. After cautery, gentle manipulation is used to depress the haptics back into the scleral tunnels and achieve centration of the lens. This transconjunctival technique has been widely accepted because it is free from scleral flaps, tunnels, sutures, and fibrin glue with relative short-learning curve and faster postoperative recovery.

Artisan Iris Claw Lens

The Artisan iris-claw IOL (Ophtec) is another available option for secondary IOL fixation. The IOL fixation can be performed on either the anterior or posterior iris by using an enclavation forceps and needle. The main drawback of this method is the requirement of a 6 mm corneoscleral incision to accommodate the PMMA material, leading to astigmatism. However, studies have shown that Implantation of the iris-claw IOL in the retropupillary position through a scleral tunnel incision is an effective and safe alternative that can provide better refractive results compared with other techniques. Complications can include chronic inflammation, cystoid macular edema, and iridodonesis. Dislocation of an anteriorly placed IOL could lead to corneal endothelial cell loss, while dislocation of a posteriorly placed IOL would fall into the vitreous space.

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