Dear MSO Members,
 
Welcome to the first issue of our newsletter for the year 2020. This year had been one of the most awaited years for many of us Malaysians. It is the year when our “Vision 2020” was supposed to have been achieved. For some of us, this meant being perched high up the new world order as a modern, multi-racial, first-world nation. For the rest of us who were children in the 90s, who have been dreaming of flying cars, bionic humans, levitating bullet trains and buildings that reach into the stratosphere, this was our version of Atlantis. Globally this was supposed to be the Renaissance 4.0 with man and machine working seamlessly, where money is to be fully digital and mankind is to be setting off to explore new planets light years away, travelling from giant space stations.

Unfortunately the fantasy bubble burst, we seem to be stuck and undone in a world with growing income disparity and lesser humanity, rapid overpopulation and reducing quality of life. With the global Covid-19 threat restricting travel and trade on an unprecedented scale, coupled with political uncertainty domestically and abroad, it feels as if a dark cloud is lingering above us preventing the ray of sunshine from reaching us. However, German philosopher Friedrich Nietzsche proffered “From chaos, comes order”. When you are at the lowest point, the only way is to go up. Martin Luther King Jr. correctly pointed out that, “only in the darkness, can you see the stars”. Let’s continue to be hopeful for things to take a positive turn for the rest of 2020.

As for our fraternity, we started off the year quite successfully with the 35th Singapore-Malaysia joint meeting in Ophthalmology in conjunction with the 1st Asia Pacific Ocular Imaging Society Meeting which was held in Singapore from 17-19th of January. Participation from Malaysian delegates in this event was indeed commendable. A global YO symposium was also held during this meeting and saw many of our brilliant YOs as speakers. We would like to take this opportunity to convey our gratitude to all the YOs involved, as your active and enthusiastic participation did light up the event.

ARTICLES

SUB-SPECIALTY FOCUS-PART 2 : THE UNFORESEEN JOURNEY OF FELLOWSHIP: THE MENTORS' PERSPECTIVE

1. What are some of the things that sub-specialty fellows can do to make the most of their fellowship training?

Widad Md Yusof, MBBS: Each person has his own strengths/weaknesses. The realization of one's capacity and potential, with clarity of purpose is a good starting point. Thereafter, plans could be made to fill gaps of experiences in places where he is posted. However, do bear in mind subspecialty service does not exist in a silo. Being a good general ophthalmologist and team player are prerequisites of being an excellent vitreo-retinal trainee/surgeon.

Norhalwani binti Husain, MD: My advice is to read journals and articles to get the latest updates on management, intervention and new advances. Recording your surgery and replaying the videos to gauge your performance and improving your techniques is highly recommended. Fellows should also make it a habit to review patients pre-operatively, follow-up post-operative cases and discuss with their supervisors regarding management plans as each glaucoma case has different outcomes and individualization of patients is important. In addition, keeping an up-to-date logbook with detailed documentation of complications, although may seem tedious, is pertinent in the long run.

Chandramalar T.S Thelagan, MBBS: Firstly, I agree with Dr Widad; candidates must be aware of the reasons they have chosen that particular sub-specialty along with the structure of its training programme with emphasis on the objectives of the training and what is expected from them especially in terms of knowledge. Fellows must do whatever necessary to propagate a higher order level of thinking in dealing with complicated cases and have clarity in formulating management plans in difficult cases. This can only be achieved by intensive study of theory coupled with surgical training and opening one’s mind to continuously improve the level of advanced clinical and surgical knowledge. They should exhibit leadership abilities and possess sufficient intellectual curiosity coupled with the ability to be proactive and develop the initiative to work diligently.

CATARACT SURGERY IN POST-LASIK PATIENTS

A growing number of patients who opted for LASIK in the early 90’s now require cataract surgery. Managing post-LASIK patients with cataract can be challenging because the visual outcome may not be as predictable as in routine cataract surgery. The risk and treatment plan to address the potential residual refractive error should be thoroughly discussed with these patients who are used to having clear vision after LASIK. Realistic expectations must be established from the start. Though the current IOL calculations have improved significantly, one must remember not to over-promise.

Why can’t it be as predictable?

Myopic laser vision correction (LVC) results in central flattening of the anterior corneal curvature as shown in Figure 1. Hyperopic LVC on the other hand results in central steepening of the anterior corneal curvature.

Figure 1: corneal topography of a post-LASIK patient

Most of the IOL formulae assume the cornea to be a sphero-cylinder and corneal power is usually measured based on only the anterior keratometric readings .Therefore in post-LASIK patients estimation errors occur as the measured optical zone is now either flatter or steeper depending on the type of LVC while the posterior corneal curvature remains unaltered.

The corneal refractive index is also different after the changed relationship of the anterior and posterior corneal curvature following LASIK. The anterior chamber depth is wrongly estimated to be shallow since calculation relies on the flat central cornea in myopic LVC resulting in a more anterior effective lens position (ELP). These errors result in post-operative significant hyperopic shift in myopic LVC and a myopic shift in hyperopic LVC if standard IOL formulae are used.

3D HEADS-UP OPHTHALMIC SURGERY COMES TO A POSTGRADUATE TEACHING CENTRE: WILL IT STAY?

Ophthalmic surgery is an essential and exciting part of being an ophthalmic surgeon. The eye is a complex structure in which its anatomy is difficult to appreciate in standard 2D settings especially for learning purposes. There have been many innovations in operating microscopes since the 1990s and the advancement in 3D technology has enabled 3D heads-up surgery with both surgeon and assistant not needing to look into the microscope during surgery. 3D heads up surgery is a revolutionary type of surgery using a television screen that displays images in 3D with the surgeon’s head looking directly at the screen. In this manner, the audience may also watch in 3D with the same resolution as seen live by the surgeon.

The Department of Ophthalmology at Universiti Kebangsaan Malaysia Medical Centre (UKMMC) had the wonderful opportunity of being the first teaching hospital in Malaysia to host a demonstration of the new NGENUITYTM 3D Visualization System with DATAFUSION from Alcon Laboratories, Texas, USA from 7th August to 6th September 2019. This provided the opportunity for 7 surgeons to experience operating with this 3D viewing system and a number of operations (32 surgeries) including phacoemulsification, pterygium surgery, glaucoma surgery and vitreo-retinal surgery were performed during this period. A delighted audience of 33 trainee ophthalmologists also had the opportunity of a “surgeon’s eye view”.