Dear Friends and Colleagues,

And just like that, we have entered the fourth quarter of the year. Three quarters of 2026 have already passed, bringing with them their share of challenges, milestones, new experiences and hopefully, a few moments of joy. The final quarter is often viewed simply as the last stretch before the year comes to an end, but perhaps it is also an opportunity to reset, refocus and finish well.

For those goals that have been sitting patiently on our lists, perhaps now is the time to revisit them. For projects that have been started but not completed, let us find the momentum to see them through. And for the things that did not go quite as planned, perhaps the fourth quarter is a reminder that there is still time to recalibrate. We do not have to accomplish everything; but we simply need to make the remaining months count.

As we move into these final months, we also need to be mindful of the environment around us. Haze has once again become a concern in parts of Malaysia, while the strengthening El Niño conditions are expected to bring hotter and drier weather with increased risk of haze and associated health concerns. For us as ophthalmologists, this is particularly relevant as poor air quality and dry, hot conditions can aggravate ocular surface symptoms and discomfort. Let us remember the simple things such as staying hydrated, reducing unnecessary outdoor exposure when the air quality is poor, protecting ourselves with appropriate masks when needed and paying attention to the health and wellbeing of our patients, colleagues and families.

This month's newsletter brings you three interesting reads across our regular segments:

In Eyestreet News: What's Happening in Ophthal City? we take a closer look at Small Incision Cataract Surgery (SICS) through the experience of a surgical skills transfer workshop at Hospital Sultan Ismail Johor Bahru. The article explores how this seemingly “old” technique continues to have a place in modern ophthalmology

In Behind the Lens: A Conversation with the Expert, we turn our attention away from the operating theatre and towards something every ophthalmologist should understand but may not always think about: Medical indemnity. Our conversation explores what indemnity really offers, what doctors should look for when comparing policies and why scope of practice, documentation, consent, early notification and continuity of coverage matter.

ARTICLES

Eye Street News: What’s Happening in Ophthal City?

SICS: A HIGH-VALUE ASSET IN THE MODERN CATARACT SURGEON'S ARSENAL

While phacoemulsification remains the standard of care in Malaysia and across the world, Small Incision Cataract Surgery (SICS) provides an option for cataract surgery to be performed in resource limited settings and in dense cataracts where traditional Extracapsular Cataract Extraction (ECCE) would have perhaps been used. These days, even the densest of cataracts can be broken down with phacoemulsification or with the assistance of a femtolaser. This comes at a cost to the health of the corneal endothelium in the former, and or is limited to only select centres with access to such machines in the latter. ECCE was an alternative, being a good option for when corneal endothelium preservation was a factor and was even accessible in places where phacoemulsification machines were not available. For years, medical officers and masters’ trainees performed ECCE as the stepping stone procedure prior to moving on to phacoemulsification. We wouldn’t be the first to complain about the large amount of astigmatism it usually leaves, requiring frequent and repeated visits by the patient for suture removal in the postoperative period. In good hands, this would definitely be a non-issue. Personally however, I find myself increasingly avoiding ECCE just because of the hassle and dissatisfaction from the patients who are made to make these recurring visits.

We jumped at the chance to invite Dr Norlelawati binti Abu, Consultant Ophthalmologist and former Head of Department at Hospital Tuanku Jaafar Seremban (HTJ) after hearing her talk on SICS at one of the regional CMEs in late 2025. She spoke about how she picked up this skill during her fellowship years abroad, was actively teaching and training the skill to her MOs at HTJ and at that time was probably the only surgeon in Malaysia performing SICS based on the National Eye Database registry data. Dr Norlelawati, affectionately known as Dr Lela brought the experience of over 500 SICS surgeries performed and supervised in the operating room. We invited Dr Lela, to Hospital Sultan Ismail Johor Bahru (HSIJB) where a team of Ophthalmologists, MOs and paramedical staff conducted a live surgical workshop, with the primary aim of facilitating skills transfer and introducing the SICS procedure. It is no secret that government hospitals across the country struggle with long surgical waiting lists. Therefore, the chance to learn an entirely new-to-us technique without additional technology investment, allowing our trainees and MOs to perform safe supervised and semi-independent cataract surgery, and at the same time offers significantly better outcomes than conventional ECCE was very enticing.

Supported by decades of robust global trial data, this article shares the workshop's initial outcomes and examines why keeping SICS in the modern surgical arsenal is great for training young surgeons, handling dense cataracts, yet provide phaco-comparable results.

Behind the lens: A Conversation with the Expert

PROTECTING THE PRACTICE, PRESERVING THE PROFESSION: A CONVERSATION ON MEDICAL INDEMNITY

Since ancient times, physicians have been guided by the principles of the Hippocratic Oath, to act in the best interest of patients, avoid harm and uphold professional integrity. These principles remain the foundation of modern medical practice and continue to shape the relationship of trust between doctors and patients.

However, medicine has always existed within a landscape of uncertainty. Despite advances in technology, refined surgical techniques, and adherence to evidence-based guidelines, complications and unexpected outcomes may still occur. In ophthalmology, where even a seemingly small complication can result in significant and permanent visual consequences, the impact can be profound for both the patient and the treating doctor.

The medicolegal environment surrounding healthcare has also evolved. Patients today are more informed, expectations are higher and doctors are increasingly required not only to provide safe clinical care but also to demonstrate clear communication, appropriate informed consent, meticulous documentation and sound clinical decision-making. An adverse outcome does not always equate to negligence, but the process of navigating complaints, investigations and claims can be complex and challenging.

In this context, medical indemnity serves a role beyond fulfilling regulatory requirements for annual practising certificate (APC) renewal. It provides doctors with professional support, legal guidance and financial protection when facing medicolegal challenges. Understanding the nuances of indemnity coverage is therefore an important aspect of modern clinical practice.

In this interview, the Malaysian Society of Ophthalmology speaks with Mr Japhire Gopi Kannan, founder of Doctor Shield, to explore the evolving role of medical indemnity, common misconceptions among doctors and the key considerations ophthalmologists should understand when reviewing their protection.

1. Many doctors purchase indemnity insurance primarily to fulfil APC requirements. Beyond regulatory compliance, what role does medical indemnity play in modern clinical practice?

For many doctors, indemnity begins as an APC requirement. But that should only be the starting point.

In modern practice, medical indemnity is part of the protection ecosystem around a doctor. It protects the clinician, the practice and ultimately the patient relationship when an unexpected outcome, complaint or allegation arises. It helps ensure that a difficult situation is handled in a structured, professional way, rather than leaving a doctor to face legal costs, expert evidence, regulatory processes and patient communication alone.

Its value is therefore not simply financial. A well-designed arrangement can provide access to appropriate legal and medicolegal support, help the doctor respond early to concerns and protect personal assets and future earnings where the policy responds. In ophthalmology, where clinical outcomes are closely connected to sight, quality of life and patient expectations, that support matters greatly.

My view is simple: no doctor should have to practise in fear that a single difficult case can destabilise a lifetime of work. Indemnity should give doctors the confidence to exercise sound clinical judgement, communicate honestly and continue caring for their patients responsibly.

Next in Vision: Ophthalmic Innovations and Updates

OPTIMISING THE IOP CONTROL: THE ROLE OF RIPASUDIL-BRIMONIDINE FIXED COMBINATION

Intraocular pressure (IOP) reduction remains the only proven modifiable factor in glaucoma progression, and topical therapy continues to be first-line in most patients. While multiple drug classes are available, targeting aqueous production and outflow pathways, real-world management is often limited not by efficacy, but by adherence, tolerability and treatment complexity. As a result, there has been a gradual shift towards fixed-dose combination (FDC) therapy as a more practical approach to long-term disease control.

FDCs offer advantages beyond pharmacological synergy. By reducing the number of bottles and instillations, they simplify treatment regimens, eliminate the need for spacing between drops and minimise washout effects. In addition, reduced preservative exposure may improve ocular surface tolerance. These factors are particularly relevant in elderly patients and have been consistently associated with better adherence and more stable IOP control in clinical practice.

GLAALPHA, a fixed combination of ripasudil and brimonidine, exemplifies this approach. It provides a complementary mechanism of action by enhancing trabecular outflow via Rho kinase inhibition while simultaneously reducing aqueous production and increasing uveoscleral outflow through alpha-2 agonism. This multi-pathway targeting allows for effective IOP reduction, particularly in patients who remain above target on monotherapy or require lower pressures.

Clinical evidence supporting this combination includes a 52-week multicentre Phase III study conducted in Japan involving patients with primary open-angle glaucoma, ocular hypertension, and secondary glaucomas, many of whom were already receiving background therapy. Twice-daily ripasudil–brimonidine FDC demonstrated sustained IOP reduction when used as both adjunctive therapy and monotherapy, with consistent efficacy across different treatment regimens. The safety profile remained in line with the known effects of its individual components.