medico (oct - dec 2014)

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  • Thyroid Eye Disease A New Look

    Eye Surgery Centre at the NUH Medical Centre

    03-04 Medical Spotlight 05-13 Insight 14-15 Treatment Room 16-17 Doctors Heartbeat 18-19 Medical Notes

    Advances in Cataract Surgery

    Medical Sp tlight

    A/Prof Clement TanDepartment of Opthalmology

    MdicoA quarterly publication of GP Liaison Centre, National University Hospital, Singapore. MCI(P) 151/07/2014

    October to December 2014

  • About GPLCAt the National University Hospital (NUH), we recognise the pivotal role general practitioners (GPs) and family physicians play in providing and ensuring that the general public healthcare is of the highest quality and standard. As such, we believe that through closer partnerships, we can deliver more personalised, comprehensive, and efficient medical care for our mutual patients. The General Practitioner Liaison Centre (GPLC) aims to build rapport and facilitate collaboration among GPs, family physicians and our specialists. As a central coordinating point, we provide assistance in areas such as patient referrals, continuing medical education (CME) training, and general enquiries about our hospital's services.

    Through building these important platforms of shared care and communication, we hope that our patients will be the greatest beneficiaries.

    If we could be of any assistance to you, please feel free to contact our office from Mon - Fri : 0900-1200hrs, 1400-1800hrs at:

    GP HotlineTel: +65 6772 2000Fax: +65 6777 8065

    NUH Continuing Medical Education (CME) Events

    At NUH, we strive to advance health by integrating excellent clinical care, research and education. As part of our mission, we are committed to provide regular Continuing Medical Education (CME) events for GPs and family physicians. These events aim to provide the latest and relevant clinical updates practical for your patient care.

    Organised jointly by the GP Liaison Centre (GPLC) and the various departments, our specialists will present different topics in their own areas of specialties in these symposiums, which are held monthly.

    For more information on our CME events, you can go to www.nuhcme.com.sg or scan the following QR code.

    GP Appointment Hotline: +65 6772 2000

    GPLCNUH GP Liaison Centre

    2 MEDICO OCT OBER - DECEMBER 2014

  • Dr Vivien LimAssociate Consultant,Department of Ophthalmology

    Dr Vivien Lim is an Associate Consultant with the Department of Ophthalmology, National University Hospital. Dr Vivien Lim completed her medical training with the Faculty of Medicine, National University of Singapore (NUS) in 2004.

    During her residency years in Ophthalmology from 2006 to 2012, Dr Lim has held various administrative appointments, including Chief Registrar in the Department of Ophthalmology, National University Hospital (NUH) from 2010 to 2011.

    Dr Lim became a Member of the Royal College of Surgeons of Edinburgh and was awarded the Master of Medicine (Ophthalmology) by NUS in 2009. Upon completion of her residency in 2012, Dr Lim became a Fellow of the Academy of Medicine, Singapore (FAMS). Her practice interests include general ophthalmology, adult cataract surgery and refractive (LASIK/ Implantable Contact Lens) surgery.

    Dr Lim has published scientific papers in respected peer-reviewed medical journals, and presented at numerous international and local conferences. Her research interests are in cataract and refractive surgery. She is active in teaching medical students and ophthalmology residents, and is a faculty member at the Yong Loo Lin School of Medicine, NUS.

    Email: vivien_sy_lim@nuhs.edu.sg

    M EDIC AL S PO TL IGHT

    Advances in Cataract Surgery

    Traditional cataract surgery is one of the most frequently performed surgeries and considered as one of the safest and most effective procedures with predictable outcomes. Cataract surgery is estimated to be performed 19 million times annually. The World Health Organisation estimates this number will increase to 32 million by the year 2020.1,2 Femtosecond laser technology, introduced clinically for ophthalmic surgery in 2001 as a new technique for creating lamellar flaps in laser in situ keratomileusis (LASIK), has recently been developed into a tool for cataract surgery. At the National University Hospital (NUH), we obtained the CATALYST Femtosecond Laser Machine in 2012.

    In traditional cataract surgery, the eye surgeon uses a hand-held metal or diamond blade to create an incision in the area where the sclera meets the cornea. The goal in creating this incision is to go a partial depth vertically, then go horizontally in the cornea about 2.5mm and then enter into the eye. The surgeon can then break-up and remove the cataract, which is located right behind the pupil. Next, an intraocular lens (IOL) is inserted and implanted, to replace the cloudy natural lens.

    With the laser approach to cataract surgery, the surgeon creates a precise surgical plan with a sophisticated 3-D image of the eye called an OCT (Optical Coherence Tomography). Real time live OCT imaging function of the laser platform tracks progress of the procedure and gives real time feedback of eye images to the surgeon during the entire surgical process, providing an added level of safety to the patients.

    The corneal incisionThe Femtosecond laser creates a corneal incision that is of an exact length and depth. This is important not only for accuracy, but also for increasing the likelihood that the incision will be self-sealing at the end of the procedure, which reduces the risk of infection. The capsulotomyThe eyes natural lens is surrounded by a capsule that is very thin and very clear. In cataract surgery, the front portion of the capsule is removed in a step called the capsulotomy to gain access to the cataract. It is important that this capsule is not damaged during the cataract surgery because it must hold the artificial lens implant in place for the rest of the patients life.

    In traditional cataract surgery, the surgeon creates the capsulotomy by using forceps to tear the capsule in a circular fashion. The laser machine is able to create a well-centred opening that is of a specific size. This allows for highly accurate positioning and centration of the artificial intraocular lens, reducing optical aberrations and refractive errors.

    Removal of the cataractIn the traditional technique, after the capsulotomy, the surgeon uses the ultrasound machine to break-up and remove the cataract. Lens fragmentation by laser reduces the amount of ultrasound energy used during phacoemulsification, reducing risk of capsule complications and corneal injury.

    Studies3 have shown that there is 99% reduction in ultrasound energy for cataracts of different grading, 25% less cornea edema, 47% less endothelial cell loss, and 19% less inflammation post-op. Femtosecond laser-assisted cataract surgery represents a paradigm shift in cataract surgery. Studies so far suggest that the use of the femtosecond laser precision will deliver superior outcomes, an improved safety profile for patients and thus pave the way for further advances in the field.

    Types of intraocular lens availableArtificial intraocular lenses (IOLs) replace the eyes natural lenses that are removed during cataract surgery. IOLs have been around since the mid-1960s, though the first FDA approval occurred in 1981. Before that, if you had cataracts removed, you had to wear very thick eyeglasses in order to see afterward since the natural lenses that had been removed were not replaced with artificial ones.

    2014 OCT OBER - DECEMBER MED ICO 3

  • Traditionally, a monofocal IOL is used. Cataract surgery with implantation of a traditional monofocal IOL, targeting distance vision, leaves most individuals dependent on some correction, usually spectacles, for near vision.

    Having to frequently take reading glasses on and off is inconvenient for many people. With todays advanced lens procedures, patients now have a choice in the type of lens that is implanted during cataract or clear lens extraction surgery. Unlike conventional single vision (monofocal) intraocular lenses (IOLs), multifocal IOLs are lens implants that are designed to help patients see at varying distances using different points of focus. The goal of a multifocal IOL is to provide functional vision at different distances to minimise the use of glasses. Although they might still prefer to wear glasses for prolonged reading, the vast majority of multifocal IOL patients experience freedom from glasses for tasks such as driving, watching TV, using their cell phone and computer, looking at photos, reading magazines, price tags, product labels, receipts, and menus. There are different manufacturers who make these lenses, such as AMO, Carl Zeiss and Alcon. The price differs, depending on the company and on the type of lens, with the most complicated being the most expensive.

    How does a multifocal IOL work?With bifocal glasses, you look through the top part of the lens for distance and through the bottom area of the lens for near. A multifocal IOL, designed using advanced technology called diffractive and refractive optics, is entirely different, providing both a distance and near focus at all times. The brain will learn to automatically select the focus that is appropriate for the task at hand. There is a learning curve for using this new, advanced optical design. For example, patients often will have to learn the optimal distance for holding reading material as it will likely differ from what the patient was used to before surgery.

    Depending on pupil size, the multifocal IOL patient may experience some halos, or rings around lights at night. These halos are different from and less problematic than those typically caused by cataracts. Fortunately, these h