The International Intraocular Implant and Refractive Society of India (IIRSI) held its annual meeting in Chennai, India in 2023, attracting over 3,000 eye care professionals from around the world. It was here that Prof. Farhad Hafezi, Medical Director of the ELZA Institute, not only gave several lectures to the attending global experts, he was also awarded the IIRSI Gold Medal, an accolade that “serves as a testament to his expertise, innovation, and dedication to advancing the field of ophthalmology.”
During the meeting, Prof. Hafezi gave the following presentations:
Individualizing CXL For Keratoconus
In this presentation, Prof. Hafezi introduced PACE (Phototherapeutic Keratectomy-Assisted Customized Epi-on Cross-linking), a second-generation customized keratoconus treatment that has shown promising results. PACE combines cross-linking with an epithelial map-guided PTK to achieve significant corneal flattening. Unlike the first-generation technique, PACE does not require an eye tracker during the UV-irradiation of the cornea. A small epithelial map-driven PTK is performed over the cone, creating epi-off and epi-on areas, resulting in a riboflavin gradient between them. This gradient allows different cross-linking efficacies in different areas of the cornea. With nearly twice the flattening effect compared to the first-generation technique, PACE is particularly effective for myopic patients with corneal values in the range of about 53–55 D. Subsequent fine tuning with wavefront-guided PRK can be considered after the corneal topography (shape) has stabilized. Ongoing refinement of the PACE technique aims to enhance outcomes further, providing better results and improved vision for patients with keratoconus.
Third Generation Epi-on CXL and Office-based Epi-on CXL at the Slit Lamp: Democratising Access to Treatment
In these presentations, Prof. Hafezi discussed the two main challenges of ensuring that epi-on CXL at the slit lamp works: ensuring sufficient riboflavin passes through the epithelium and reaches the stroma, and enhancing the UV irradiation protocols to compensate for the approximate 15% reduction in the essential reaction component, oxygen, in the stroma when the epithelium is left intact. Furthermore, he explained how his work with second-generation riboflavin penetration enhancers and pulsed high-fluence protocols have now brought effective, epi-on CXL to the slit lamp, bringing the field closer to the goal of making CXL more accessible to everyone.
CXL in ultra-thin corneas
Prof. Hafezi explained to the assembled ophthalmic surgeons the central (and rate-limiting) role that oxygen plays in CXL in the corneal stroma. This knowledge enabled ELZA’s surgeons and researchers to model the whole UV, riboflavin, oxygen and stromal tissue reaction and enabled them to develop the sub400 protocol to safely cross-link thin and ultra-think corneas, without the drawbacks of traditional thin cornea CXL protocols that typically involve artificially thickening the cornea, which can have unpredictable results.
By measuring corneal thickness and referring to the sub400 algorithm, ophthalmologists can determine the appropriate duration of UV irradiation for the measured thickness, enabling a tailored and reliable framework for cross-linking thin corneas – everything else remains the same as any other Dresden protocol cross-linking!
High-fluence PACK-CXL keeps the promise
Prof. Hafezi explained how photoactivated chromophore for keratitis-corneal cross-linking (PACK-CXL) for corneal infections has evolved away from Dresden protocol, low fluence/ lower intensity ultraviolet irradiation protocols CXL to faster, accelerated higher fluence/ higher intensity protocols, and how this delivers a greater and deeper pathogen-killing effect.
Dilemma cases
The “What Will You Do?” session, Moderated by T P Lahane, D Ramamurthy, and Ragini Parekh, aimed to help surgeons make the right choices when addressing the challenges and dilemmas faced in the clinic; Prof. Hafezi Hafezi was an expert panel member giving that advice.
Prof. and Nikki Hafezi wish to thank Dr. Agarwal and all of his colleagues who organised and ran the IIRSI meeting for their warm welcome, kind hospitality, the IIRSI Gold Medal award, and for an excellent IIRSI meeting.
