Ophthalmology South of the Equator

Bruna Ventura, MD, joins Gary Wörtz, MD, to talk about her practice and her family's role in ophthalmology in her home country of Brazil. Dr. Ventura, a third-generation ophthalmologist, comments on her experience with pediatric cataract surgery and explains the current technology and tools she utilizes in her practice.

Gary Wörtz, MD: Open, outspoken. It's Ophthalmology off the Grid—an honest look at controversial topics in the field. I'm Gary Wörtz.

As lifelong learners, many ophthalmologists are in constant pursuit of new information, insights, and experiences. One of the best ways to broaden our minds is by going global and interacting with our colleagues who practice in other countries. Hearing about their cases, their technologies, their challenges, and their passions is an enlightening and enriching experience.

For this episode of Ophthalmology off the Grid, I sat down with Dr. Bruna Ventura, of Recife, Brazil. Bruna opens up about her family’s contributions to eye care in Brazil, her passion for pediatric cataract surgery, and the emotional demands of treating children. She also sheds light on how congenital Zika syndrome influenced her research and practice and sheds light on some of the technologies she relies on to provide her patients with the best possible outcomes. Here’s Bruna.

Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.

Gary Wörtz, MD: This is Dr. Gary Wörtz with another edition of Ophthalmology off the Grid, and today I have the pleasure of speaking with Dr. Bruna Ventura from Recife, Brazil, which is in the northeast on the coast. Bruna and I were talking a little bit before this just about her practice and the things that she's excited about in ophthalmology. I'm so excited to get to share her experience with the listenership. So Bruna, with that being said, thank you so much for being willing to come and talk to me today about what you're giving back and what you're doing in ophthalmology. It's very exciting.

Bruna Ventura, MD: Thank you for the invitation. It's such a pleasure to participate and be here.

Gary: Yeah. Well, thank you. One thing that was so interesting, and this theme has played itself out as I've talked to a number of ophthalmologists, is that ophthalmology really seems to run in families. It seems to be a dominant gene, and that dominant gene definitely took place in your family. Will you give us a little bit of a historical perspective on your family's role in ophthalmology in Brazil?

Bruna: Yeah, this is so interesting. It all started in our family with my grandfather. His name is Altino Ventura, and he was an ophthalmologist. My father followed his steps and became an ophthalmologist. My mother was supposed to be a cardiologist and met my dad when she was about to finish med school, and then got convinced to do ophthalmology also. So both of my parents are ophthalmologists. My dad does mainly cataract and retina, and my mom is a pediatric ophthalmologist. I have two siblings, so I have my sister that's a retina specialist and my brother that's finishing med school and probably going into ophthalmology in 6 months. Let's see.

Gary: He might be disowned if he didn't follow in the tradition, correct?

Bruna: He has to decide now if he's going to go into glaucoma or neuro-ophthalmology or what.

Gary: Right, he's going to have to fill one of those unmet categories.

Bruna: Yes, yes.

Gary: Well, that's awesome. I know that cataract surgery is really a passion of yours, but not just the adult cataracts. You actually have it seems like quite a subspecialty that you've carved out in taking care of pediatric cataracts as well. Talk to me a little bit about that. How did that come about? Is it just that there was a need for someone to be willing to own that group of patients and you stepped up to the plate, or maybe with your mother being a pediatric ophthalmologist there was a large opportunity to help in her side of the clinic?

Bruna: Yeah, it's interesting how I got involved with pediatric ophthalmology, specifically pediatric cataract surgery. My dad, Marcelo Ventura, he operates in children with congenital cataract and infantile cataract since 1994. When I was doing my residency in the Altino Ventura Foundation, I started going to the OR with him to see him operate the children and I would follow them up in the pediatric ophthalmology department after, and I just fell in love with it.

At that time my father was doing his PhD thesis in studying these children and specifically the use of intracameral triamcinolone at the end of the surgery to modulate inflammation, and I got very involved with these studies and with the children and I started operating on them on my third year of residency. My father started teaching me, and it was something that made me wake up. We were just talking about that before the interview. The days that I was going to operate a child were the bright days. I just loved it.

It's so challenging and at the same time so rewarding to see children having a life change. The child usually comes to you and is like he can only see and identify light or hand motion, and after your surgery and with visual rehabilitation, you see that you make a huge impact in this person's life. For me it's so rewarding. I started to dedicate myself more and more to this, so nowadays my father continues operating with me every Tuesday morning. We do that together, and most of Wednesday mornings we also have children that we operate on. It's something that really gives me a lot of pleasure to help these children.

Gary: You know, it's interesting. Just as I'm hearing you and hearing the enthusiasm that you have and passion for this, I get that sense of satisfaction from taking care of cataract patients who are in their 60s or 70s. But these are patients who have already lived a good life, who have a normal, for the most part, visual development. Cataract surgery is going to impact them for maybe the next 10, 20 years, maybe more. But when you are able to take care of a child, the years of impact that you're able to have on that child and their potential for taking care of themselves, being a productive member of society, going on and not only taking care of themselves but not having to be cared for by their mother or family. It's such a burden that you're relieving for those families, and so I can really see how that would be such a rewarding thing and to see a child who really goes from having little hope to restoring their sight. You know, it doesn't get much better than that. Would you agree?

Bruna: I totally agree. I think adult cataract surgery also gives me a lot of pleasure and the sense of reward with the results, and I love doing my adult cataracts also, but with children their parents or caregivers come and they're so afraid of the future of that child. So it's emotionally very involving. I love being involved with the families and supporting them in this hard time and teaching them how they can make that vision of that child be developed more and more and more. It's really rewarding for the physician.

We totally depend on the family's involvement in the treatment. I always tell them it's totally different in adult cataract surgery where the vision has already been developed. Once you operate, 2 seconds after you take off the microscope light, the patient will be seeing better. With a child, no. You have all the rehabilitation that you need to do. It's a treatment that demands more of the family, but they're so willing to participate and be engaged in that because they know it will change their baby's life. For me, it's very rewarding emotionally also. I love being involved with these patients.

My adult cataract patients, I love all the technology and the femto cataracts and the new lenses, the trifocals, the extended depth of vision lenses. I also have that side of being very involved and liking a lot the technology and being able to help and provide to my patients the best care in ophthalmology. I always tell the residents in my place that we are so fortunate because ophthalmology 20 years ago, we had a big gap between Latin American and Brazilian ophthalmology, for example, versus the American ophthalmology or the European ophthalmology. Nowadays, it's something that's amazing how it's so global. What you have here, we have there and we can offer it to our patients. We learn together, like in these meetings, in the academy, in the ASCRS, in Brazilian meetings. It's such a rich exchange of information. We're so connected, and we learn so much from each other that we can always offer to our patients the best care.

Gary: Well, and I would say I've learned so much from my international colleagues. The fact that global ophthalmology is, I guess, equilibrating or becoming very standardized, it allows more experts across the entire field who can offer solutions, can innovate, can teach. Where you come from does not determine your ability to have a great idea or willingness or ability to teach and show others how it's done. I would just say that I'm so thankful for all of my international colleagues who do amazing things and a lot of times have access to technology years ahead of us in the US. Now we are, in the US, in many cases, really trying to learn from our international colleagues how to do it. How do you make a panoptics work? How do you make a trifocal work in your practice? Because we don't have access to those things yet.

Bruna: Yeah. One thing that I think recently was so interesting to see how we affected the world was with the congenital Zika syndrome that started in Brazil, so Recife was the epicenter of the epidemic. My sister, Camila Ventura, that's a retina specialist and my mom, Liana Ventura, they are both head of all the studies that we are undergoing and now and we're doing in the Altino Ventura Foundation with these children. When the congenital Zika syndrome first, like when we first started reporting it, it was interesting because we didn't have any answers for all the questions. We only had questions.

Now, slowly by slowly, step at a time, we have the answers to give to the world so now the US, for example, is starting to have their own cases and they already have learned from us, let's say. We have so many people going to Brazil to Recife from all over the world, and we love to have them because we know that we need to spread information on this congenital disease so that other families don't have to undergo what we are undergoing there and if they do have a child that has congenital Zika syndrome, how they can get better assisted. This was something that was interesting, because we weren't learning from the world. The world went to Recife to learn that. It's an exchange, I think, that represents well how global we are now and how well we're learning and exchanging information with our colleagues.

Gary: Yeah. I want to dive in a little bit to just your adult cataract population. I would love to hear what tools you're using, from biometry to laser to lens, and maybe give me a little bit of a peek into what your adult cataract population looks like. How many are choosing to go for advanced technology, and what are your philosophies on the newer technology that we're all trying to use?

Bruna: Yes. With regards to technology, I think I got a lot of that from my dad that I'm very open to technology. Our private practice that's called the HOPE Eye Hospital in Recife was one of the first in Brazil to have the femtosecond laser when it first arrived in Brazil. We, since then, are very enthusiastic about it. We use it routinely. It's something that I really defend and I see a benefit in my patients. Various-

Gary: What femto are you using, just out of curiosity?

Bruna: Yeah, I'm using the LenSx. That's what we have, but I have used the Catalys also. When I was training at Baylor College for one year, they had both the LenSx and the Catalys, so I got to see both. But back home we have the LenSx, which was the first one that was available and it's a very good platform. It's interesting how technology evolves and competition is very positive, so I love it that we don't have only the LenSx in Brazil, but we have it for a long time now and we have a lot of experience. At first, the patients we would have to talk about the laser. Most of the patients did not hear about femtosecond laser cataract surgery, but it's interesting now how many patients will come to us at the office and they will arrive and be like, in their first consultation they'll be like, "Oh, I came because I want to be operated by you with the laser." I'm like, "Oh, interesting."

The same thing happened with the multifocal lens. At first, we would also have to have a lot of chair time to explain what's the multifocal lens, how does it work, and what are the advantages. Now it's the opposite. I usually spend more time, when I contraindicate a multifocal lens for whatever reason, explaining why I'm not going to implant that for the patient to understand. Then, when I'm just explaining about the technology because they already usually have a friend or a family member that had the surgery with a multifocal lens. With regards to the lenses now, my practice, my routine, is to use the extended depth of focus lens. I always do a mini-monovision and I have great results for all distances.

Gary: Are you talking about the Symfony lens?

Bruna: The Symfony specifically, yes.

Gary: Okay. Yes, got it.

Bruna: Symfony and Symfony toric lens. The Symfony toric online calculator is very good because can incorporate posterior corneal astigmatism, and that was something that came in the last version of the calculator and that's wonderful. It really improves the outcomes. It's very good. All the studies in the posterior corneal astigmatism by Doug Koch, his colleagues, it's amazing and it really helps us for sure.

Gary: That's very interesting because I also really enjoy using extended depth of focus lenses. I want to ask you, because it seems like there's a little bit of a divide between ophthalmologists who are using extended depth of focus. I was having a conversation with a colleague yesterday, and he said that he really tries to hit both eyes for hard plano, like really close to plano, because he felt like if you leave them a little more myopic you might get more nighttime glare and halos. There are some studies that have shown that if you take the dominant eye and you hit them at plano and you take the non-dominant eye and target about a -0.75, you really maximize the benefit of all the ranges. That's what I believe, and so I actually am a proponent of doing a mini-monovision with Symfony, which sounds like you're doing the same thing.

Bruna: Yes.

Gary: What are your thoughts on that? Do you feel like when you do that you get more glare and halos at the nighttime driving conditions in those eyes that end up a little more minus?

Bruna: No, actually. This is my routine strategy for my patients with the Symfony. I aim the dominant eye for far and the near eye with a target of around 0.5, 0.6, maybe 0.7, but usually around -0.6. What I see is that the patients don't have an increased complaint of halos and glare, and they get the J1 for near. Many of our colleagues that are like, "Oh, this is a lens for far and intermediate, not for really near near." Well, with this strategy of mini-monovision the patients don't lose far vision, so they continue 20/20 for far, and they do get J1 very, very easily. At least in my clinical experience, that's what has been happening.

If the halos and the glare has gone away, like zero glare and halo, no, that's not true. Some of our patients still complain of them, but it's not the routine. Not most of my patients come in the office and will be like, "Oh my God, I can't drive at night." No, no, no. That's an exception. It can occur, and I tell all of my patients about this advantage of all multifocal lenses, up until now, trifocals, multifocals, extended depth of vision lenses. But it seems to be less than with other lenses.

One advantage that I wanted to point out about the Symfony lens is the flexibility. Sometimes you've missed your target, so you aim for a plano and you end up with a patient staying a +0.75, for example. With some lenses you would be like, "Oh my God," you would 20/40 for far and a J4 or whatever for near. It would be chaotic. In this lens, the technology that the Symfony uses, you don't have the decreasing vision that you would expect with other lenses if you had that target missed. That's something that of course you're not aiming at that. You're missing your target, because we know that science, it's not an exact science, but this makes the doctor more comfortable and more reliable on the technology because it's more forgiving.

Gary: Right. I've found the exact same thing. What's interesting, we're talking about doing that mini-monovision, if you look at the defocus curve, it's not like a sharp peak at plano and then a decline. It's sort of a gradual peak to plano and then a gradual decline, almost like a plateau of vision. Actually, if you look at the defocus curve you can miss by up to 0.50+ and you're still at 20/20. I'm sorry, I said that incorrectly. You can miss on the minus side by a half a diopter and still be at that 20/20 level. The defocus curve works backwards for 0.50 D and forwards for a diopter and a half.

In my opinion, some of the best results are the patients who end up about minus a half, because they end up getting a full two diopters of vision and if not these two peaks of vision where the multifocals in the past you could see at distance and then at a very specific point at near. This really is a continuum of vision, and I really love your philosophy of this mix and match because I guess it matches my own. I'm a little biased. We share the same biases, I guess.

Bruna: Yeah.

Gary: Well, that's wonderful. One question I have is, are you doing any of these type of advanced technology lenses in children, or are you specifically using monofocal lenses in them? What are your thoughts about exchanging them down the road or laser vision correction as they mature?

Bruna: That's a very good question, very interesting question. I don't defend multifocal lenses in children. We know that for these eyes to develop the child has to have the best contrast sensitivity and best corrective visual acuity, so I think the decrease in the quality of vision that we still have with all the technologies that provide multifocality can make it more harder for the eye to develop. At the same time, let's say when you operate on a baby we follow a table that my father developed with the hypocorrection.

Let's say if I operate a baby that's a 3-month-old baby, I will hypocorrect him in 9.00 D so that by the age of 4 he'll be emmetropic. That's, in theory, in the majority of the patients that works. If he's 3 months old, I'll decrease 9.00 D. If he's 6, I'll decrease 6.00 D. Depending on the age, I'll hypo decrease him ... Hypocorrect him, I'm sorry, in a specific amount. But we know that's not an exact science, again. Sometimes you aim for him to be plano at 4 years old, and no, he's +2.00 or -3.00. With a multifocal lens, you can't really do that, like miss the target so much.

One of the big challenges of using these lenses in children is obtaining good vision with no compromise of the quality of vision throughout the development of this eye of the vision of the child. Another thing is it's very common for us to see that with the healing process the bag of the child contracts, and that can decenter your lens. Where will you center the inner ring of the lens in a child? He or she is sleeping, and that's very hard. We routinely implant an endocapsular tension ring to avoid that contraction, but still, there's so many challenges to implant a multifocal lens. So my go-to lens in children is a three-piece IOL that's from Alcon. It's called Type 7, and it's just like the MA60AC, but a little bit smaller so it fits better on babies' eyes.

Gary: Okay, excellent. Excellent. I really appreciated you sharing your perspectives and getting a glimpse into your practice. Any other things in your personal life or just other passions that get you out of bed in the morning and make you excited about either your practice or personal life? I'd love to just hear a word or two about what makes you tick.

Bruna: Yeah. I think many things makes me tick. Working with the children as we spoke at the beginning, that's something that really I love, and my adult cataract surgeries also. I'm very involved with the administration of the businesses, the private practice and the foundation. It's a new challenge for us doctors. We don't really learn how to run a business in med school.

Gary: Right.

Bruna: Right? So learning about finance and all the statistics and everything, it's another challenge. It's as if it were a third part of my life, running the business. I think teaching residents and fellows is something that keeps you learning and keeps you involved. The new generation is very avid for knowledge. I think now one of our big concerns and big challenges of the new generation is to filter what's important to read and learn, because there's so much information available. I like learning with the residents and guiding them. At the same time, when they see something interesting they guide me and they show me. That's something that I really enjoy.

The fourth point is how global the world is, as we were talking, and small at the same time. I love having friends from all over that I can depend on. Let's say there's a new technology coming in Brazil but it has been in Europe for a while now. I have someone that I trust that I can go to and have information and, "Oh, tell me how you would plan the surgery. Give me tips, pearls. What wouldn't you do?" I think that makes me so more comfortable when I'm changing an approach or a lens or a technology that I'm adopting, and I think that's something that's very positive for all of us for sure.

Gary: That's right. Well, I share your enthusiasm for our field. It's such a privilege to help people in such a tangible way. I don't know that there's maybe anything else in medicine that is so immediately gratifying than restoring someone's vision, and the way that plays out and also interacts with technology and us trying new techniques all the time, it just is a field that is always evolving and it's always exciting. I really am appreciative of the fact that you share my perspectives, and I totally agree. When you have colleagues that you can lean on and trust when you're trying a new technology makes you feel so much more comfortable when you're doing that for the first time.

Bruna, I just want to say thank you so much for sharing your perspectives. You're doing such a great job taking care of patients and children in Brazil. Brazil's a country I absolutely love. I went when I was 16 to Rio. I took a two-week trip and left a little piece of my heart there, I think. I just love it so much. Big fan of Brazil. Thank you so much for coming on the podcast. We'd love to have you come back any time you would like, and if you had more to share we'd love to follow up the conversation in the future.

Bruna: Thank you so much. This was a great pleasure.

Gary: Okay. Bye. Thanks.

Bruna: Thank you. Bye.

Gary: Bruna and her family have made significant contributions to ophthalmology in Brazil and beyond. Treating children in the midst of an epidemic such as Zika is no easy feat, but Bruna’s passion for her work is palpable. As Bruna mentioned, ophthalmologists today are becoming increasingly global, and I think the benefit of remaining connected to our international colleagues is crystal-clear.

This has been Ophthalmology off the Grid with Dr. Gary Wörtz. As always, I encourage you to head on over to iTunes and leave us a review. You can also catch up on past episodes at eyetube-dot-net-slash-podcasts. Thanks for listening.

Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.