CAKE & PIE Post (53rd RANZCO 2022 Edition) - Issue 4

Putting a Stop to Retinal Occlusion Confusion

by Matt Herman

As an American abroad, one of the most startling revelations about life outside of Uncle Sam land is how nearly every other country on the planet exists without relying on the automobile as the primary mode of transport. While piloting an offensively violet electric rental scooter on the way to Day 3 of the 53rd Annual Scientific Congress of the Royal Australian and New Zealand College of Ophthalmologists (RANZCO 2022), your correspondent couldn’t help but notice a distinct lack of morning rush hour traffic. No honking, no noise, and clear lanes meant a smooth commute to the Brisbane Convention & Exhibition Centre with only the faint whir of the scooter’s electric motor in the background.

This is quite the contrast to those unfortunate sufferers of central retinal vein occlusion (CRVO), which is essentially a New York Cityesque traffic jam in one of the most critical regions of the eye. This potentially sight-robbing disease and its past, present and future was the topic of Professor Ian McAllister’s 2022 Sir Norman Gregg

seemingly intractable problem of American traffic congestion, the current and future state of CRVO has never been brighter.

A CRVO retrospective – then and now Prof. McAllister began by giving readers a peek into the past of CRVO research. The disease is not new, having been described for the first time

by

The next 155 years, which is also roughly how long it takes to pronounce the good doctor’s name (pun intended!) – saw almost zero developments in the field for a century and a half. Until, that is, the anti-VEGF revolution, which saw marked improvements in visual outcomes for the first time in history for CRVO patients.

But despite the critical breakthrough of anti-vascular endothelial growth factor (anti-VEGF) treatment, massive questions still remain until we should feel comfortable in our fight against the second most common retinal vascular disease on the planet. Prof. McAllister’s litany of unresolved issues was nine strong, and his lecture detailed his own efforts to advance the description, diagnosis and treatment of this global menace.

Location, location, location

One of the major issues in CRVO today is where exactly it is and what it’s made of. CRVO is a site-specific disease, explained Prof. McAllister, and we need to know where it is to help us understand it better. Many studies have been done that locate it in the lamina cribrosa in chronic patients, but research by Hayreh, Beaumont and Kang, have indicated that this can vary, and the location can result in different clinical presentations.

The nature of the occlusion also plays a role, and more research is giving an insight into this. Multifunctional endothelial cells could be the culprit, according to one study by a group including Prof. McAllister. Retinal vein contraction may also be induced by Endothelin-1 (ET-1), a potent vasoconstrictor. Three other proteins (myosin, calponin, and alpha-SMA) are also in the mix, and research is ongoing to establish a linkage between these factors and retinal vein occlusion.

CRVO and the not-soimmaculate macula

It was then time to take an ever-so-slight detour to the macula. Macular edema and ischemic damage are extremely common with retinal vein occlusion, and

the why is critical. According to Prof. McAllister, macular issues stem from raised venous pressure in the occluded vessel, and a breakdown of the inner blood ocular barrier. Inner blood ocular barrier breakdown can be caused by several things, including the presence of VEGF induced by retinal ischemia, down regulation of occludin, the release of interleukin-6+8, SDF-1 and other inflammatory mediators, and the recruitment of macrophages.

“Our current treatments only address partly the second of those two causes [inner blood ocular barrier breakdown], and not the first,” Prof. McAllister admitted. But the time for new investigations to solve this has come, and it turns out venous pressure is even more critical than previously imagined.

“Those with high venous pressure [in the study] basically ended up blind by three months, whereas those with low venous pressure basically kept their starting visual acuity,” he said. So what can be done?

choroidal venous anastomosis (L-CRA) was combined with an anti-VEGF treatment (ranibizumab). Versus the control group, improvements of over 14 letters were observed, against around 3 letters in groups with only one treatment.

Achieving our ends with porcine friends

Even more novel therapies are emerging, and a lot of this work is coming from work on acute branching retinal vein occlusion (BRVO) in pigs. One of the most interesting findings coming out of this work is that not only is there a window where neuroprotective agents could stop RVO in its tracks, but that anti-VEGFs might actually have some of these effects.

These studies also investigated the role of various cytokines. Although anti-VEGF therapies have shown great results, the conclusion here is that the intra-retinal cytokine cascade in response to venous obstruction is complex (to say the least), and VEGF is not always the answer.

“We’ve developed a treatment of anastomosing a retinal vein with an unobstructed choroidal vein,” he continued. In this technique, a high density power laser is used to create an anastomotic connection. This solution, he asserted, is still preferable over anti-VEGF treatments like ranibizumab, where visual acuity gains fade quickly after the first year.

The best results, however, happen when both therapies are combined. Prof. McAllister found the superior results against a control occurred when laser

In the end, Prof. McAllister led the audience through an exceptionally detailed exploration of the state of the art in CRVO. And there are many conclusions that can be drawn. For one, we must look beyond pharmacological therapy alone for the final solution to this common disease. One of the main reasons for this is that the current treatment burden is high, and long-term. New therapies are exploring alternatives in alleviating intravenous pressure with great results, but once vascularization is lost, revascularization is likely impossible.

We still don’t know why people develop CRVO, but new potential culprits like venous endothelial cell contraction and signaling in response to hemodynamic stress are great starting points for investigation. Prevention of CRVO and other vein occlusion in the eye are likely critical to prevent us from getting past the point of no return, and detecting and treating neurodegeneration is a promising early biomarker for this.

and PIE

on the Anterior and Posterior

by German ophthalmic pioneer Friedrich Wilhelm Ernst Albrecht von Gräfe in 1855.

“We’ve developed a treatment of anastomosing a retinal vein with an unobstructed choroidal vein.”

— Professor Ian McAllister

Unfolding a Steadier Solution with TECNIS Toric II

by Joanna Lee

Building on its proven TECNIS® platform, Johnson & Johnson Vision’s TECNIS® Toric II 1-Piece IOL takes its potentials a level up with improved rotational stability performance.

Building up a better toric lens

Toric lenses are ideal for correcting pre-existing corneal astigmatism in patients, even as low as 0.5 D cylinder. Often the concerns surrounding toric lens misalignment after surgery are caused by incorrect placement of the IOL. This could arise due to inaccurate calculations of the astigmatic axis among other inaccuracies. However, the misalignments do happen mostly due to sudden rotations after implantation.1 Furthermore, many studies indicate the different levels of rotational stability among various brands of toric lenses.2-5

In the past, some issues with rotational stability and occurrences of misalignment had colored the regards that surgeons held of the TECNIS® Toric IOL lens. However, Johnson & Johnson Vision’s determination to overcome these issues have resulted in the newer improved design of the TECNIS Toric II lens.

Improved rotational stability

The modified haptic design of Johnson & Johnson Vision’s TECNIS® Toric II 1-piece IOL enables it to minimize lens rotation. During its proof-of-concept study involving 8 surgeons in three countries outside of the United States, it was shown to have less than 1° of absolute rotation at 1 week and 1 month after implantation. What was remarkable was it achieved a 100% of lenses having had 5° or fewer degrees of rotation at 1 week while 99% of lenses had 5° or fewer degrees rotation at 1 month.6

Another study published in the Journal of Refractive Surgery also concluded that the TECNIS Toric II IOL has “significantly improved rotational stability compared to its previous model.7

Its performance is also proven in another study which found that “TECNIS® Toric II IOL with the frosted haptics showed significantly better rotational stability than its predecessor, probably due to quicker unfolding and greater friction with the capsular bag”.8

Essential alignment unlocked

Excellent postoperative results showing the TECNIS® Toric II’s high rotational stability, thanks to its improved haptic design, was brought to light in a collaborative study involving the Ryukgasaki Saiseikai Hospital in Ibaraki, Japan, and University of Tsukuba, most recently in 2021.

Setting out to study the TECNIS® Toric II’s rotational stability, astigmatism correction effect and visual performance, the prospective investigation by Dr. Shinichiro Nakano and his team compared the results of 100 cataract surgery patients equally divided into the group receiving the TECNIS® Toric II lens implants and those receiving brand A’s toric lens implants. The comparative results of these two groups involved measuring each group of patients’ nakedeye distant visual acuity, misalignment and residual astigmatism at the points of 1 day, 1 week, 1 month and 3 months post-surgery.

Three months after the surgeries, it was found that the TECNIS® Toric II lens group had significantly less misalignment than brand A’s group. The misalignments were at 1.52 ± 2.16° versus 2.17 ± 2.42°, which saw the TECNIS group performing better.

Apart from that, the postoperative visual acuity and residual astigmatism were similar in both cases being 0.19 ± 0.30 and 0.13 ± 0.25 D, respectively. Postoperative astigmatism prediction error was 0.17D @ 139°±0.32D and 0.05D @ 127°±0.28D (centroid) respectively.

The outcome from this study of significant interest was presented at the American Society of Cataract and Refractive Surgery (ASCRS)’s meeting in July 2021 at Las Vegas.9

Less rotations, more satisfaction

Having been approved in 2021, the TECNIS® Toric II’s improved haptic design technology is based on the TECNIS® Toric IOL platform which has already delivered

several impactful key features for patients with astigmatism.

For one, it was able to give 94% of patients binocular UCDVA 20/25 or better at 6 months, increasing their spectacle independence for distance vision. Besides, it also enabled 88% of patients to achieve 20/20 or better monocular corrected distance visual acuity.

It enables one of the highest image contrasts under all lighting conditions while sustaining high-quality vision with capsular clarity.10

About 92% of patients receiving the TECNIS® Toric IOL report higher confidence with “no difficulty at all” driving at night without glasses.11

What’s more, 97% of patients said they would choose to have the TECNIS® Toric IOL implanted again12, indicating a high level of satisfaction among patients with astigmatism receiving this lens.

The new TECNIS® Toric II platform features the same overall dimensional, mechanical and optical characteristics as the current toric 1-piece lenses with the exception of one unique feature – its new, haptic design which has a squared and frosted appearance, engineered specifically for rotation stability.

The Toric II platform is also available through Johnson & Johnson Vision’s

References

Eyhance™ and Synergy™ series of lenses. In order to gauge the performance of the TECNIS® Eyhance™ Toric II IOL under real world conditions, an initial expert group of surgeons from across Europe were granted early access to this lens. Over 400 lens implantations involving 17 surgeons later, the results have been very positive.

“The TECNIS Eyhance Toric II IOL shows predictable and stable alignment after surgery,” states Dr. Nic Reus while Prof. Filomena Ribeiro said “the change in the toric haptics for TECNIS® is a great improvement; it should empower surgeons to correct the astigmatism in their patients.”

Meanwhile, Dr. Bogdan Galan stated that TECNIS® Eyhance™ Toric II IOL was “the perfect lens for drivers. For Prof. Ramin Khoramnia’s demanding patient who is a surgeon herself, it was reported that her “visual acuity of above 0.20 LogMAR or better was achieved over a large range, and the patient is very happy with her vision.”

As surgeons are routinely facing the challenge of keeping patients waiting after toric IOL implantations to check on the proper IOL position 30 minutes post-op, Dr. Elmar Winsauer emphasized that, “this is just not necessary with the TECNIS® Eyhance™ Toric II IOLs as no rotation is experienced”.

1. Inoue Y, Takehara H, Oshika T. Axis Misalignment of Toric Intraocular

Lens: Placement Error and Postoperative Rotation. Ophthalmology. 2017;124(9):1424-1425.

2. Potvin R, Kramer BA, Hardten DR, Berdahl JP. Toric intraocular lens orientation and residual refractive astigmatism: an analysis. Clin Ophthalmol. 2016;10:1829-1836.

3. Lee BS, Chang DF. Comparison of

6.

7.

8.

Influence of frosted haptics on rotational stability of toric intraocular lenses. Sci Rep. 2021;11(1):15099

9. ASCRS Presentation. Available at: https://ascrs.confex.com/ascrs/21am/meetingapp.cgi/Paper/73019 Accessed on 30 October 2022.

10. Data on File, Johnson & Johnson Surgical Vision, Inc. 2015.

11. TECNIS®Toric1-Piece IOL [package insert]. Santa Ana, Calif. Johnson & Johnson Surgical Vision, Inc.

12. TECNIS®Toric1-Piece IOL [package insert]. Santa Ana, Calif. Johnson & Johnson Surgical Vision, Inc.

Addressing Clinical Controversies

by Tan Sher Lynn

Experts discussed the controversies surrounding normal tension glaucoma and the face-down positioning in macular hole surgery on Day 3 of the 53rd Annual Scientific Congress of the Royal Australian and New Zealand College of Ophthalmologists (RANZCO 2022).

Normal tension glaucoma (NTG) risk factors and approach to therapy

Normal tension glaucoma (NTG) is a relatively common form of open angle glaucoma often found in the Asian population possibly due to genetic effects. NTG has been defined as a progressive optic neuropathy in the settling of clinically normal intraocular pressure.

“The question is, what is the contribution of IOP independent risk factors?,” asked Dr. Janey Wiggs of Massachusetts Eye and Ear, Harvard Medical School (USA).

According to Dr. Wiggs, the Collaborative Normal Tension Glaucoma Study (CNTGS) suggested that while lowering IOP may be beneficial, other factors in addition to IOP are likely to impact pathogenesis. Vascular abnormalities are important risk factors. This includes a lower ocular perfusion pressure (OPP), vascular endothelial cell dysfunction and reduced peripapillary vessel density.

In addition, lower cerebral spinal fluid (CSF) pressure is also an important risk factor, as it can cause an adverse translaminar pressure gradient in NTG patients. “This is something we usually see with people with lower body mass index and it has been proposed that lower CSF pressure could explain the higher prevalence of NTG in Japanese people (who tend to have lower mass index),” she said.

Further, Dr. Wiggs noted that NTG

for larger macular holes whose success rates are less high, a variable period of face down positioning may be advised. However, this position can be disabling, uncomfortable and often unfeasible. The perceived need to maintain a prolonged facedown position can be a disincentive for those considering surgery. So, advice around this varies widely,” said Prof. James Bainbridge of the UCL Institute of Ophthalmology (United Kingdom).

treatment considerations may favor minimally invasive glaucoma surgery or MIGS (iSTENT) and ROCK inhibitors. “The American Academy of Ophthalmology (AAO) IRIS Registry published a report on the usage patterns of MIGS, and showed that the iSTENT trabecular microbypass was the most commonly performed MIGS in NTG. In addition, Rho-kinase inhibitors (ROCK inhibitors), showed efficacy in IOP reduction in NTG, or as add-on treatment in NTG patients. They increases nitric oxide production, potentially reducing vascular dysregulation, and increasing perfusion,” she said.

To address whether a face-down positioning is helpful, Prof. Bainbridge and his colleagues started a pilot trial in London in 2012 (Lange et al, Eye) which included 30 eyes randomized to facedown or face-forward (control). They found that the macular holes closed in 14/15 eyes in the face-down group, but only 9/15 in the face-forward group. All holes less than 400 μm regardless of positioning, while for holes larger than 400 μm, 10/11 holes closed in the facedown group and only 4/10 holes closed in the face-forward group.

He also examined the other studies, including the Cochrane systemic review, retrospective registry studies (Essex et al., Australia and New Zealand Society of Retinal Specialists Macular Hole Study Group, Ophthalmology, 2016), and a database study of 1483 macular holes (Steel et al., BEAVRS macular hole outcome group) and came to the conclusion that for smaller holes, success in closure is over 95%, and a facedown positioning offers no measurable advantage.

Macular holes cause severe impairment to sight and surgery can result in favorable outcomes for holes of shorter duration, better acuity and smaller size.

“With the aim of improving outcomes for surgery of macular holes, particularly

Meanwhile, for larger holes, success is typically over 85%, and face-down positioning might improve this by up to 10%. A randomized controlled trial to measure 5% difference is unfeasible. In the meantime, these data can be used to counsel patients to make an informed decision for themselves, he noted.

The value of face-down positioning after macular hole surgery

IOL Choice with an Aussie Legend

by Matt Herman

In the Cataract Update Lecture on Day 3 of RANZCO 2022, a new go-to IOL king was crowned by optics wizard Dr. Graham Barrett…

As the final day of the 53rd Annual Scientific Congress of the Royal Australian and New Zealand College of Ophthalmologists (RANZCO 2022) wound down, something – or someone – seemed missing before your man on the scene trudged into the Thunderdome (Great Hall 2) for his final series of lectures. It would hardly seem like a RANZCO Congress without a sighting of one of the region’s brightest stars, the usually-omnipresent Dr. Graham Barrett. And finally, after much anticipation and a glowing introduction from Cataract Update Lecture chair Dr. Jacqueline Beltz, Dr. Barrett took the stage and all was right in Brisbane, Australia again.

Changing of the guard

There is no better choice for laying down the law on IOLs and optics than Dr. Barrett, inventor of the eponymous Barrett series of IOL calculation formulae, amateur astronomer, and all around class-act. And as per usual, Dr. Barrett’s lecture announced yet another massive shift in the IOL landscape.

It started innocently enough, with a review of the current galaxy of IOL choices, which at this point must rival the amount of stars in the sky (kidding, obviously). Dr. Barrett began by describing the hype, and his own excitement, surrounding the invention of the first multifocal lens. “It may surprise you, but I was one of the first surgeons to use multifocal IOLs, but the optical imperfections, the compromise in optical quality, soon became apparent – and my enthusiasm has waned,” he admitted.

Pleased to meet you, won’t guess my name

After an in-depth review of the optical quality pitfalls inherent in multifocal IOLs, he quoted a little-known song by

some band called The Rolling Stones Something about not being able to always get what you want. Your correspondent’s voice recorder was muffled, but it seems like this music group might be worth checking out.

In any case, Dr. Barrett finally came to the topic of extended depth-offocus (EDoF) lenses, a term he coined himself. He reviewed various optical principles (diffractive, refractive, aspheric surface, pinhole optics, rotational asymmetrical optics) behind EDoF lenses, before arriving at his main conclusion. The faustian bargain with optical quality in multifocal lenses simply isn’t worth it, and the age of EDoF lenses is upon us.

EDoF your caps

There is no one reason for this, in Dr. Barrett’s eyes, but the decision comes down to the way the dust has settled for vision needs and the criticality of patient satisfaction in our modern world.

Of course multifocal IOLs offer unparalleled spectacle independence at all distances, but this should no longer be prioritized over all-important patient satisfaction, which is what truly suffers with multifocal lenses. And according to Dr. Barret, the needs of the modern world with regards to intermediate and near vision (think mobile phones and electronic devices) can still be met by EDoF lenses without the sacrifice in visual quality necessitated by multifocal lenses.

“When I look at the tradeoff between these factors – spectacle independence versus quality of vision, it seems to me that a combination of extended depthof-focus and an element of monovision may be a preferred solution,” he asserted.

“There’s no doubt that an extended depth-of-focus lens provides better quality vision… And I think it’s this quality of vision parameter which is the reason why patients with extended depth-of-focus IOLs are highly satisfied,” he added.

DMEK, the Artificial Iris and the Virtual Cornea Clinic

by Tan Sher Lynn

DMEK,

the most advanced form of partial corneal transplant procedure indicated in diseases affecting the innermost, endothelial layer of the cornea, appears to have major advantages in terms of visual performance, and reduced risk of allograft rejection, but comes with major surgical and technical challenges, especially in eyes with anterior chamber (AC) comorbidities.

According to Prof. Donald Tan, there are various complex cases that require corneal transplant, such as corneal decompensation with anterior segment disorganization. The characteristics of such complexities are: the AC being limited by peripheral anterior synechiae (PAS), iris adhesion, inadequate posterior surface of the AC, and intraocular lens (IOL) placement abnormalities. Even if DMEK can be performed successfully, situations like these can recur after a few weeks to months in many of these cases, which can lead to graft rejection and DMEK graft failure

In 2012, Prof. Tan and his colleagues developed a hybrid DMEK (H-DMEK) pull-through technique using a Descemet

stripping automated endothelial keratoplasty (DSAEK) pull-through donor inserter and donor stroma as carrier.

“Finally in 2018, we developed the DMEK EndoGlide device, which allow us to insert the Descemet’s membrane through a smaller incision which provides a lot more control of the anterior chamber. And that became our standard,” he said.

He noted that the pull-through technique actually holds on to the DMEK tissue, providing one with more control. “The pull-through, endo-in approach to DMEK provides for better surgical control of the donor, while restoring the anatomy of the anterior chamber with the use of artificial iris enables DMEK to be performed in the most challenging cases of endothelial dysfunction,” explained Prof. Tan.

He also shared that during the pandemic, keratoplasty patients (especially complex cases) require constant follow-up for grafts to survive. “Prior to COVID-19, many patients from Southeast Asia came to Singapore for corneal transplantation. In March 2020, the Singapore government imposed significant travel restrictions on foreign medical patients,

and so, in March 2020, the Eye & Retina Surgeons (ERS) in Singapore and Jakarta Eye Centre in Indonesia, developed a new teleophthalmology initiative specially geared at looking after these keratoplasty and other complex cases, which we call the Virtual Corneal Clinic,” he said.

The Virtual Corneal Clinic is a real-time teleopthalmology approach where specialists at both clinics, the patient and sometimes their relatives, come together to review the patient’s medical summary, carry out real-time video slitlamp exam, discuss on the management of the case, and share in decision-making and counselling. “Through the Virtual Corneal Clinic, we made a huge difference in altering the medical and surgical treatment of these patients,” Prof. Tan added.

“Regular and life-long follow-up of keratoplasty patients remain most important for long-term graft survival, and the concept of a Virtual Cornea Clinic is an innovative approach which can hopefully enhance our efforts to keep our patients healthy and seeing well,” he said.

Prof. Donald Tan of the Eye & Retina Surgeons (ERS), Singapore, shared his experience in performing Descemet’s membrane endothelial keratoplasty (DMEK) and establishing the Virtual Corneal Clinic.

by Joanna Lee

The World Health Organization (WHO)’s classification of tumors of the eye (WHO Classification of Tumours of the Eye, WHO Classification of Tumours, 4th Edition, Volume 12) is considered as the gold standard for diagnosing tumors. Giving an update on its latest edition, George Holt Chair in Pathology and Honorary Consultant Histopathologist Professor Sarah Coupland, of the University of Liverpool (United Kingdom), unpacked how the new WHO classification of ocular lymphomas will influence the future of identifying and treatment of these diseases.

Lymphomas, are divided into the Hodgkin’s and non-Hodgkin’s lymphoma types with further subclassifications according to where they occur. Lymphomas in and around the eye are extranodal lymphomas. The WHO’s classification of lymphomas incorporates as much as possible information derived from clinical studies, immunophenotypes, histomorphology and molecular genetics.

“Revolutions are occurring in more areas of medicine including in the area of molecular diagnostics,” Prof. Coupland said. “As a result, the new WHO classification is not only including

genetics, but also transcriptomics, proteomics and epigenetics as well.”

Besides being on the editorial board, Prof. Coupland was also involved in the classification efforts through WHO’s updated Hematolymphoid Blue Book, a body of work involving 380 authors comprising pathologists, molecular biologists, hemato-oncologists, pediatric oncologists and radiation oncologists from across 31 countries. The updated volume will be released this coming November.

The overview of the updated classifications has been published in the Leukemia journal1-2 in July 2022. Focusing on intraocular lymphomas, she revealed some of the changes that the new volume has captured. For instance, there is a new umbrella term of classification called “Diffuse Largecell B-cell Lymphoma of an immune privileged site” under which are found three lymphomas. Essentially both VRL and CNS lymphomas now come under this new umbrella term.

The advantages of placing these lymphomas together is that besides being able to compare and differentiate

between the two, “it can initiate collaborations between centers to fasttrack research in these areas”. Treatment for VRL can then be according to the site of the occurrence, whether it is ocular, ocular and CNS or if it is systemic. These would also be helpful when reporting the diseases under progressively global registries such as the International VR B-Cell Lymphoma Registry.

Prof. Coupland also discussed ocular lymphomas, in particularly highlighting the low grade B-cell lymphoma (extranodal marginal zone B-cell lymphoma or EMZL) which is significantly rarer. “However, it is important to distinguish between the choroidal lymphomas and the vitreoretinal lymphomas because patients with choroidal lymphomas really have a good prognosis,” she said. Previously termed as uveal pseudotumor, uveal lymphoid hyperplasia, or uveal lymphoid neoplasia, these lymphomas only affect the uveal tract.

Primary choroidal lymphomas are lowgrade EMZL similar to ocular adnexal MALT lymphomas. The new WHO Blue Book indicated that MALT lymphomas have a range of locations. “Interestingly, according to their locations, they have differing genetic alterations,” she said.

“As a traditional pathologist, I believe morphology and immunophenotyping are the gold standard for making diagnoses for lymphomas in whatever body sites. The WHO classification is continually revising and incorporating important information which helps us understand the biology of disease and design clinical therapies. Molecular tests (including NGS and metagenomic sequencing) do make unequivocal diagnoses. Some of these tests are freely available and their costs are decreasing so they could be used in lower socioeconomic situations.

Most importantly, concerted international efforts like registries and shared bioresources are important to improve outcomes through the use of AI and multicenter clinical trials.

References

1. Alaggio R, Amador C, Anagnostopoulos I, et al. The 5th edition of the World Health Organization Classification of Haematolymphoid Tumours: Lymphoid Neoplasms. Leukemia. 2022;36(7):1720-1748.

2. Khoury JD, Solary E, Abla O, et al. The 5th edition of the World Health Organization Classification of Haematolymphoid Tumours: Myeloid and Histiocytic/Dendritic Neoplasms. Leukemia. 2022;36(7):1703-1719.

Update on Ocular Lymphomas What’s new in the WHO?

Stellaris EliteTM combines phacoemulsification and vitrectomy in one device

by Brooke Herron

In

order to protect and enhance the “gift of sight” for patients through every phase of life, surgeons must be able to trust the devices and products they use to provide consistent and reliable outcomes. And when it comes to trust and dependability, ophthalmologists often look to Bausch + Lomb (Rochester, NY, USA), a global leader in developing products that ultimately allow surgeons to have true “procedural choice.”

During the 53rd Annual Scientific Congress of the Royal Australian and New Zealand College of Ophthalmologists (RANZCO 2022), Bausch + Lomb is showcasing some of its state-of-the-art surgical products and devices including the Stellaris EliteTM, a true combined

phacoemulsification and vitrectomy platform which helps doctors and patients alike to fully realize the company’s simple, yet powerful, mission: “See better. Live better.”

The evolution of ophthalmology and phaco

Of course, this surgical innovation and evolution didn’t happen overnight. Rather, decades of research and development have resulted in a truly revolutionary system in the Stellaris EliteTM — a device that fully supports anterior and posterior segment procedures, with the reliability, expertise and innovation Bausch + Lomb is known for.

It all began in 1984 with the MicroVit, their first disposable guillotine cutter. Two years later, the Daisy (Digital Aspiration Irrigation System) followed. The subsequent years saw three more innovations from Bausch + Lomb: the dual linear control technology Premiere and Protege (both in 1992), followed by Millenium in 1997.

Each of these innovations built upon the former iteration, and along with key input from surgeons, the Stellaris was launched in 2007. The company continues to work alongside surgeons to create targeted surgical solutions that suit their needs — and this dedication to reliability and innovation is clearly reflected in the Stellaris EliteTM

See it to believe it

The advanced capabilities of Stellaris EliteTM — which supports both anterior and posterior segment surgeries — utilizes different approaches and technologies to add value in a single capital purchase, while incorporating elements that can ultimately reduce complications due to chamber instability.

For example, its Adaptive Fluidics technology continuously tracks vacuum flow rate and integrates automated aspiration control with Dynamic Infusion Compensation. This maintains anterior chamber stability by stabilizing intraocular pressure, compensating for changes in fluid flow, and allowing for a more responsive and controlled surgical setting — thus, resulting in better postoperative outcomes. In addition, its Attune phaco energy management works synergistically with Adaptive Fluidics to deliver low power emulsification (with a six crystal 28.5 kHz handpiece frequency); meanwhile it can perform anterior vitrectomy at 2,500 cuts per minute. All of these features combine to reduce the chances of complications occurring.

Another prime example of Bausch + Lomb’s commitment to innovation and

surgical ease comes with the Bi-Blade vitrectomy cutter, a dual-port and double-sided blade that supports aspiration and guillotine-style cutting with 15,000 cuts per minute and up to 230% faster flow for more efficiency — without sacrificing stability. This improved efficiency is a result of the Bi-Blade’s dual-edge blade which doubles the effective cut over rate over single-sided blades and shortens surgical time.

The Bi-Blade’s dual-port design is another advantage: By offering a 100% duty cycle that allows for cutting without port closure, surgeons will feel confident in various surgical situations, from shaving near a mobile retina to performing dissections and removing intraocular tissues. It’s thanks to this intuitive open-port design that the Bi-Blade can provide continuous aspiration while cutting, reducing the need for a duty cycle — all while maintaining a consistent flow rate and continuous holding force.

Surgeons will also delight in the Stellaris EliteTM’s ease-of-use. Designed with function and ergonomics in mind, the platform has a wireless dual linear foot pedal with rapid response and control in changing conditions. This helps manage both pitch and yaw planes, and irrigation on-off is available on the yaw planes. Further, these integrated movements provide simultaneous control of irrigation, ultrasound and aspiration — creating a more controlled surgical environment.

In addition, other accessories are available with Stellaris EliteTM to further improve upon this already impressive platform. These include the addition of a 27-gauge range of products; and comprehensive visualization technology with light probes, chandeliers, color filters and directional laser probes.

Optimization at its finest

Of course, surgical outcomes are the highest priority when it comes to ophthalmic technology — but efficiency and optimization are important, too. Working closely with surgeons, Bausch

+ Lomb has taken their considerations to heart and optimized the Stellaris EliteTM to be the perfect fit in any operating room with its small footprint; wireless foot pedal; easy set-up, priming and tuning of tubing and handpieces; preassembled, ready-to-use cassette/tubing with a new configuration; and wide range of accessories, handpieces and Storz and Synergetics ophthalmic instruments — all of which are designed to decrease turnaround time.

With all of its advanced tech and accessories, it’s clear that the Stellaris EliteTM is not only a major innovation from Bausch + Lomb, it’s also a reliable partner in the operating theater — from a dynamic company that continues to evolve with both patient and physician needs. The ability of one platform to perform both cataract and vitreoretinal procedures is indeed a look into the future of ophthalmic surgery, with Bausch + Lomb at the forefront of innovation to improve outcomes.

STE.0002.AU.22-RANZCO Sponsored by Bausch + Lomb Australia

PH: 1800 251 150