Cont. on Page 3 >> Experts discuss cataract surgery and comorbidities ... find outOSDsmore. are front and center on Cornea Day!0604HIGHLIGHTSMattYoung CEO & Publisher Hannah Nguyen COO & CFO Gloria D. Gamat Chief Editor Brooke Herron Editor Maricel Salvador GraphicWritersDesigner Andrew Sweeney Matt Herman Customer Care Ruchi Ranga InternationalDevelopmentBusiness Brandon Winkeler Robert Anderson Adam Angrisanio Media MICE Pte. Ltd. 6001 Beach Road, #09-09 Golden Mile Tower, Singapore 199589 Tel.: +65 8186 7677 Email:www.mediaMICE.comenquiry@mediamice.com Published cakemagazine.orgby
the work the ESCRS has done to support Ukrainian medical workers during the invasion of their country by Russia. Ukrainians have been a notable in-person presence at this year’s event with many of them wearing their national costume the vyshyvanka. The ESCRS’s assistance is laudable and a reminder of how we can all help Ukraine at this time.
DMEK, DSAEK and Some Bad Genes
A
One of the symposium’s highlights was a debate over which was the better technique; Descemet’s membrane endothelial keratoplasty (DMEK) versus Descemet’s stripping automated endothelial keratoplasty (DSAEK). Team DMEK was represented by Dr. Jose Güell, associate professor of ophthalmology at Autonoma University (Barcelona, Spain).
On Spotlight at ESCRS 2022
1ISSUE 09 | 17 | 22 CAKE MAGAZINE’S DAILY CONGRESS NEWS ON THE ANTERIOR SEGMENT cataract • anterior segment • kudos • enlightenment
by Andrew Sweeney
Before the first day’s main symposium, Emerging Treatment Options for Corneal Endothelial Disease got underway, a number of slides were projected on the screen, highlighting
year ago the misty dawn broke over Amsterdam’s cold canals and delegates made their way to one of Europe’s most significant ophthalmology events, fewer in number than usual due to the COVID-19 pandemic. Yesterday, as the scorching sun broke over Milan, Italy’s capital of fashion and finance, a flood of ophthalmologists, optometrists and more came to attend the 40th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2022), coming from all over the continent and further abroad. The European ocular healthcare community was back in full force once again.
17 September 2022 | Issue #12 Join us for two Symposia!engaging VISUMAX 800 and What’s in it for me and my patient? Myth or reality? “Digitalization enhances your cataract surgery” Saturday 17 September 2022 1:00 – 2:00 PM Sunday 18 September 2022 09:30 – 10:30 AM
Oliver Findl
Wolfgang Mayer
Nic Reus Supriya Sriganesh
Holger Ruchatz
Save the date
Madonna Al-Dreihi Yves Guldenfels
Dan Z. Reinstein
Liem Trinh
you–WhereversusDSAEKDMEKdostand?
CAKE Magazine’s Daily Congress News on the Anterior Segment 3
study (ETDRS) score of 85 versus 75, respectively, and the same results were maintained at six months.
corneal edema, large pupils, sulcus sutured IOLs, and aphakic patients. We look forward to reviewing the one-year results.
Nature or nurture? It’s in the genes!
Research into the genetic level was also featured during the symposium thanks to a fascinating lecture by Dr. Viridiana Kocaba, a senior clinician scientist and cornea expert at the Netherlands Institute for Innovative Ocular Surgery in Rotterdam. In her report, Is Fuchs’ Dystrophy an Inflammatory Process or Just Bad Genes?
Team DSAEK was represented by Dr. Jesper Hjortdal, an associate professor at Aarhus University’s department of ophthalmology in Denmark, with his presentation, Why is DSAEK Still a Treatment Option? Dr. Hjortdal reported on an ongoing study into the efficacy of DSAEK where his university carried out a randomized clinical study to compare visual outcomes between DMEK and DSAEK after one year, with results recorded at three-month and six-month intervals. The patients selected to participate in the trial were receiving treatment for Fuch’s dystrophy and for Dr.cataracts.Hjortdal reported that while DMEK was more associated with faster visual acuity recovery, there was no difference found between the two techniques when it comes to patient-reported happiness. At the three-month interval, it was clear that DMEK had achieved a better visual outcome more rapidly than DSAEK, with an early treatment diabetic retinopathy
In Europe, an annually.aretransplantations30,000estimatedcorneaperformed
— The European Cornea and Cell Transplantation Registry (ECCTR)
During his presentation, DMEK is the Surgical Treatment of Choice for Endothelial Failure he argued that DMEK was the preferred technique as it represents a developmentsignificant on DSAEK.
condition and the related guttae issues are more prevalent among women and Caucasians, and Dr. Kocaba reported that there has been significant process in finding out why and what genes cause the issues in these affected populations. For example, the TCF4 gene located on chromosome 18 was found to be specifically linked to larger guttae size. This is important, as while guttae can vary wildly in size and shape, the larger the guttae, the more toxic it is to the cornea’s cells.
Dr. Kocaba also reported on another discovery she is hoping to make by analyzing the protein mix composition of the Descemet’s membrane, where there are 300 proteins involved in a number of pathways. The answer as to why cells tend to die around large-sized guttae remains unknown, and it is her hope that by analyzing the Descemet’s membrane an answer will be found. This would also help to explain why in large guttae only one protein is found, food for thought indeed.
Dr. Kocaba postulated that it was a balance of both issues, but that those faulty genes play an oversized part. This issue, she said, becomes particularly visible when one examines how the corneal guttae become larger as the disease progresses, leading to dysfunction of both the cornea’s pumping mechanism and its underlying Bothbarrier.the
Despite the discrepancy, Dr. Hjortdal said that both groups of patients reported satisfaction with visual outcomes and that both groups enjoyed good results with contrast sensitivity too. The trial remains ongoing, and our Danish doctor recommends DSAEK for cases involving
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According to Dr. Güell, the deal breaker is the “risk of graft rejection being reduced by an order of magnitude and better overall optical quality.” While conceding that DMEK still has a risk of rebubbling on the cornea (though that has itself been reduced in risk) DMEK’s key advantages are also that it is ideal as a rescue technique and can be used in a “progressive expansion of its indications.” These include complex eye cases, eyes with glaucoma devices, corneal ‘decompensation’ due to phakic intraocular lenses (IOLs), and more.
Things took a turn for the unique with the final two presentations of the day. Dr. Vincent Borderie spoke about some positive long-term outcomes he is seeing with allogeneic limbal stem cell transplantation. Though the surgery is scoring successes in improving corneal epithelium condition and visual acuity, the procedure remains expensive, and runs risks like infectious keratitis. All in all, Dr. Borderie called for more research.
17 September 2022 | Issue #14
The first step to managing ocular surface diseases starts with the time around surgery, and Dr. Miriam Barbany Rodriguez led off the session with a few hot tips for what can be done before surgery. The main takeaways were that outside of an assessment of the current refractive situation and extensive testing, getting to know the patients and their individual proclivities is king.
Wrapping up the perioperative talk was Dr. Elisabeth Messmer of Germany, who spoke specifically on dry eye. She echoed a lot of Dr. Mencucci’s sentiments in avoiding NSAIDs and preservatives, maintaining lid hygiene, keeping an eye on meibomian gland dysfunction, and considering emerging
Dr. Jesper Hjortdal then went on to overall impacts of corneal surgery on the ocular surface, and then it was on to glaucoma surgery and its impacts on the ocular surface with Dr. Andreia Rosa. Generally speaking, glaucoma surgery and its effects disrupt the health of the ocular surface. A crowd-pleasing takeaway was Dr. Rosa’s throwback promotion of using trabeculectomy for better homeostasis of the ocular surface.
A Cornea Day Keeps Postop Ocular Surface Issues at Bay
C
ornea Day rolled on with more anterior segment action on Day 1 of ESCRS 2022 in Milan, and this time the ocular surface was front and center.
The session ended with an empathetic and heart-warming presentation of improved hope for unfortunate sufferers of ocular graft vs. host disease (OGVHD). Gone are the days when patients must be resigned to blindness or flippant dismissals by the patient’s hemo. Outcomes with scleral lenses and soft bandages are gaining steam, and doctors can achieve the unthinkable with these new treatments and medical interventions like lubrication, drainage, evaporation and inflammation control.
Achieving good results for the patients involve a variety of the above pre-, post-, and intraoperative management techniques for maintaining the ocular surface. Doctors need to be wary of the quality of the ocular surface and tear film, and as the surge in popularity of cosmetic eyelid surgeries increases, so too does the importance of maintaining a database to nip common complications in the bud.
Dr. Rita Mencucci took over from there to talk about intraoperative tips for preventing OSD. She went over issues like corneal incisions (smaller is better), phototoxicity (decreasing surgical duration is critical), eye drops (no NSAIDs or preservatives), and surgical trauma (femto is inferior).
The first day of the 40th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2022) in Milan was host to a themed ‘day’ sessions: Glaucoma Day and Cornea Day. After a riveting first section on comorbidities and cataract surgery, (see article on page 6) the sequel on the ocular surface disease (OSD) proved just as riveting.
by Matt Herman
Cosmetic eyelid surgeries are on the rise with changing beauty standards and Dr. Jutta Horwath-Winter had some words of wisdom for doctors who are seeing a tidal wave of related ocular surface disease.
Perioperative peril
Trends in cosmetic surgery and the corneal surface
Odds and ends with some rare ocular surface birds
La secunda parte continued with your correspondent still wedged in elbow to elbow with seemingly every young ophthalmologist in Europe, much to his chagrin. And as the lights went down and the first speaker struck up the first presentation on ocular surface issues in anterior segment surgery, any hope of a reprieve from the first session’s crowd dimmed as well as an all-star cast of speakers dished out corneal knowledge in abundance.
treatments like intense pulsed light (IPL) therapy.
I
t was back to school for Cornea Day in one of the opening sessions of the 40th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2022) as top doctors went full throttle on comorbidities and cataract surgery…
It was the good stuff first with perhaps the most common and critical comorbidity to consider before cataract complications come about –ocular surface disease (OSD). Dr. Allan Slomovic of the hallowed University of Toronto flew through a flurry of tips about what to consider with diseases like pterygium, epithelial basement membrane dystrophy, and dry eye disease.
Pearls abounded for this wide variety of conditions; remove pterygia with conjunctival autograft first, and stay away from NSAIDs in the perioperative period, to name a few among many. But the main takeaway was to manage patient expectations with OSD before they undergo treatment. As Dr. Slomovic reminded the audience, “if you tell them before surgery, they own it; if they become aware after, it’s all your fault.”
Aquarium amoebas and other miscellanea
If the crowd in Space 3 of the MiCo (Allianz MiCo) – Milano Convention Centre was any indication, the future of ophthalmology burns bright. Your correspondent had to jostle and bump his way through a swelling crowd of young doctors just to find a place to sit.
Imagine – you’re minding your own business, feeding your fish. Suddenly water splashes into your eyes and before you know it, you’ve got amoebas – acanthamoebas, to be exact, and
Getting down with OSD
over the following 90 minutes was nothing less than a masterclass on one of the most complex and wide-ranging topics in anterior segment – what to do with cataract surgeries in the face of comorbidities.
17 September 2022 | Issue #16
Cataract Surgery and Comorbidities with the Maestros
by Matt Herman
The superficial expectation was that this would be just another run-of-themill early-conference session at ESCRS 2022 in Milan, Italy. But the reality was something different. What unfolded
radii ratio is the metric for IOL formulae. And of course, for patients without corneal edema or subclinical corneal edema, it’s best to just go for cataract surgery and avoid DMEK.
Dr. Abi Ablafia of Israel continued with keratoconus and its havoc-wreaking influence on intraocular lens (IOL) power calculation. KC drops IOL power
presentation by Dr. Vincenzo Sarnicola, DALK is quickly replacing more traditional procedures like therapeutic penetrating keratoplasty (TPK) or medicinal interventions. The key to avoiding failure is to identify surgical patients early, move fast, and not waste time with early or late TPK.
calculation prediction accuracy by 80%, but there is some help available despite a relative dearth of research. It is of the highest importance to use a variety of formulae in these calculations, and especially the Kane, Barrett, and SRK/T formulae. But most important of all is patient counseling. And as always, the rule is to underpromise and overdeliver, especially when something as tricky as keratoconus is involved.
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One of the main impacts of the diseased cornea is in IOL power calculation, and the distorting effect corneal diseases like keratoconus (KC) can have on getting it right. For Dr. Gatinel, the placido topograph and aberrometer are useful for higher order aberrations (HOAs) and KC, Scheimpflug and swept-source optical coherence tomography (SS-OCT) for corneal HOAs, high resolution optical coherence tomography (HR-OCT) for KC, and double pass aberrometry for scarring, fibrosis, haze, and loss of transparency.
In one of the more entertaining and enlightening presentations of the day, Dr. Ruth Lapid-Gortzak tackled an extendeddepth-of-focus (EDOF) IOL implantation after corneal refractive surgery. With her ever-present sharp wit and eye for key points, Lapid-Gortzak lamented the lack of research into this topic both now and in the future, and shared data from her own prestigious practice.
When things aren’t so critical, the picture gets a bit clearer, however. Demanding patients are strong candidates for a DMEK-first approach, but crucially true posterior to anterior corneal curvature
Optics and formulae, oh my
The final comorbidity discussed was Fuchs’ dystrophy and cataract refractive surgery. With the cornea’s massive influence on optical power, the primary concern was compensating for this in IOL
that spells trouble for your cornea. Fortunately, there’s deep anterior lamellar keratoplasty (DALK), and it works wonders for patients with acanthamoeba keratitis
It was then on to corneal endothelial disease with Dr. Björn Bachmann, who presented a variety of evidence for clinicians to take into account when considering options with Descemet’s membrane endothelial keratoplasty (DMEK) and cataract surgery. Combined? Sequential? It all depends, according to Dr. Bachmann. For patients with corneal edema and cataract with a significantly reduced quality of life, combined surgery is the go, but with one important caveat. Presumed postoperative posterior to anterior corneal curvature radii ratio must be taken into account for IOL calculation.
CAKE Magazine’s Daily Congress News on the Anterior Segment 7
The optics and its menagerie of tools and gizmos can be bewildering to ophthalmologists of all ages. But Dr. Damien Gatinel made it his mission to clear the air with optics and the diseased cornea. After all, the cornea provides around 60% of ocular power, and this needs to be taken into account .
In the end, she made a call for clinicians to create a database to establish a set of parameters that draw the line between implanting true EDOF IOLs and diffractive premium IOLs. This data would go a long way in helping to solve the currently intractable situation with clinical trials. She also cautioned against asymmetric and refractive IOLs in patients who have undergone refractive surgery, and reinforced a key theme of the session. Patients are more informed than ever before, but doctors still need to be confident in their expertise and the power of saying no.
Ofcalculations.course,with solutions like triple DMEK, the usual risks of immune system rejection, progressive cell loss, and graft failure need to be taken into account. Checking and rechecking measurements like K readings and axis measurements are important, but in the end clinicians need to be aware of the degree of severity of the Fuchs’ dystrophy, especially when deciding on premium IOLs. But the crowd favorite takeaway and tip that elicited the praise of moderators? Pay attention to the peripheral cell count.
IOL mania and Fuchs’ dystrophy
