EuroTimes Vol. 23 - Issue 9

SPECIAL FOCUS CATARACT & REFRACTIVE COMPLICATIONS

September 2018 | Vol 23 Issue 9

THE

OF

CATARACT & REFRACTIVE | CORNEA | RETINA | GLAUCOMA PAEDIATRIC OPHTHALMOLOGY

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Content Editor Aidan Hanratty Senior Designer Lara Fitzgibbon Designer Monica De Iscar Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS

CORNEA

Contributors Maryalicia Post Leigh Spielberg Gearóid Tuohy Priscilla Lynch Soosan Jacob

CATARACT & REFRACTIVE COMPLICATIONS

18 Is eye rubbing the root

Colour and Print W&G Baird Printers

04 In the first of a new

Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org

Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland.

No part of this publication may be reproduced without the permission of the managing editor.

Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance.

ESCRS EuroTimes is not responsible for statements made by any contributor.

These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes.

ISSN 1393-8983

series, we look at the typical complications that can occur in the operating room

potential for stromal regeneration

21 New agents for treating dry eye disease

RETINA

06 Suturing the lens to a

24 New approaches for treating

the 2018 ESCRS Clinical Research Awards

10 Patient-reported outcome measures can help improve overall clinical outcomes

12 Study follows effectiveness of intracameral mydriatic-anaesthetic combination

13 Pars plana vitrectomy can avoid enlarging posterior capsule rupture

examine progression of intermediate-stage AMD

36 Doctors debate which

approach is best in paediatric cataract surgery

geographic atrophy

26 Ophthalmologica update

GLAUCOMA 27 Improved prospects for vision-restoring optic nerve regeneration

28 Stage at diagnosis is key in lifetime risk of blindness from glaucoma

29 More evidence is needed

before adopting screening for glaucoma

30 When is intervention appropriate?

16 Noel Alpins reflects on

PAEDIATRIC OPHTHALMOLOGY

17 JCRS highlights

31 Doctors learn from

decades working to improve astigmatic outcomes

As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2016 and 31 December 2016 is 43,593.

20 Cell therapy shows exciting

22 European-wide project will

08 Announcing the winner of

P. 47

cause of keratoconus?

CATARACT & REFRACTIVE capsular tension ring can prevent movement in large eyes

www.eurotimes.org

REGULARS 38 ESCRS/Alcon Fellowship 39 Book reviews 40 Hospital diary 41 ESCRS news 43 Vienna charity run 45 Project management 47 Exploring Athens 49 Industry news 51 Young ophthalmologists 53 My mentor 55 Calendar

Supplement September 2018

a mock trial

Included with this issue...

34 What was the cause of

a painless swelling of a young boy’s upper lid?

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2

EDITORIAL A WORD FROM OLIVER FINDL MD, MBA, FEBO

GUEST EDITORIAL

Salt in the soup ESCSRS aims to mentor young ophthalmologists, says Dr Oliver Findl

Oliver Findl

MEDICAL EDITORS

I

am very honoured to welcome friends and colleagues to the 36th Congress of the ESCRS in Vienna, Austria.

This is the third time the ESCRS has hosted the Congress in Vienna.

In 1999, when ESCRS first visited my home town, Dr Thomas Neuhann was president of the society. It is fitting therefore, that we should return to this beautiful city to deliver the inaugural ESCRS Heritage Lecture at our 36th Congress.

That year, at the XVII Congress of the ESCRS we also honoured the great Harold Ridley with the ESCRS Grand Medal of Merit on the occasion of the 50th anniversary of the intraocular lens.

HOW TIME FLIES!

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

INTERNATIONAL EDITORIAL BOARD Noel Alpins (Australia), Bekir Aslan (Turkey), Roberto Bellucci (Italy), Hiroko Bissen-Miyajima (Japan), John Chang (China), Béatrice Cochener (France), Oliver Findl (Austria), Nino Hirnschall (Austria), Soosan Jacob (India), Vikentia Katsanevaki (Greece), Daniel Kook (Germany), Boris Malyugin (Russia), Marguerite McDonald (USA), Cyres Mehta (India), Sorcha Ní Dhubhghaill (Ireland) Rudy Nuijts (The Netherlands), Leigh Spielberg (The Netherlands), Sathish Srinivasan (UK), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Marie-José Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy)

EUROTIMES | SEPTEMBER 2018

The second visit to Vienna was in 2011, when we convened the XXIX Congress of the ESCRS. I had the honour that year, during the presidency of Dr José Güell, of becoming the chairman of the newly formed Young Ophthalmologists Committee.

This month, when we meet for the third time in Vienna, I will have the privilege and honour of meeting many of those who served on that first Committee.

One of the great achievements of the ESCRS over the past eight years has been the development of excellent education resources for our trainees including iLearn, the Peter Barry Fellowship, the EuroTimes Eye Contact Videos and ...while I get great the Observership pleasure from my programme.

As I have said work as a surgeon and before, while I get researcher, teaching great pleasure from my is “the salt in the work as a surgeon and soup”, where I get the researcher, teaching is “the salt in the opportunity to work soup”, where I get the with enthusiastic young opportunity to work trainees and students with enthusiastic young trainees and students.

The YO Programme continues to go from strength to strength and we look forward to another excellent programme in Vienna.

Finally, even though the congress centre will be the main focus of attention, I would like to encourage you to visit some of the sites of Vienna. Vienna’s coffee house tradition dates back more than 300 years, so relax and enjoy a good cup of coffee and some nice pastries in one of the numerous Viennese cafes!

Oliver Findl MD, MBA, FEBO, is secretary of the ESCRS, chairman of the Young Ophthalmologist Committee, Chief of the Department of Ophthalmology, Hanusch Hospital, Vienna, and founder of the Vienna Institute for Research in Ocular Surgery (VIROS), Vienna, Austria.

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SPECIAL FOCUS: CATARACT & REFRACTIVE COMPLICATIONS

THE OF

In the first of a new series, Soosan Jacob MD looks at the typical complications that can occur in the operating room

omplications – the most dreaded event within a surgical suite.

Something that we all wish doesn't strike us or the patient we are handling. But this remains an unattainable dream, as every ophthalmic surgeon – be it the novice or the veteran – has complications in one form or the other; major or minor, EUROTIMES | SEPTEMBER 2018

intraoperative or postoperative, objective, “clinically apparent”, or subjective, “within-the-patient’s-mind”.

Every one of us faces complications and strives hard to manage as well as avoid future similar situations.

Prevention of complications and better surgical outcomes is also something that every innovator aspires for with newer surgical techniques and devices. In fact, it may not be entirely incorrect to say that without complications, there would not be any surgical progress!

The most important thing to do for complications is to prevent them. So, how do we do this? One thing is to be aware that complications can occur anywhere, at any time. Statistics are bound to catch up with everyone, but with practice and conscious effort and by avoiding shortcuts, they can be prevented.

I remember the first time, about two decades ago, when I was assigned to perform unsupervised, what we euphemistically call a relatively difficult case – a small pupil with a hard cataract.

SPECIAL FOCUS: CATARACT & REFRACTIVE COMPLICATIONS I thought I was prepared enough as I had done similar cases under supervision. But my confidence was shattered and my ego took a dive when I had a posterior capsular rent and didn’t recognise it until my mentor, who was watching from another room over a closed-circuit system, came to the OR, told me to get up and took over.

Adding insult to injury, my name was missing from the surgical list for a month and a half. Although I was disappointed at the time, it gave me time to introspect, reflect and learn to respect the eye and its complexities. It also made me resolve to educate myself about every aspect of surgery, including recognising and managing complications.

The first step towards this common goal that every ophthalmic surgeon has, is to know the procedure, possible complications and management strategies as well as putting in sufficient practise.

It is advisable to go step by step, without skipping any, and in the hands of an expert, each step soon becomes second nature. Similar to the ‘10,000-Hour rule’ propounded by Malcolm Gladwell for becoming an expert, the more one practises, the better one becomes.

Analyse possible complications when going through steps mentally. Knowing possible complications and step-by-step analysis of the means to tackle these will help you avoid becoming flustered or panicky during an actual incident.

As an ophthalmic surgeon, it is also important to be familiar with equipment and settings. One should try and become familiar with any new equipment and should not shy away from asking “foolish questions”.

The second step is to know the patient – to spend some time not only seeing the patient’s eye but also the patient as a whole. Simple things like knowing patient expectations and setting attainable ones, explaining expected surgical outcomes and risk of complications, taking care of systemic conditions like diabetes, hypertension etc, checking for known allergies, avoiding situations leading to positive vitreous pressure etc, help avoid many complications as well as postoperatively unhappy patients. Equally important is to go through a mental checklist, take a time-out just prior to surgery and then to try and perform surgery meticulously and to the best of one’s abilities. Calling for help when required and knowing when a referral is needed are also important – such as calling in a vitreo-retinal surgeon in case of a nucleus drop.

It should be remembered that complications can be per-procedural or post-procedural. The surgeon’s job is not over with the surgery. When a complication does occur, communication with the patient becomes crucial and it is important to explain the steps taken and the possible outcomes. The patient should be made partner to the medical

Figs A-D: A posterior capsular rent occurs in a posterior polar cataract

Important lessons are knowing the environment and being aware of threats and opportunities as they come care as he/she is the most important stakeholder. Postoperative follow-up and care, appropriate medications and finally a good refraction and spectacle prescription if indicated is important.

Remember, the patient ultimately wants to be able to see clearly and not just be a beautiful clinical photograph.

Watching someone else manage a complication is one way to learn prevention and management; however, at times the surgeon actively managing the situation may not be in a position to explain steps taken.

Informative didactic articles and instructive YouTube surgical videos are also other effective ways to learn about complications. Sun Tzu’s The Art of War, which was written more than 2,000 years ago, and Karen McCreadie’s brilliant adaptation of it to the business world, can also be relevant in an ophthalmic OR when managing complications.

Important lessons are knowing the environment and being aware of threats and opportunities as they come.

Sun Tzu says: “The general who loses a battle makes but few calculations beforehand.” Availing of favourable circumstances and being willing to modify strategy when required are essentials. He also advises selecting and marshalling

one’s team properly, training them well, giving responsibilities for each team member and respecting their work.

Attention to details, however small, matters in a crunch situation.

Another important aspect of managing complications learning to act fast. However, undue haste as much as undue delay should be avoided. The big picture, as well as longterm effects rather than short-term ones, should be considered before any decision.

The surgeon should be able to control his irritation and stress and remove emotion from strategy. Recklessness, holding back and doing nothing and a hasty temper can all be pitfalls. Integration of expertise is essential, such as calling in a retinal specialist when necessary.

In the ensuing issues of this column, I will try and familiarise the reader with different complications an ophthalmic surgeon might face in cataract or refractive surgery and how to approach these. There may be many techniques and this column will try to simplify them and make them more easily understandable.

Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India, and can be reached at dr_soosanj@hotmail.com EUROTIMES | SEPTEMBER 2018

5

CATARACT & REFRACTIVE

How to deal with IOLs in large eyes DISCOVER

Suturing the lens to a capsular tension ring can prevent movement in large eyes. Howard Larkin reports

T

he 50-year-old male patient presented with cataracts, high myopia and high astigmatism in both eyes. He wanted a multifocal intraocular lens. But with his high astigmatism the only viable choice was a bi-toric plate haptic IOL from Zeiss that is available in cylinder powers up to 12 dioptres, Claudio Orlich MD told the American Society of Cataract and Refractive Surgery 2018 Annual Symposium in Washington DC, USA. The patient’s high myopia also meant large eyes, with axial lengths of 25.8mm right and 26.86mm left. “That is a big bag for a small lens,” raising the risk of post-surgery IOL rotation degrading visual acuity, said Dr Orlich, of San José, Costa Rica.

Courtesy of Claudio Orlich

6

The knot of the suture between the capsular tension ring and the IOL is made near the main incision avoiding the introduction of instruments in the anterior chamber

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One day after surgery the IOL had rotated so much that visual acuity was 20/100. So Dr Orlich waited a week for the capsular bag to contract and rotated the lens back into position. The next day visual acuity was 20/25 and the patient satisfied – but four days later the lens rotated again. “Already we had two surgeries and the patient was not very happy,” Dr Orlich recalled.

After waiting two more weeks, a third rotation resulted in 20/20 vision, which held for a month. The patient was ecstatic and asked “When can you do the other eye?”

Rather than waiting weeks after implant for the capsular bag to shrink, Dr Orlich focused instead on bulking up the lens complex inserted into the capsular bag. His solution was suturing the lens to a capsular tension ring.

Dr Orlich placed a nylon 10-0 suture through one haptic of the lens, and then inserted the lens into an injector. Using forceps designed for placing implantable collamer lenses, he pulled the suture into the anterior chamber before injecting the lens to avoid cutting it during injection. The haptic without the suture went into the bag, leaving the haptic with the suture outside.

Dr Orlich then injected a capsular tension ring into the bag behind the lens and sutured it to the lens. Inserting the sutured haptic into the bag and rotating the lens into place completed the manoeuvre. The outcome was 20/20 and a very happy patient.

“After this case I have been using this technique in all cases that have more than 24.0mm diameter,” Dr Orlich said.

Other surgeons have since adopted the technique for stabilising toric IOLs in larger eyes, he reported.

Claudio Orlich: orlichclaudio@hotmail.com

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CATARACT & REFRACTIVE

Genomics in cornea care Genomics study for the accurate diagnosis of corneal infection wins 2018 ESCRS Clinical Research Awards. Gearóid Tuohy reports

D

r Davide Borroni MD, from the Fondazione Banca degli Occhi del Veneto, Italy, has won the 2018 ESCRS Clinical Research Awards.

Dr Borroni’s research project will look at the potential for genomics technology to more rapidly and accurately identify corneal infectious agents in order to guide clinical management.

The ESCRS Clinical Research Awards, now in its seventh year, provides research funding of up to €750,000 over a threeyear period and is open to all ESCRS members (with at least three years’ ESCRS membership) and a full-time clinical/ research post at an EU-based clinical or academic centre. The Awards are designed to support, encourage and fund individuals that actively conduct clinical research in the field of cataract and refractive surgery, and to facilitate and support an independent culture of clinical study for the ultimate benefit of improving patient care and outcomes.

Dr Borroni, a graduate of Insubria University, Varese, Italy, undertook specialist ophthalmic training in Rīga Stradiņš University, Latvia, where, working with Prof Guna Laganovska, he developed an interest in the practical use of genomic technology in clinical care. His surgical interests include cataract, refractive surgery and corneal transplantation, while his clinical interests include translational medicine, corneal diseases and infections.

In 2016 Dr Borroni completed a training in medical and surgical cornea, the year after joined The Venice Eye Bank Foundation and The Royal Liverpool University Hospital to develop new diagnostic methods for corneal infections. Currently he is undertaking a surgical fellowship in cornea, refractive surgery and advanced ocular surface disease at The Royal Liverpool University Hospital in the St Paul’s Eye Unit.

The novel research to be funded by the ESCRS will be focused on the use of whole genome sequencing technology to study ocular surface microbial communities directly in their natural environment.

Dr Borroni told EuroTimes: “Ocular infections are an important cause of ocular morbidity and worldwide blindness.

Diagnosis of these infections is challenging due to low specificity and sensitivity of currently available assays, inability to collect suitable clinical samples and difficulty for many clinicians to recognise and treat ocular infections appropriately. Rapid advances in sequencing technology and bioinformatics have made metagenomics a fertile area for developing clinical diagnostics and therefore prompted us to evaluate a hypothesis-free approach to identify ocular infections by performing unbiased metagenomic deep sequencing on clinical samples.”

Metagenomics refers to a field of research that is fast becoming a central tool for identifying a broad range of organisms through their unique genetic sequence. In broad terms, the approach refers to the use of high-throughput DNA sequencing to provide taxonomic and functional profiles of microbial communities without the need to culture the microbes in the lab. Dr Borroni explained that “less than 2% of bacteria can be cultured in the laboratory and therefore metagenomics tries to overcome this by developing and using culture-independent approaches to identify the 98% of microbes that resist culture techniques – whether they are prokaryotes, eukaryotes or viruses”.

A fundamental aspect of the proposed research aims to use the hypothesis-free approach facilitated by metagenomics to directly identify infectious agents and then use such information to guide clinical management. At present, patients with corneal infections are treated with a broad spectrum of antimicrobial agents while

laboratory culture techniques attempt to grow and identify the bacterial or fungal agent causing the infection. Oftentimes such techniques may either fail to detect an agent or simply take too long to provide a clinically useful result.

Instead of trying to culture the infectious agent or use defined polymerase chain reaction (PCR) primers to fish out known pathogens, Dr Borroni’s approach will follow a “shotgun” strategy whereby a corneal scrape will be taken, to which the metagenomics approach will aim to sequence everything that is in the patient’s sample.

The genetic information obtained will be cleaned of human DNA sequence and then compared with the genetic microbial profile of a normal eye. The result should provide a quantitative picture of gene signatures detectable in the infected eye, allowing the clinician to identify the likely causative agent and then determine the optimal medical management.

Dr Borroni’s research project, entitled “METAgenomics guided treatment of CORneal infections – a blinded interventional randomized clinical trial” (META-COR), will recruit an estimated 160 patients and will involve a team of up to 15 ophthalmologists across several EU locations including sites in Latvia, Italy, United Kingdom, Sweden, Greece, Austria and Spain and the University of Maryland in US. The main clinical centre will be at the Royal Liverpool University Hospital under the supervision of Prof Stephen Kaye and Mr Vito Romano, and the laboratory for the Metagenomics study will be the Centre for Integrative Biology (CIBIO) at University of Trento (Italy) under the supervision of Prof Nicola Segata. EuroTimes will aim to update readers on the progress of this exciting study as results become available.

Davide Borroni: Davide.Borroni@fbov.it

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CATARACT & REFRACTIVE

Patient-reported outcome measures Large-scale data collection shows why patients may be unhappy after surgery. Aidan Hanratty reports

T

aking account of patient-reported outcome measures can help improve overall clinical outcomes, Professor Mats Lundström told the 22nd ESCRS Winter Meeting in Belgrade, Serbia. He described a variety of approaches to measuring data and how best to measure patient-reported outcomes.

The goal is to compare patient-reported outcomes with clinically reported outcomes, seeing how and why discrepancies between the two may arise.

Questionnaires are formulated with great attention paid to varying items, such as the degree of difficulty a patient faces in performing various tasks. The questionnaires follow the Rasch model of item response theory, which helps create interval data to differentiate between different strata of patients.

In the case of the Catquest-9SF study, a nine-item, shortform questionnaire for measuring patient-reported outcomes of cataract surgery, questions were asked on the difficulty of different

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10

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tasks: from reading text in newspapers and watching television to recognising faces in the street and reading the price of goods while shopping. Also considered was satisfaction with sight preoperatively, across a range of four options. The same questions were then asked after surgery.

The results showed that in most cases – 90.5% – both clinically reported outcomes and patient-reported outcomes were positive.

In 1.7% of cases clinical outcomes were negative while patients were happy with their postoperative vision. In just 0.5% of cases both clinical and personal outcomes were poor, while in 7.4% of cases, clinically reported outcomes were positive, but patients were unhappy.

Prof Lundström explained that upon investigation of the data, researchers learned that many of these patients were most likely myopic before surgery, with good reading ability. After surgery they Mats Lundström were rendered emmetropic, so they could read the chart, but were unable to read up close without glasses, which they could do before surgery.

Such discrepancies arise when doctors look at what they regard as excellent clinical outcomes without taking into account the patient’s own expectations and requirements.

Prof Lundström described the various methods of data collection, detailing optimal timing and patients for selection. Examining the data, he showed how one clinic had problems related to complications during surgery or anisometropia: “They operate in one eye and then waited half a year and then took the other eye, and if you live for half a year with anisometropia and answer the questionnaire you are not happy.”

About 7,000 questionnaires are completed each year in the National Swedish Registry, with postoperative responses from 75-80% of these. The results are published openly, so that all participating clinics can see where they fare. “No one wants to be in the lower end of the outcome. So, it’s a good thing.”

Mats Lundström: mats.lundstrom@karlskrona.mail.telia.com

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The European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) has included Catquest-9SF for cataract surgery and QIRC for refractive surgery and all ESCRS surgeons are welcome to join and test their patients’ opinion about the outcome to be compared with the clinical outcome http://www.eurequo.org

12

CATARACT & REFRACTIVE

Intracameral mydriasis Intracameral mydriatic-anaesthetic combination performs as expected in real-world setting. Roibeard Ó hÉineacháin reports

T

he intracameral mydriatic and anaesthetic Mydrane (Théa Pharmaceuticals) appears to provide fast and stable mydriasis during cataract surgery in the great majority of cases, according the findings of an observational register trial, said Dariusz Kęcik MD, PhD, Medical University of Warsaw, Poland.

“The study’s results confirm that stable mydriasis may be achieved after a single, intracameral administration of Mydrane at the beginning of cataract surgery, without preoperative dilatation in a real-world setting,” Prof Kęcik told the 22nd ESCRS Winter Meeting in Belgrade, Serbia.

The trial commenced in February 2017 and included 307 patients who underwent cataract surgery at seven university clinics in Poland. The patients’ co-morbidity profile was typical of the age-group usually referred for cataract. Forty-one patients

had glaucoma, 13 had dry AMD, six had neovascular AMD and 36 had other eye diseases. Non-ocular comorbidities included hypertension in 241 patients, diabetes in 72, prostate disease in 29 and depression in 17.

All eyes had pupils that were capable of dilatation to 6.0mm or more during preoperative assessment. The participating surgeons recorded patients’ pupil diameters just prior to the intracameral injection of Mydrane and at key moments of the operation. In addition, immediately after surgery, the operating surgeons’ recorded their opinions on the time to obtain mydriasis and the stability of mydriasis on a five-point Likert Scale, Prof Kęcik explained.

The researchers found that the mean pupil diameter was 2.35mm prior to dilatation, 7.0mm just before capsulorhexis, 6.9mm just before implantation of the intraocular lens and 6.6mm just before the end of the surgery, Prof Kęcik said.

In 92% of procedures, surgeons reported that they agreed or strongly agreed that mydriasis was obtained quickly after administration, and in only 1% of procedures did surgeons strongly disagree. In addition, in 88% of procedures, surgeons said that they agreed or strongly agreed that mydriasis remained stable throughout the operation.

Mydrane was introduced to the market in 2015. It is the first ready-to-use, standardised, commercially manufactured intracameral mydriatic-anaesthetic combination indicated for cataract surgery.

It is now approved in several European countries, including Poland. It contains tropicamide 0.02%, phenylephrine 0.31% and lidocaine 1% and is designed for intracameral administration directly after the first cataract surgery incision.

“Mydriasis obtained during cataract surgery was fast and stable in nearly 90% of cases in the opinion of surgeons,” Prof Kęcik added.

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CATARACT & REFRACTIVE

Tackling posterior capsule rupture Pars plana vitrectomy can avoid enlarging posterior capsule rupture.

Howard Larkin reports

S

ooner or later every cataract surgeon will face a posterior capsule rupture. Managing the resulting vitreous loss using a pars plana, rather than an anterior, vitrectomy is more likely to produce a better outcome, Samaresh Srivastava DNB told the American Society of Cataract and Refractive Surgery 2018 Annual Symposium in Washington DC, USA. Approaching the prolapsed vitreous from the posterior is less likely to expand the rupture than an anterior approach, noted Dr Srivastava, of Raghudeep Eye Hospital, Ahmedabad, India. As a result, a pars plana approach will more often leave enough of the capsule intact to create a symmetric, uniform IOL platform, leading to a stable, centred IOL.

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ADDITIONAL DAMAGE While an anterior vitrectomy approach may seem more familiar to cataract surgeons, it tends to pull the vitreous body forward, often widening the rupture and pulling additional vitreous into the anterior chamber. What was a small rupture at the beginning becomes a ragged rupture by the end of the surgery, Dr Srivastava said. This additional damage to the capsular bag can require fixating the lens in the sulcus, which is less than optimal.

By contrast, a pars plana vitrectomy tends to pull the vitreous posteriorly, Dr Srivastava said.

“Whatever vitreous is there tends to prolapse back into its own cavity in a very elegant fashion.”

Often, the posterior capsule rupture can be converted to a posterior capsulorhexis to preserve the integrity of the bag.

Any vitreous left behind can then be cleaned up from the anterior. A pars plana vitrectomy also can be done for tears after the IOL is implanted, he added.

BE PREPARED AND DON’T PANIC Dr Srivastava recommended that cataract surgeons learn the pars plana approach. He also suggested preparing a vitreous loss kit, including a vitrectome, microforceps, trocar cannula system, high-molecular weight dispersive viscoelastic, triamcinolone, pilocarpine and capsular tension ring, to have on hand for every cataract surgery.

“The best thing to do in the event of posterior capsule rupture is stay calm. Do not pull out instruments in panic.

The moment you pull out the instrument, the anterior chamber collapses and more vitreous prolapses out into the anterior chamber, and the posterior capsule rupture, if it was small, will become large and it will become an unmanageable situation,” Dr Srivastava warned.

Instead, lower the bottle height and inject dispersive viscoelastic to tamponade the vitreous loss, and triamcinolone to make the vitreous visible. Use good lighting and instruments to manipulate the eye to ensure all vitreous in the anterior is removed, he advised.

“A pars plana approach compared to limbal approach can give a predicable outcome and a favourable lens position most often,” Dr Srivastava concluded.

Samaresh Srivastava: samaresh_srivastava@yahoo.com

Dr. Juan Carlos Izquierdo

Dr. Victor H. Gonzalez

Dr. Loic Bazin

Complete agenda available at endooptiks.com or BVI Booth B410

ESCRS & EURETINA 2018 22 September, 2018

Date: Location:

Mozart Meeting Room Mezzanine D, Level 1 Congress Hall

Registration:

17:15 – 18:00

Course:

18:00 – 20:00

Food and beverages will be provided throughout this exciting course!

Register NOW at endooptiks.com

ESCRS Booth B410

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EUROTIMES | SEPTEMBER 2018

13

14

ADVERTISING FEATURE

BENEFITS OF A NEW STATE-OF-THE-ART IOL INJECTOR Five renowned surgeons report their experience with Medicel‘s new IOL injector ERGOJECTTM injector very close to the eye only using one hand.

ERGOJECT allows me to rest my hand on the patient‘s forehead and operate the injector very close to the eye only using one hand.

John Bolger MD My-iClinic North London, UK It was immediately clear to me that the ERGOJECT system is a much safer and more precise device for IOL implantation. I use a 1.8mm incision and the previous devices could eject the IOL in an uncontrollable manner.

„With the ERGOJECT, the speed of the implantation is completely controllable “ With the ERGOJECT the speed of the implantation is completely controllable. There is no sudden explosive movement of the IOL and it can be directed safely directly into the bag. I personally prefer to have the ratchet engaged for injection but it also works beautifully without it. I have now changed entirely over to using the ERGOJECT. José Luis Güell, MD Institut de Microcirurgia Ocular Barcelona, Spain I have used Medicel’s ERGOJECT injector for lens implantation on a regular basis for several months and generally the injector works extremely smoothly regardless of IOL type. I also use the ERGOJECT for my DMEK cases and found similarly excellent results.

Handling the injector only 2-3cm away from the limbus ensures much higher control and security compared to a push injector, which is held 6-7cm away from the eye and pushed with the thumb.

This way, it is much easier to compensate for uncontrolled patient eye movement during implantation without sliding the cartridge out of the incision. The analogy of a painter explains the advantage of this position. If you want to paint a picture, you would never hold the brush at the proximal end of the handle 7cm away from the picture. Rather, you would hold the brush close to its distal end. Consequently, it is also completely illogical to hold an injector at a distance of 7cm away from incision when the best results are achieved when the injector is held closer. The ERGOJECT allows me to rest my hand on the patient‘s forehead and operate the

This style of handling is much more secure than the style when using classical push injectors.

Even more important is the highly precise advancement of the lens allowed by the use of the index finger instead of the thumb.

The control provided by the ERGOJECT is comparable to that of a screw injector but only requires the use of one hand to operate.

Compared to using thumb operated injectors, the index finger method provides maximum movement control and accuracy.

Having full control and a free hand for an additional instrument allows me to position my implant at the intended position every time, saving time by eliminating the need for repositioning.

The precision that comes from one-handed implantation is also an advantage for my DMEK surgeries. Full control during graft implantation enables me to better position the delicate graft in the anterior chamber, allowing for easier unfolding.

I am very happy that Medicel and I were able to modify the ERGOJECT together so that it works perfectly for DMEK in addition to other operations. This DMEK injector, named the Güell DMEK injector, will be commercially available in the near future.

Gilles Lesieur MD, Ophthalmologic Center Iridis Albi, France I used the Medicel’s new injector ERGOJECT for the first time a couple of months ago. As a BMICS surgeon, I usually load IOLs using the wedge assist technique so I was very interested in seeing improvements in the lens injection system. The injection of hydrophobic IOLs is very challenging to preserve an incision size under 2mm.

Medicel‘s VISCOJECT-BIO 1.8 Injection System works quite well in my daily practice, but I feel a stronger resistance using high power lenses during injection. In the beginning of 2017, I tried out the new ERGOJECT Injection System for the first time. After the initial trials it was clear to me that ERGOJECT was revolutionary compared to the other injectors available on the market.

What features stood out for the ERGOJECT eg. 1.6 or 1.8?

The loading chamber is bigger and helps enhance the manipulation of the IOL. Therefore, I can avoid problems such as leaving marks on the IOL. In micro-incision surgery, specifically wound-assisted surgery for example, it is very important to control the injection process and eliminate any back-motion of the IOL especially when you turn the wheel a second time.

ADVERTISING FEATURE

„In my opinion, ERGOJECT is the best injector available for MICS lenses.“ Hydrophobic IOLs like MicroPure PhysIOL® are easier to load into the anterior chamber. With the appropriate wheel position, the IOL can be loaded in one step without any risk of wound contact.

ERGOJECT allows for efficient, secure, and effortless loading of hydrophilic and hydrophobic acrylic MICS lenses. In my opinion, this is the best injector available for MICS lenses. I would certainly recommend it for all your crystalline lens surgeries - make it your choice!

Prof. Cyrus Tabatabay Clinique Générale-Beaulieu Geneva, Switzerland ERGOJECT is the smoothest and most controllable injector system I have used. There are no unintended moves or surprises due to a direct relationship between screw movement and the IOL advancement.

Regardless of the size, any incision performed in the clear cornea harms the endothelial cells and changes the refraction due to transient increased thickness of the cornea. For these reasons, I use small limbal incisions for phacoemulsification. The size of the incision is crucial in limbal incisions to reduce swelling and bleeding of the conjunctiva; ERGOJECT allows me to use a limbal 1.6mm incision and insert the cartridge tip into the capsular bag with unprecedented control. In my opinion Limbal surgery is the future of cataract surgery – and ERGOJECT is the key.

„ERGOJECT is the key for further development in cataract surgery“

Patients paying a premium for multifocal or toric IOL require safe and perfect results immediately. Even a small wrinkle or corneal oedema due to the tunnel can negatively influence vision for weeks.

Post- op Biometry done on an incised cornea cannot be precise as the cornea is impacted during surgery. ERGOJECT and limbal incision allows me to offer a better and faster service to my post-op patients: Rapid visual results.

With the foundation T.E.S. (tesfoundation.org), I’m travelling to teach ophthalmologists in the Indian Ocean countries. It’s important for me to use the same products supporting my techniques anywhere I go. ERGOJECT is available in most countries globally and compatible with many hydrophilic IOL’s. I can perform and teach surgical procedures, (i.e limbal incision) with familiar equipment and can be sure that the fellows have access to the same products no matter where they work.

tunnel. Now, I can perform the same procedure without creating a large incision.

„It also offers advantages for both hydrophobic and hydrophilic IOLs.“ For hydrophobic IOLs, the internal gear provides more pressure to deliver the IOL through the cartridge tip. Because of this, I can avoid enlarging the incision even for higher diopter hydrophobic IOLs. For hydrophilic IOLs, the gear-drive mechanism allows for a more controlled advancement of the IOL, preventing the IOL from „jumping“ into the eye.

Additionally, the loading chamber of the ERGOJECT is larger and opens more easily than in other injectors. Therefore, I can now delegate the loading process to my OR technician or nurse with reduced instruction and training. Now, all my IOLs are preloaded for me - no matter how they were provided by the supplier.

ERGOJECT not only speeds up the IOL preparation, but also offers options for improving surgical efficiency. For example, the IOL implantation with ERGOJECT is fully one-handed. Now with the option of using my free hand, I no longer need to fill the anterior chamber with OVD during IOL implantation in straight-forward cases. After cortical clean-up and capsular polishing with the bimanual I/A cannula, I can simply keep the irrigation cannula (with my non-dominant hand) in the side-port. The nurse then places the ERGOJECT into my dominant hand and I can start IOL injection without taking my eyes away from the binoculars.

„It shortens the total time of my cataract procedures. I can do more cases in the same amount of time or go home earlier to enjoy my free time“ The combination of perfect control, smaller incision size, easy IOL loading, and one-handed technique improves the quality and shortens the total time of my cataract procedures….. What an injector!

ERGOJECTTM Ergonomic position of injector, held like a pen

Interlock switch for selection of operating mode

Drive wheel close to the eye, operated by the index finger

Florian Sutter MD Eyecenter Herisau, Switzerland I have used Medicel’s ERGOJECT injector for lens implantation on a regular basis for several months.

Using the ERGOJECT one-handed screw injector has greatly improved my cataract surgery experience. When I first saw Medicel’s ERGOJECT injector, my initial thought was: „Why another injector? the ones I use work just fine for me” Well, I was wrong. First, I can implant the same IOL’s through a smaller incision using the ERGOJECT novel screw-type injection system.

Previously, I often had to open the wound from 2.2mm to 2.4/2.5mm to implant the IOL through my limbal/sclerocorneal

Variable cartridge sizes from 1.6 to 3.0mm

www.medicel.com info@medicel.com

Integrated gearbox

15

CATARACT & REFRACTIVE

A lifetime quest A new book gathers together several decades of work by Prof Noel Alpins that seeks to improve astigmatic outcomes. Dermot McGrath reports

I

n the mid-1980s, around the time that Ronald Reagan was in the White House and extracapsular cataract surgery was still being widely performed, a young Australian ophthalmologist called Noel Alpins gave his first talk on astigmatism to a gathering of colleagues in Melbourne.

The topic of Alpins’ talk was dynamic vector analysis, inspired by long hours spent removing sutures after cataract extraction so as minimise or rotate the astigmatism for optimal outcomes.

Looking back at that moment, Prof Alpins said that he “realised then that there was a significant amount of mathematical and scientific evaluation required to quantify and improve astigmatic outcomes”.

What he didn’t perhaps Single-angle polar plots as they appear on an eye based on the Alpins Method of astigmatism analysis realise, however, was just how much time he would devote to unravelling the deeper mysteries of vector analysis and astigmatism calculation.

To help redress the balance, Prof Alpins has now gathered Since his first scientific paper on the topic in 1993, Prof together all of his published papers, book chapters and other Alpins has continued to expand and refine his thinking on articles into one comprehensive volume, Practical Astigmatism: the subject in numerous peer-reviewed articles. Although his Planning and Analysis, which has just been published. The methodology slowly gained traction among colleagues, it still 24-chapter compendium is designed to serve as a definitive, took several decades for the “Alpins Method” to reach its comprehensive and accessible reference document on current level of recognition as the “best allthe Alpins Method and all of the developments that have round interpretation” (in the words of Dan followed from it.

Z Reinstein) for analysing astigmatic Prof Alpins said that the book is designed to give ophthalmologists outcomes. a deeper understanding of the techniques underpinning the Alpins Official establishment recognition Method and how they interrelate with each other. has also followed suit. The Alpins “I do feel that I have taken analysis of vectors to new heights for Method has now been adopted by both the corneal and refractive measures of astigmatism, and that the major journals, my work helps put the eye-care community on the same page when including the Journal of it comes to planning and analysing astigmatism associated with Cataract and Refractive both refractive and cataract/intraocular surgery,” he said.

Surgery, the Journal of After a lifetime of searching for answers, Prof Alpins is Refractive Surgery and confident that the current version of the Alpins Method will Ophthalmology, as the ultimately stand the test of time. standard means for the “I simply do not feel that a better way will be found for astigmatism reporting of astigmatic analysis. I believe that the Alpins Method will continue to grow results published in them. in importance in concert with an increasing Prof Alpins is the first awareness of the method within the eye-care to acknowledge, however, community,” he said. that understanding the Noel Alpins: alpins@newvisionclinics.com.au Alpins Method is no easy task. “I believe that far more ophthalmologists do not Practical Astigmatism Planning and Analysis understand it versus the http://bit.ly/eurotimes-alpins number who do,” he says.

Noel Alpins

I do feel that I have taken analysis of vectors to new heights for both the corneal and refractive measures of astigmatism

EUROTIMES | SEPTEMBER 2018

Courtesy of Noel Alpins

16

CATARACT & REFRACTIVE

THOMAS KOHNEN European editor of JCRS

JCRS HIGHLIGHTS VOL: 44 ISSUE: 7 MONTH: JULY 2018

ANTERIOR OR POSTERIOR CHAMBER IMPLANTATION? Researchers compared anterior chamber implantation and posterior chamber implantation in 95 patients with absence of capsular support undergoing iris-claw IOL implantation. Fifty-seven patients had prepupillary implantation and 38 patients had retropupillary implantation. Regardless of location, the iris-claw IOL provided good visual outcomes with few complications. However, there was greater endothelial cell loss and CME (cystoid macular oedema) seemed to appear earlier with prepupillary IOL implantation than with retropupillary IOL implantation. R Touriño Peralba et al., JCRS, “Iris-claw intraocular lens for aphakia: Can location influence the final outcomes?”, Volume 44, Issue 7, Pages 818-826.

NEW PREMED RESULTS Subconjunctival triamcinolone acetonide effectively prevents the occurrence of CME after uneventful phacoemulsification in diabetic patients, whereas intravitreal bevacizumab had no significant effect, according to the latest report from the PREMED research group. The multi-centre study randomised diabetic patients having phaco to receive no additional treatment, a subconjunctival injection with 40mg triamcinolone acetonide, an intravitreal injection with 1.25mg bevacizumab or a combination of both. At six and 12 weeks postoperatively, the central subfield mean macular thickness was 12.3μm and 9.7μm lower, respectively, in patients who received subconjunctival triamcinolone acetonide than patients who did not. No patient who received subconjunctival triamcinolone acetonide developed CME. The risk of increased IOP linked with triamcinolone injection must to be taken into consideration. LHP Wielders et al., JCRS, “Randomized controlled European multicenter trial on the prevention of cystoid macular oedema after cataract surgery in diabetics: ESCRS PREMED Study Report 2”, Volume 44, Issue 7, Pages 836-847.

FLACS FOR FUCHS’?

In eyes with Fuchs’ endothelial corneal dystrophy and cataract, femtosecond laser-assisted cataract surgery (FLACS) reduced the central cornea thickness and the rate of endothelial cell density loss more effectively than conventional phacoemulsification surgery. This approach could help to postpone the need for corneal transplantation in these patients, researchers suggest. This was based on a clinical study that evaluated 31 eyes undergoing one or the other procedure. Endothelial cell density loss was significantly higher in the phaco group from one to 12 months postoperatively.

Central corneal thickness was significantly thicker in the phaco group one, three and six months postoperatively. In both groups, central corneal thickness at all follow-up visits was significantly greater than the preoperative level. W Fan et al., JCRS, “Femtosecond laser–assisted cataract surgery in Fuchs’ endothelial corneal dystrophy: Long-term outcomes”, Volume 44, Issue 7, Pages 864-870.

JOURNAL OF CATARACT & REFRACTIVE SURGERY ® SYMPOSIUM

CONTROVERSIES

in Cataract and Refractive Surgery

Sunday 23 September 14.00 – 16.00

During the 36th Congress of the ESCRS Vienna, Austria

Chairpersons: T. Kohnen GERMANY (EUROPEAN EDITOR) W.J. Dupps USA (US ASSOCIATE EDITOR)

Intraoperative OCT for the anterior segment 14.00

N. Hirnschall AUSTRIA We need it!

14.15

M. Busin ITALY We don’t need it!

14.30

Discussion

Cataract and corneal transplantation 14.40

J. Hjortdal DENMARK Combined

14.55

D. Tan SINGAPORE Separated

15.10

Discussion

Corneal refractive surgery 15.20

T. Seiler SWITZERLAND The best outcome is after PRK

15.35

E. Donnenfeld USA The best outcome is after LASIK

15.50

Discussion

16.00

End of session

Become a member of ESCRS to receive a copy of EuroTimes and JCRS journal

EUROTIMES | SEPTEMBER 2018

17

18

CORNEA

The effects of eye rubbing Is eye rubbing the root cause of keratoconus?

Dermot McGrath reports

C

hronic and vigorous eye rubbing is the main and necessary causative factor of keratoconus rather than just another risk factor among others in the evolution of the condition, according to Damien Gatinel MD, PhD. “The time has come to challenge the common conception of keratoconus as a dystrophy of unknown genetics and biomolecular substratum. I believe that keratoconus is primarily a mechanical and behavioural disease in which the sleeping position plays a key role maybe by reducing the corneal resistance and also triggering some rubbing,” said Dr Gatinel, speaking at the World Ophthalmology Congress (WOC) in Barcelona.

Summing up his theory as “no rub, no cone”, Dr Gatinel said that his clinical experience looking at hundreds of case histories of keratoconus patients is that the absence of rubbing may actually prevent keratoconus from occurring in the first place.

“We believe the problem is that eye rubbing has been positioned as a risk factor, but when you think about it the other risk factors for keratoconus are more risk factors for eye rubbing than keratoconus itself. Eye rubbing is the only risk factor that is exerted directly against the cornea, and the force that is applied with the fingers or knuckles can sometimes be as high as the force resulting from the pressure in a car tyre,” he said.

Dr Gatinel said that not every eye rubber will develop keratoconus but that patients with the particular “keratotype” of an existing thin and weak cornea are particularly at risk.

“I often use the analogy of sunburn to explain what I feel about this association between keratoconus and eye rubbing.

There are risk factors for sunburn, such as light skin and exposure to the sun at certain times of the day. But what causes the sunburn is the UV light. So we have risk factors and a phototype, but if there is no UV there is no sunburn. Likewise, I believe that if there is no rubbing there is no cone and that there are certain keratotypes which may expose you to keratoconus if you rub and you have a thin or a soft cornea,” he said.

The orthodox teaching is that keratoconus is an unknown genetic dystrophy that leads to cornea weakening through a series of factors involving EUROTIMES | SEPTEMBER 2018

Damien Gatinel

the reduction of collagen/elastin, extracellular matrix degradation and collagenase and enzymatic activity, among others, said Dr Gatinel.

“However, the literature shows that only 14% of cases are non-sporadic, so it does not really fit the bill of a true genetic disease. It also does not explain why left and right eyes can be affected very differently and there has been no gene found yet despite many family studies conducted,” he said.

The theory that inflammation triggered by dry eye syndrome may be responsible for keratoconus initially seems plausible, said Dr Gatinel, since surface inflammation can lead to impaired surface barrier and temperature rise triggering a cascade leading to corneal weakening.

“The problem with this theory is that inflammation usually causes flattening, not steepening as in cases of diffuse lamellar keratitis or stromal keratitis. Furthermore, even if you believe in the theory of surface inflammation and dystrophy there is still a major issue in that a soft cornea is not a keratoconus cornea,” he said.

Dr Gatinel noted that Marfan syndrome should perfectly support the theories of keratoconus that attempt to explain the ectatic process. In Marfan syndrome, the gene mutation is identified, and the molecule involved in this connective tissue dystrophy is responsible for the reduction of the strength of the collagen present in the ocular tissues, including the corneal stroma.

“However, despite all these features no keratoconic ectatic pattern is seen in the corneas of patients with Marfan syndrome. The Marfan corneas are thinner but tend to be flatter instead of steeper,” he said. These characteristics (progressive thinning and stretching causing corneal flattening) may in fact better correspond to the term “ectasia” than what is observed in keratoconus.

The focality of the corneal damage pleads in favour of a local vulnerate agent, which is the repeated trauma inflicted by the patient’s fingers. Over time, the applied force results in a progressive thinning and focal steepening of the corneal wall. Keratoconus, from form fruste to severe, corresponds to variable levels of permanent warpage caused by a corneal buckling of primarily mechanical origin.

Summing up, Dr Gatinel advised doctors to warn their patients of the deleterious effects of chronic and vigorous eye rubbing.

“If our ‘no rub, no cone’ conjecture is correct then we must have stabilisation when people stop rubbing, or else there are other factors involved. I am happy to say that all of our cases apart from three, which we have documented on our website defeatkeratoconus.com, are stable. The three patients who have not stabilised all continue to rub their eyes,” he said.

Damien Gatinel: gatinel@gmail.com

20

CORNEA

Using stem cell therapy New approaches show exciting potential for stromal regeneration as a treatment of keratoconous. Dermot McGrath reports

C

orneal stromal enhancement based on stem cell therapy seems to be safe and effective and may prove to be a potentially exciting new therapy for the treatment of keratoconus and other corneal dystrophies, according to Jorge L. Alió MD, PhD, speaking at a special session on corneal disease at the World Ophthalmology Congress in Barcelona.

“Based on our results, we believe that adipose‐derived adult stem cells (ADASC) can be a cell source for stromal regeneration and repopulation in diseased corneas. This is a new type of corneal surgery, the beginning of a new approach for the treatment of corneal stromal diseases such as keratoconus,” said Dr Alió.

The ADASC technique consists of implantation of autologous adipose tissuederived stem cells into corneal stroma.

“Adipose stem cells are ideal for this task as they are easily obtained and highly

EUROTIMES | SEPTEMBER 2018

efficient. They allow for keratocyte differentiation in vitro and in vivo and possible autologous use,” said Dr Alió.

The first stage of the research saw Dr Alió and his team develop an experimental animal model using autologous stem cells to produce corneal collagen “in situ”, identify the best carrier for the cells and accomplish experimental corneal stromal enhancement using cells and the selected carrier.

Once this was successfully achieved, the next step was to confirm the experience in human patients affected by corneal stromal disease such as advanced keratoconus.

The pilot clinical study for cell therapy of keratoconus included three groups of five patients each: group 1 with intrastromal injection of autologous ADASC; group 2 with intrastromal implantation of decellularised human corneal stroma; and group 3 with intrastromal implantation of recellularised human corneal stroma with autologous ADASC.

Stem cells were obtained from the adipose tissue of each patient via liposuction. For groups 2 and 3, once the cultured cells were prepared a 9.5-mm diameter intrastromal pocket was created using a femtosecond laser. In group 3, the surgeons used a cannula to transfer more than 1 million cells through the pocket into the stroma.

Groups 2 and 3 showed similar results in terms of visual acuity outcomes and keratometry six months post- surgery.

“When we reviewed these patients at the one-year mark the corneal transparency was very good. The visual condition also improved in most cases, with stable keratometry and corneal thickness. Confocal microscopy showed a significant increase in cells and no complications were reported,” said Dr Alió.

To confirm these results, a multi-centre clinical trial sponsored by the Spanish Ministry of Health is currently being conducted.

Jorge L. Alió: jlalio@vissum.com

CORNEA

New strategy for treating dry eye Reproxalap could represent important treatment for patients with dry eye disease. Sean Henahan reports

R

eproxalap, a novel agent that targets toxic aldehydes in tear film, could offer a new option in the treatment of dry eye disease, reported researchers at the Association for Research in Vision and Ophthalmology (ARVO) 2018 Annual Meeting.

Fifty-one patients with active dry eye disease received one of three formulations of the drug in a randomised, double-masked, phase IIa clinical trial. The formulations tested were topical ocular 0.1% reproxalap, 0.5% reproxalap or a 0.5% lipid formulation of reproxalap four times daily.

Pooled results after 12 weeks of treatment showed statistically significant changes in the Symptom Assessment in Dry Eye (SANDE) score, the ocular discomfort score, the overall four-symptom score, Schirmer’s tests, osmolarity and corneal staining with lissamine green, announced David Clark MD, Chief Medical Officer at Aldeyra Therapeutics.

The study also showed a modest dose response, with improvement in symptoms seen after only one week of therapy. Improvement in corneal staining and osmolarity correlated with reduction in levels of tear reactive aldehyde species. The treatment was safe and well tolerated. A follow-on phase IIb trial is now under way that aims to enrol 300 patients with active disease, randomised equally to receive either 0.1% reproxalap, 0.25% reproxalap or vehicle for three months.

IMPORTANT TREATMENT “Reproxalap could represent an important treatment for many patients that suffer from dry eye disease. The activity demonstrated within one week of therapy in the phase IIa clinical trial suggests that reproxalap could have significant potential for the treatment of dry eye disease,” said Gary Foulks MD, FACS, Professor Emeritus, Department of Ophthalmology & Visual Sciences at the University of Louisville, US. The treatment represents a different approach to dry eye therapy than current options. It is based on the idea that proinflammatory aldehyde mediators may contribute to ocular inflammation. Reproxalap acts to sequester pro-inflammatory reactive aldehyde species. The developers hope that the topical ocular aldehyde trap approach could augment existing dry eye therapy, ideally reducing the need for corticosteroids and their attendant risks.

A phase III clinical trial with reproxalap is also under way for the treatment of allergic conjunctivitis. That trial will also enrol 300 patients with active disease, randomised equally to receive either 0.1% reproxalap, 0.25% reproxalap or vehicle for three months. In a phase II trial, patients reported rapid resolution of ocular itching following administration of the drug.

Topical reproxalap is also being studied in a phase III clinical trial as a treatment of non-infectious anterior uveitis. Toxic aldehydes are known to be associated with inflammation, fibrotic changes and lipid destruction that lead to surface irritation, pain, photophobia, redness and vision loss in that rare disease.

D.O.R.C. Satellite Meeting, EURETINA, Vienna

How can innovation deliver real benefits to improve VR surgery?

Moderator: P. Stalmans, Belgium

Saturday, September 22nd 13.00 – 14.00 room D2 Lunch included

How more options in fluidics can benefit complex cases J. Fortun, USA

Why surgical liquids purity matters?

M. Romano, Italy

How my preferred VR system just got better!

P. Stalmans, Belgium

Why instrument innovations give more options for my complex VR surgery R. Avci, Turkey

David Clark: dclark@aldeyra.com Gary Foulks: gnfoul01@louisville.edu EUROTIMES | SEPTEMBER 2018

21

22

RETINA

STUDYING

intermediate-stage AMD Development of clinical endpoints for clinical trials in intermediate AMD. Roibeard Ó hÉineacháin reports

A

new European-wide research The study will examine the morphological project now under way, called and functional characteristics of the MACUSTAR, is aiming different stages of AMD as well as the to investigate a set of tests functional, morphological and patientto analyse functional and reported changes that occur during structural changes in eyes with intermediate iAMD progression. Another aspect of the age-related macular degeneration (iAMD). study is to determine structure-function “The aim of the MACUSTAR project is to correlations, he said. develop clinical endpoints and prognostic “The vast proportion of patients in the indicators for use in interventional studies study are those with iAMD. But iAMD is investigating the prevention or associated with quite heterogeneous delay of progression of iAMD manifestations and functional to late-stage AMD, or to deficits. iAMD always progresses. improve the functional So, we will look at progression deficit characteristic to over the course of three years iAMD. At the moment, in each patient examined. We there is an unmet need to also have subgroups of 50 prevent progression of patients with early AMD and intermediate but there are late AMD, and also 50 normal no FDA- or EMA-approved patients, so that we can contrast clinical endpoints to test new what we find in intermediate AMD therapies,” project co-ordinator Prof patients to those other groups’ disease Frank G. Holz Frank G. Holz MD, Department states,” Dr Holz added. of Ophthalmology, University of Bonn, Structural assessments of the retina will Germany, told EuroTimes in an interview. include high-resolution optical coherence To define the new clinical endpoints, a tomography (OCT), confocal scanning multi-centre study will carry out a state-oflaser ophthalmoscopy including fundus the art structural assessment of the retina, autofluorescence and OCT angiography. and a toolbox of functional testing and A subset of patients will be examined using patient-reported outcomes instruments. quantitative autofluorescence and sweptThe five-year project will recruit 750 source OCT and also adaptive optics. patients from 20 clinical centres in seven Functional tests include visual acuity, countries across Europe. The recruitment mesopic and scotopic microperimetry, is ongoing and will continue until March reading speed, Moorfields Acuity 2019 and the last patient examination will Test (vanishing optotypes) and also be completed in 2022, Dr Holz explained. navigation performance.

ask the experts EUROTIMES | SEPTEMBER 2018

Traditionally, AMD is diagnosed based on structural analysis of the retina via clinical exam along with OCT or fundus photography.

Stages of the disease are typically categorised by drusen characteristics and the presence of pigmentary changes. Over the past decades, research has shown that before the development of late-stage AMD rod function or dark adaptation may be impaired. Such functional impairments will be assessed in depth in the context of the study.

The MACUSTAR is being funded with €16 million by the European Innovative Medicines Initiative (IMI), which is the biggest public-private partnership in life science. Within the European Framework Research Programme Horizon 2020, IMI is funded jointly by the European Commission and EFPIA (European Federation of Pharmaceutical Industries and Associations).

The MACUSTAR consortium includes researchers from academic institutions in the Netherlands, France, Portugal and the United Kingdom. It also includes four industrial companies: Bayer, Zeiss, Novartis and Roche.

Frank G. Holz: Frank.Holz@ukbonn.de www.macustar.eu

If you have a clinical question regarding a straightforward or complex case, send it to EuroTimes Executive Editor Colin Kerr at: colin@eurotimes.org The questions we receive will then be sent to our Medical Editors and International Editorial Board. We will publish a selection of their answers in the magazine.

See into the future of eye surgery and patient care.

www.escrs.org

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24

RETINA

New approach for geographic atrophy Latest round of testing for novel treatment to begin later this year.

Sean Henahan reports

W

ith more than one million people affected by sight-threatening geographic atrophy secondary to age-related macular degeneration in the US alone, the need for a useful treatment is urgent. Oneyear results of a clinical trial with a novel complement C3 inhibitor suggest potential for this treatment approach, according to a report at the Association for Research in Vision and Ophthalmology (ARVO) 2018 Annual Meeting, in Honolulu, Hawaii.

Charles Clifton Wykoff MD, PhD, Retina Consultants of Houston, Blanton Eye Institute, Houston, Texas, US, presented the latest results from the FILLY trial, a multi-centre phase II placebo controlled randomised clinical trial. The 18-month trial looked at the safety and efficacy of a complement C3 inhibitor, APL-2 (pegcetacoplan, Apellis Pharmaceuticals), in 246 patients with geographic atrophy secondary to age-related macular degeneration (AMD).

Inclusion criteria included geographic atrophy measuring from 2.5 to 17.5mm2 and visual acuity of at least 20/320.

Patients received one of three regimens, monthly intravitreal injections of APL-2, APL-2 injections every other month, placebo injections monthly or placebo every other month.

The study met its 12-month primary efficacy outcome, which was the difference in mean change from baseline of the square-root geographic area based on fundus autofluorescence. Monthly injection of APL-2 was associated with a statistically significant 29% reduction in the rate of geographic atrophy lesion growth. Patients treated with the active compound every other month showed a 20% slowing in lesion growth. These effects continued to increase through the 12-month study period.

Patients on active treatment did not show any Charles Clifton Wykoff improvement in best-corrected visual acuity.

One unexpected finding was a dosedependent difference in study eye conversion to the exudative form of AMD. Eighteen eyes (21%) receiving monthly injections converted to exudative AMD, as did seven eyes (9%) in the group treated every other month, along with one eye (1.2%) treated with sham injections. Active treatment was discontinued in all of those patients.

Subsequent analysis showed that patients who had a history or presence of choroidal neovascularisation in the other, nonstudy eye had a higher rate of conversion to the exudative form of the disease, with those receiving monthly treatment having the highest rate.

During a six-month follow-up period without active treatment, geographic atrophy lesions grew at a rate similar to that observed in placebo recipients. Patients previously treated with monthly APL-2 showed a slightly greater reduction over the six-month follow-up, 12% reduction compared to placebo.

Those who had received treatment every other month showed a 9% reduction.

A phase III protocol for APL-2 for the treatment of geographic atrophy is scheduled to begin later this year (2018).

Charles Clifton Wykoff: ccwmd@houstonretina.com EUROTIMES | SEPTEMBER 2018

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RETINA

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OPHTHALMOLOGICA VOL: 240 ISSUE: 2

EURETINA AWARD LECTURE This issue of Ophthalmologica includes the text of the EURETINA lecture, which Francine Behar-Cohen MD PhD delivered at the 17th EURETINA Congress in Barcelona, Spain. In her presentation she stresses the need for a better understanding of corticosteroids’ mechanisms of action in order to optimise their use in the treatment of ocular inflammatory conditions. She cites research indicating that glucocorticoids may induce retinal cell death through pathways undetectable by classical toxicology tests. She adds that a combination of low doses of glucocorticoids together with antagonists to mineralocorticoid receptors holds promise as a therapeutic strategy for treating ocular inflammation. F Behar-Cohen, “Towards an Optimized Use of Ocular Corticosteroids: EURETINA Award Lecture 2017”, Ophthalmologica 2018, Volume 240, Issue 2.

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Patients with macular oedema (ME) related to branch retinal vein occlusion (BRVO) who receive intravitreal dexamethasone implants within the first few months of the condition’s onset achieve greater, more rapid and longer-lasting visual improvements and morphological improvements than those who receive the implant at a later stage in their disease, according to the results of the multi-centre COBALT study.

Among 71 BRVO patients who had ME for less than three months, the mean improvement in best-corrected visual acuity (BCVA) was 18.6 letters and 15.3 letters at six and 12 months respectively, following an initial injection of the dexamethasone implant. Over the 12-month treatment period, 32% received one injection and 49% of patients received three injections. YH Yoon et al, “Dexamethasone Intravitreal Implant for Early Treatment and Retreatment of Macular Edema Related to Branch Retinal Vein Occlusion: The Multicenter COBALT Study”, Ophthalmologica 2018, Volume 240, Issue 2.

BEVACIZUMAB AND RANIBIZUMAB SHOW SIMILAR EFFICACY IN ROP The findings of a retrospective study suggest that bevacizumab and ranibizumab have similar efficacy in the treatment of type 1 retinopathy of prematurity (ROP) affecting zone 1. The retrospective study included 68 eyes of 37 patients. All had initial disease regression, although four patients who received bevacizumab and two who received ranibizumab showed reactivation (p = 0.679) and 15 eyes in the bevacizumab group and 12 in the ranibizumab had incomplete vascularisation (p = 0.725). The mean spherical equivalent refraction at one year was more myopic in the bevacizumab group (-1.49 D) than in in the ranibizumab group (0.98D) (p < 0.001). S Kimyon et al, “Comparison of Bevacizumab and Ranibizumab in the Treatment of Type 1 Retinopathy of Prematurity Affecting Zone 1” Ophthalmologica 2018, Volume 240, issue 2.

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GLAUCOMA

27

Optic nerve regeneration Improved prospects for vision-restoring optic nerve regeneration in eyes with glaucoma. Roibeard Ó hÉineacháin reports

R

esearch shows that regeneration of the optic nerve is possible. However, directing axonal growth in a way that will restore cortical function and spatial perception remains an unsolved problem, said Keith Martin MD, FRCOphth, Cambridge University, Cambridge, UK. “It is a very exciting time for the understanding of the biology of optic nerve degeneration and how to simulate these cells and potentially how to guide the regenerated axons to their targets in the brain,” Dr Martin told the 13th European Glaucoma Society Congress in Florence, Italy.

Dr Martin noted that as far back as 1987, work by Albert Aguayo and associates showed that a transected optic nerve could be successfully connected to the superior colliculus of the brain using a peripheral nerve graft. In animal experiments this approach has resulted in functional axonal connections throughout the visual system and has even restored the subjects’ pupillary reflex (Vidal-Sanz et al., J Neurosci. 1987;7:2894-2909).

“The issue is not whether retinal ganglion cells have the capacity to regenerate, but in the normal circumstances they don’t tend to because the environment of the central nervous system is inhibitory,” Dr Martin said.

Directing the axonal growth in ways that restore function remains a problem. In knock-out mice that lack the regeneration-inhibiting PTEN/SOCS3 gene, optic nerve damage is followed by robust axonal regeneration. However, the axon growth tends to follow twisted paths through the optic nerve, with many axons reversing course and others extending towards the other eye (Luo et al., Exp Neurol. 2013 ; 247: 653–662).

There is also now evidence that axonal growth can be directed more correctly to some extent by combining growth stimulation and/or inhibition-blocking treatments with intensive visual stimulation in one eye and light exclusion, by eyelid suturing or removal, of the other eye. Mice undergoing this regime following optic nerve crush exhibit behavioural responses to light and shadow (Lim et al., Nature Neuroscience. 2016; 19:1073–1084).

“The qualifications of that is that so far this has only provided restoration of brainstem level visual functions. But what has not been demonstrated is any restoration of spatial vision, the ability to determine where in a particular space a stimulus is actually located. This is a major challenge at the moment,” Dr Martin said.

Keith Martin: krgm2@cam.ac.uk

STIMULATING AXON GROWTH Methods to directly stimulate retinal ganglion cell regeneration that have been demonstrated in animals include damaging the crystalline lens (Lorber et al., Eur J Neurosci. 2005 Apr;21(7):202934) and also, paradoxically, raising IOP (Lorber et al., Neurobiol Dis. 2012, 45:243-252). Ganglion cells from eyes with glaucoma may therefore be more primed to regenerate and the effect of the disease response appears to be modulated by activated glia, he said.

More recently, Craig Pearson MD, PhD, and the team at Cambridge have shown that arylsulfatase B (ARSB) significantly enhances axonal regeneration in vivo when the enzyme is delivered to the injured optic nerves of adult mice in combination with intravitreal injection of zymosan and CPT-cAMP, an intrinsic growth stimulus (Pearson et al., eLife. 2018;7:e37139 DOI:10.7554/eLife.37139). ARSB has the advantage of already being FDA-approved for the treatment of lysosomal disorders.

FCI18/020 Ind. A - Juin 2018 - ©Istock

BLOCKING INHIBITION The inhibitory factors of neuroregeneration include myelinassociated glycoproteins, chondroitin sulphate proteoglycans and neurite outgrowth inhibitory protein (NOGO). Research has shown that, to a limited extent, these inhibitory factors can be blocked, stimulating retinal ganglion cell regeneration.

Dr Martin reported that he and his associates have conducted optic nerve regeneration experiments using stem cell transplantation enhanced with chondroitinase ABC, an enzyme that breaks down chondroitin sulphate proteoglycans. They found that the implanted stem cells differentiated into Muller stem cells, and that the anti-inhibitory enzyme appeared to facilitate neurite outgrowth from the transplanted Muller stem cells (Bull et al., Invest Ophthalmol Vis Sci. 2008; 49:3449-56).

“What we’re working on now is combining intrinsic mechanisms which induce a pro-regenerative response and an extrinsic response which reduces inhibition to regeneration within the optic nerve,” Dr Martin said.

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GLAUCOMA

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“It would be highly desirable to reduce the number of patients with more than early disease at the time of diagnosis. Unfortunately, this is a great problem and it is probably maybe the largest risk factor for becoming blind,” he told the 13th European Glaucoma Society Congress in Florence, Italy.

Glaucoma is the second leading cause of blindness worldwide. Indeed, the rate of glaucoma-caused blindness is probably underestimated. Many epidemiological studies define glaucoma blindness based on visual acuity alone.

However, that may leave out two-thirds of those blind in terms of visual field testing in addition to visual acuity definitions.

He noted, for example, that in a study involving a cohort of 914 glaucoma patients in Malmo, Sweden, only 14 (1.5%) were blind according to WHO visual acuity criteria alone, but 40 (4.4%) were blind in terms of WHO criteria for both visual acuity and visual fields.

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Studies involving cohorts of glaucoma patients usually find a low frequency of blindness. However, studies reporting lifetime outcome suggest that the lifetime risk of blindness from glaucoma is many times higher.

In a Finnish study conducted in 2007, which reviewed the lifetime visual status in a population of open-angle glaucoma patients, 15% were blind in both eyes and 26% were blind in one eye at their last visit before death. In some cases this was not due to glaucoma but due to other causes such as macular degeneration.

Dr Heijl and associates obtained similar results when they repeated the Finnish study with a larger population.

It included all patients with primary open-angle glaucoma and pseudoexfoliation glaucoma who died in Malmo between January 2006 and 2010.

At their last follow-up, 16% were blind in both eyes and 42% were blind in at least one eye from glaucoma. The time between the onset of blindness and death for most patients was twoto-three years. Very few patients became blind bilaterally before the age of 80.

Risk factors for blindness included elevated IOP, which increased the risk by 8% for every millimetre of mercury above normal.

More important was the stage of glaucoma at the time of diagnosis, which increased the risk by 80% for every stage of Anders Heijl MD, PhD glaucoma progression.

It would be highly desirable to reduce the number of patients with more than early disease at the time of diagnosis

GLAUCOMA

Is screening the best approach?

More evidence required before adopting screening for glaucoma.

Roibeard Ó hÉineacháin reports

T

he value of population screening for glaucoma has yet to be determined, and the results of a large, randomised clinical trial will be needed to determine whether the number of new cases it yields will justify its costs, said professor Anja Tuulonen MD, PhD, Tampere University Hospital, Tampere, Finland.

“A major randomised clinical trial is far less costly than unplanned growth of poor quality screen. Well conducted randomised controlled screening trials provide the best evidence,” Dr Tuulonen told the 13th European Glaucoma Society Congress in Florence, Italy.

She noted that the consensus meeting of the World Glaucoma Association in April, 2008, identified three major shortcomings in modern glaucoma care. Namely, unequal access to care with large variations in service, an underdiagnosis rate of 50%, and an equal, 50% rate of overtreatment.

The consensus meeting also concluded that there was insufficient evidence regarding the cost-effectiveness of screening for glaucoma.

In particular there is a lack of evidence Anja Tuulonen for most important parameters, based on realworld data and evidence.

Since that time, a longitudinal study published in 2014 showed that screening had no impact on cumulative diagnosis of glaucoma during the years 1981 to 2002, among 856 individuals who were born in 1915 in one city of Sweden. In addition, authors of a UK study concluded that it might not be a cost-effective use of resources to run a screening trial in the UK. Dr Tuulonen and her associates have initiated the Northern Finland Birth Cohort Eye Study, which is a randomised controlled screening trial in the 1966 Northern Finland Birth Cohort. The original cohort includes 12,058 people born in a northern region of Finland in 1966. In the NFBC Eye Study screening group, 1.1% had definite glaucoma and of those, 95% were undiagnosed previously and 89% were normotensive. Longer follow-up may reveal the best combination of diagnostic tests for detecting glaucoma in an unscreened population, she said.

There are a number of inherent biases that need to be considered when designing a randomised controlled trial of screening, she noted. For example, screening is more likely to pick up cases with a good prognosis, since it is usually the more health-conscious people who attend screening. In addition, it will usually only pick up the slowly progressing disease.

Meanwhile, in the absence of any systematic population screening, opticians are offering screening with directto-consumer advertising, inducing patients to undergo unnecessary and expensive tests. That in turn can lead to an overdiagnosis epidemic.

She referred to American Academy of Ophthalmology guidelines refraining from unnecessary testing in patients without visual complaints.

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Anja Tuulonen: Anja.tuulonen@pshp.fi EUROTIMES | SEPTEMBER 2018

29

30

GLAUCOMA

Glaucoma IN THE CLINIC Knowing how and when to intervene in glaucoma requires consideration from the patient’s perspective. Roibeard Ó hÉineacháin reports

A

n individualised approach to treat glaucoma patients, taking into account all factors that may affect vision and quality of life, can help clinicians steer their course of therapy safely between over- and under-treatment, counsels Ivan Goldberg, Clinical Professor, Discipline of Ophthalmology, University of Sydney, Australia.

“We know that the more basic information that we put together, the more accurate we are likely to be, the greater will be our certainty and the less will be our doubt in our glaucoma diagnostic powers,” Dr Goldberg told the 13th European Glaucoma Society Congress in Florence, Italy.

He noted that patients with chronic diseases like glaucoma will have a different perspective from that of an ophthalmologist.

He therefore recommends to his colleagues that they imagine that they are the patient themselves.

To achieve this, he suggested a review of all the tests the patient is undergoing and the advice and information they have received from staff members. In addition, sitting in the consulting chair and undergoing some of the examinations can further reveal the impact of diagnosis, monitoring and treatment on the patient’s quality of life.

PRESERVING VISION AND QUALITY OF LIFE He noted that the goal of therapy is to identify risk factors for onset or worsening of disease and then to eliminate or reduce them. In glaucoma, IOP is at present the major proven modifiable risk factor.

However, the relationship between IOP reduction and the slowing of vision loss is not linear, and different patients will require different amounts of IOP reduction to achieve optimal results.

Moreover, there are a many lifestyle factors that may contribute to a patient’s disease and the response to IOP-lowering treatment. Patients should be advised to avoid habits like the Valsalva technique, globe compression, physical inversion and water loading, Dr Goldberg said. There are also non-pressure-related aspects that must be taken into consideration, such as EUROTIMES | SEPTEMBER 2018

Ivan Goldberg

genetics and cardiovascular comorbidities.

In addition, diagnoses like diabetes should be controlled, and sleep apnoea needs to be detected and treated

GUIDELINES HAVE LIMITATIONS There are guidelines available for treatment based on randomised controlled studies and anecdotal experience. The general rule is that the more damaging the disease, the more aggressive the therapy advised. The caveats are that their concepts, definitions and strategies are dependent on what the technology can measure.

For example, the invention of ophthalmoscope in the 1860s by von Helmholtz led von Graefe to discover the changes in the optic nerve head that characterise the disease. However, when tonometers became more accurate and available, glaucoma became known as a pressure-dependent disease. This has led to advice and management that may not be appropriate, Dr Goldberg said.

Furthermore, the guidelines cannot promise the desired outcome in each individual patient with absolute certainty, he noted.

“We have to deal with less than certainty because the foundation of science is

the opposite of certainty, it is a radical uncertainty about our knowledge and our equipment and an acute awareness of the extent of our ignorance,” Dr Goldberg said.

When a new patient presents with glaucoma, the first question to ask is whether there is structural damage and functional loss, and if there is, whether it is bad enough to threaten the patient's quality of life. For example, does the damage have proximity to fixation, and what is the extent and the depth of the defects? When monitoring a patient over time it is necessary to determine if they are getting worse, and if so, how quickly, and again, does it threaten the quality of life, and what are the risks of getting worse. The degree of IOP control should be assessed along with the impact any particular treatment will have on the patient’s life.

“Use the cone of uncertainty in the process of examination and get as close to certainty as we can with our patients in our diagnostic considerations, remembering that glaucoma management is a marathon, not a sprint,” Dr Goldberg added.

Ivan Goldberg: ivan.goldberg@sydney.edu.au

PAEDIATRIC OPHTHALMOLOGY

Learning from a mock trial Doctors take valuable skills from a simulated shaken baby case.

Soosan Jacob MD reports

A

mock trial relating to non-accidental injury in children proved to be a very interesting session at the World Congress of Paediatric Ophthalmology and Strabismus in Hyderabad, India.

Pediatric ophthalmologists enacted an interesting courtroom trial playing the roles of fact witness, expert witness, judge, defence and prosecuting attorneys. The attending delegates played the role of the jury.

The trial started with a presentation of the details of the case. The expert witnesses – paediatric ophthalmologists – were then questioned by the defence and prosecuting attorneys followed by the jury. The verdict was finally given by a vote from the jury.

The case presented was that of a baby with injuries for the jury to decide whether it was a case of shaken baby syndrome/abusive trauma or accidental trauma because of an alleged fall of the 70-year-old nanny down five carpeted steps on to the baby.

Fundus photographs showing multiple retinal haemorrhages and retinoschisis with blood collection within the retinoschisis were shown with similar picture in both eyes. The drama proceeded to show a simulated experience and how it was also possible in real life that as an expert witness, the paediatric ophthalmologist could be questioned and heckled.

Valuable teaching points on to how to handle such a situation were discussed. The case that was in fact one of abusive head trauma showed that words, language and attitude could be used to sway even a group of ophthalmologists and therefore, possibly, much more easily the laymen and women who compose a jury.

Alex Levin MD, MHSc, of the Wills Eye Hospital in Philadelphia, shared some important tips on testifying in court.

He advised that it was important to maintain one’s demeanour, be calm and state facts without getting ruffled or flustered even if badgered.

It was also important to Alex Levin MD, MHSc be prepared and know the relevant literature.

He also said that it was worthwhile remembering that the expert witness’ job was only to educate the court by providing information and it is wise to not get emotionally involved with the case by trying to “win” for one side. He advised using layman’s terms and explaining in as simple a manner as possible, telling the truth and acknowledging uncertainty when not sure, remembering to speak only when spoken to and to answer only what is asked. Physician experts play a critical role in these legal situations and must be prepared, within their level and area of expertise, to assist the legal system.

It is wise to not get emotionally involved with the case by trying to “win” for one side

Alex Levin: alevin@willseye.org EUROTIMES | SEPTEMBER 2018

31

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PAEDIATRIC OPHTHALMOLOGY

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What was the cause of a painless swelling of a young boy’s upper lid?

Aidan Hanratty reports

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five-year-old boy was referred by a general practitioner to the department of ophthalmology at University Hospital Galway (UHG) for right eye preseptal cellulitis, reported a poster presentation at the Irish College of Ophthalmologists Annual Conference in Kilkenny, Ireland.

This referral was made after he had experienced two weeks of right upper-lid swelling, reported Nora Mohd and Gerry Fahy, UHG. The child’s mother believed the swelling was caused following blunt to trauma to the lid by his brother while the two were playing. He did not complain of any pain or vision loss, however.

Upon examination, doctors found a firm, fixed lump measuring 3x2cm, which caused mild limitation of eye movement when looking up.

Clinical differential diagnosis suggested a medial angular dermoid cyst, lymphangioma, rhabdomyosarcoma or neuroblastoma. An excision biopsy of the lesion showed fibro adipose tissue infiltrated by rhabdomyosarcoma with a solid growth pattern.

Although rare, orbital rhabdomyosarcoma is the most common primary malignancy of the orbit in children.

It tends to develop in the soft tissue of the orbit. Most parents will notice either ptosis or proptosis, or both.

A CT scan will show the orbital mass and in advanced cases there maybe destruction of the bone. In this case the orbital mass was well circumscribed in the anteromedial orbit.

Treatment consisted of chemotherapy and consideration will be given to orbital x irradiation depending on response to chemotherapy. Cure rates have markedly improved with use of chemotherapy and x irradiation. Long term follow-up is required.

The patient received chemotherapy IVA (ifosfamide, vincristine, actinomycin) in Our Lady’s Children’s Hospital, Crumlin, every three weeks, as well as vincristine alone in UHG every week. This began in November 2017 and continued until May 2018. He has had an excellent response to chemotherapy.

The doctors concluded that rhabdomyosarcoma may appear as a benign process in its early stages. It is an important diagnosis to consider when presented with a child with an enlarging orbital lesion.

The authors recommend a high level of clinical suspicion, prompt orbital imaging and prompt biopsy to establish the diagnosis of rhabdomyosarcoma.

Although rare, orbital rhabdomyosarcoma is the most common primary malignancy of the orbit in children

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36

PAEDIATRIC OPHTHALMOLOGY

PRIMARY POSTERIOR

capsulorhexis in children Experts compare advantages of different approaches.

Soosan Jacob MD reports

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here has always been a debate on whether the limbal or pars plicata approach is better for primary posterior capsulorhexis in paediatric cataract surgery.

At the World Congress of Paediatric Ophthalmology and Strabismus 2017, Hyderabad, Marta Morales Ballús MD, PhD, from Spain, advocated the pars plicata route citing concerns of iris prolapse through limbal incisions as well as the possibility of vitreous strands getting caught in the wound, both of which can result in postoperative corectopia in the child if using the limbal approach.

Moreover, pars plicata approach would minimise inflammation and glaucoma, keeping the vitreous back to the IOL. Dr Morales Ballús, St Joan de Déu Hospital, Barcelona, also noted that the pars plicata approach would be a must in cases with posterior lenticonus or posterior plaques.

As many cases of paediatric cataracts also have the posterior capsule itself involved in the cataract, she argued that it would be very difficult to perform posterior continuous curvilinear capsulorhexis (PCCC) by an anterior approach, and therefore a posterior approach would be preferable.

Taking a different perspective, Ken Nischal FRCOphth, Children’s Hospital, University of Pittsburgh Medical Center, US, argued in favour of a limbal approach to the paediatric posterior capsule, stating that a primary posterior capsulorhexis via limbal approach had advantages over a posterior capsulectomy with a vitrector. In addition, it gave advantages of not having to disturb the conjunctiva, especially when operating on children younger than two years of age who have an increased incidence of glaucoma as compared to older children. Moreover, an improperly closed sclerotomy could possibly give rise to a bleb.

Dr Nischal added that in a case of an unintentionally torn anterior capsulorhexis, a manually performed PCCC could be utilised for optic capture of the IOL, whereas attempting a capture in a vitrectorhexis could result in a splitting of the posterior capsule. Since there are no definite anatomical landmarks as to the pars plana and pars plicata in children, a posterior approach may also carry a higher risk of retinal detachment.

He described his technique of twoincision push-pull rhexis to obtain a round rhexis, and the possible use of intraoperative optical coherence tomography for the posterior rhexis.

He also stressed the importance of good anaesthesia for uneventful paediatric cataract surgery. Use of propofol and a laryngeal mask alone do not reduce sympathetic activity and do not prevent positive vitreous pressure. A pCO2 less than 30mmHg and avoiding bolus injections of saline are helpful.

In a case of an unintentionally torn anterior capsulorhexis, a manually performed PCCC could be utilised for optic capture of the IOL, whereas attempting a capture in a vitrectorhexis could result in a splitting of the posterior capsule Ken Nischal FRCOphth In addition, good paralysis prevents the eye from rolling backwards. A traction suture should be avoided to prevent distortion of highly elastic paediatric tissues and consequent increased vitreous pressure.

All these measures help avoid iris prolapse, vitreous strands and corectopia.

He also added that any posterior capsular plaque could be used as a template for a posterior rhexis and encompassed within the rhexis if possible, using the two-incision push-pull rhexis.

Marta Morales Ballús: Mmorales@sjdhospitalbarcelona.org Ken Nischal: nischalkk@upmc.edu

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EUROTIMES | SEPTEMBER 2018

ESCRS partners with Alcon for YO Fellowship 2018 Fellowship offers €50,000 to fund expenses of one-year fellowship at a centre of excellence. Colin Kerr reports

E

ducation is a cornerstone value of the European Society of Cataract and Refractive Surgeons (ESCRS). With that in mind, we are happy to announce an exciting new initiative for young ophthalmologists.

ESCRS and Alcon have announced the launch of a one-time grant for a young ophthalmologist to support his or her continuous professional training and education.

The €50,000 grant will fund a oneyear fellowship at a centre of excellence in Europe to gain Prof Béatrice Cochener clinical experience in the field of cataract and refractive surgery. All young ophthalmologists who meet the criteria are invited to submit their application by December 1, 2018 for a fellowship commencing during 2019.

“This important grant from Alcon complements the existing ESCRS young ophthalmologists programmes and initiatives designed to provide further education and training in the specialist field of cataract and refractive surgery.” said Prof Béatrice Cochener, President of the ESCRS. “The winner will be selected by the ESCRS, based on applicants’ merit,” said Professor Cochener.

ESCRS appreciates the contribution of Alcon to the education and training of young cataract and refractive surgeons.

Applicants must be European ophthalmologists in training, 40 years of age or under on the closing date for applications and have been ESCRS members for three years by the time the grant is awarded.

Applications must include a detailed up-to-date CV, a letter of intent of one-to-two pages outlining the motivation and goals of their fellowship, a letter of recommendation from their current Head of Department and a letter of acceptance from the host institution where the fellowship will take place.

This important grant from Alcon complements the existing ESCRS young ophthalmologists programmes and initiatives designed to provide further education and training...

Please send all applications and queries to Danielle.Maher@escrs.org yo.escrs.org

BOOK REVIEWS

PUBLICATION CONTACT LENS PRACTICE THIRD EDITION EDITORS NATHAN EFRON

LEIGH SPIELBERG MD Books Editor

BOOK

Reviews PUBLICATION ATLAS OF LACRIMAL DRAINAGE DISORDERS EDITORS MOHAMMAD JAVED ALI

PUBLISHED BY ELSEVIER

A MOST EXTENSIVE BOOK

Mastering the field

The Atlas of Lacrimal Drainage Disorders (Springer), by Mohammad Javed Ali, is a PUBLISHED BY SPRINGER comprehensive, 700-page, 77-chapter guide to the evaluation and management of lacrimal drainage disorders. Dr Javed Ali is a surgeon who treats only patients with nasolacrimal disorders, and this atlas is intended to accompany his textbook Principles & Practice of Lacrimal Surgery. As such, this book covers the topic thoroughly, with thousands of photographs of everything from the embryology to the equipment used to treat each disorder.

It is a true atlas, with the vast majority of space devoted to clinical, surgical and radiologic photographs. The first several chapters cover the anatomy of the system, followed by an extensive presentation of diagnostic evaluation techniques. Particularly useful is the chapter illustrating typical CT scans in lacrimal pathologies.

Chapters 20 to 43 cover the disorders themselves, from simple punctal agenesis to nasolacrimal trauma. Each of the rest of the chapters deals with surgical techniques, including revisions after primary surgical failure.

I was pleasantly surprised with the extremely high quality of the images and the clear, concise accompanying legends. Intended for general ophthalmologists, ambitious residents and especially fellows in orbital and oculoplastic surgeons interested in mastering this field of disorders.

I have the great fortune of working in a team with an ophthalmologist colleague who has dedicated herself to the contact lens subfield. For those who are not so fortunate, may I recommend Contact Lens Practice: Third Edition (Elsevier), edited by Nathan Efron. This 470-page textbook is the most extensive book of its kind that I have come across.

The book focuses on every type of contact lens, from basic soft and rigid systems to specialised varieties, such as scleral lenses, paediatric lenses and those used in orthokeratology. It covers its topics comprehensively, using study evidence and extensive references to present the subject matter. Full-colour photographs and a clear, logical format help the reader quickly find what (s)he is looking for.

As a vitreoretinal surgeon, the chapter on contact lens myopic correction was most instructive for advising patients with anisometropia after combined phaco-vitrectomy procedure for retinal detachment. But this book goes much further, referring to large studies to illustrate difficult topics such as treating post-traumatic recurrent epithelial defects.

This text is intended for both ophthalmologists and optometrists, particularly corneal and external diseases specialists, who often must rely on contact lenses to solve problems not amenable to surgery. This book includes full access to the eBook via ExpertConsult.com.

PUBLICATION FACIAL RECONSTRUCTION AFTER MOHS SURGERY EDITORS JAMES F. THORNTON AND JOURDAN A. CARBOY PUBLISHED BY THIEME

GETTING A CLEARER PICTURE The significant advances that have recently been made in retinal and choroidal imaging require a book to summarise the research and experiences to date. Retinal & Choroidal Imaging in Systemic Diseases (Springer), edited by Jay Chhablani, Parthopratim Dutta Mjaunder and J. Fernando Arevalo, covers one aspect of the applications of these newly advanced modalities: how to use the imaging techniques to PUBLICATION assist in research, diagnosis and management of RETINAL & CHOROIDAL systemic diseases.

IMAGING IN SYSTEMIC Various systemic diseases involve the eyes, and DISEASES in a few diseases, the eyes can provide the first clue EDITORS for their diagnosis. It would thus be a shame to JAY CHHABLANI, miss the diagnosis because the imaging might be PARTHOPRATIM DUTTA misinterpreted. Some are widely recognised, such MJAUNDER AND J. as the vasculitides in systemic disease. Others, such FERNANDO AREVALO as the chorioretinal abnormalities in haematologic PUBLISHED BY SPRINGER disorders, might be less familiar. All are covered in this book, which is well-illustrated with high-quality ultrawide-field photographs, digital ICGA and other high-definition images.

This book is particularly useful for vitreoretinal specialists and fellows, who should master this EUROTIMES | MONTH YEAR material. It is also of use to general ophthalmologists who have practices based in large hospitals in which patients with the full range of systemic diseases need ophthalmic examination and imaging.

INSIGHTS AND TECHNIQUES Although Mohs is not immediately within the domain of the average ophthalmologist, many of us are confronted with periocular cutaneous carcinomas that require us either to surgically excise the lesions ourselves or refer to someone who might have more experience. The 200-page Facial Reconstruction After Mohs Surgery (Thieme), by James F. Thornton and Jourdan A. Carboy, gives us insight into the techniques used by orbitoplastic specialists and our facial plastics colleagues.

My wife, who is a fellowship-trained Mohs surgeon, took one look at the book and said, “Can I have it when you’re done with it?” That was a good sign.

The book has two sections. The first is organised by type of flaps and grafts, such as cartilage grafts, pedicled flaps and local flaps. The second covers techniques for specific anatomic locations, including forehead reconstruction and complex nasal defects. The chapter on eyelid reconstruction caught my attention and provided me with a fresh review of the complex microvascular anatomy that I memorised quite some years ago.

Although this book is intended for those surgeons whose practice involves significant surgery of facial cutaneous malignancies, orbitoplastic fellows and specialists could use it to enhance their knowledge or update their skills.

If you have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland

EUROTIMES | SEPTEMBER 2018

39

HOSPITAL DIARY

Surgical success

F

Cutting-edge treatment does not happen by itself, says Leigh Spielberg MD, who recently saw history being made

anny Nerinckx has In particular, flawless placement always said that one of the “tack”, which would fasten of the main reasons the implant to the retina, was she had come to work crucial. Erroneous placement in Ghent University might insufficiently stabilise the Hospital was to become involved implant, tear the retina or induce in the treatment of retinal genetic choroidal haemorrhage. But Dr disorders. In Ghent, she found the Nerinckx had spent many hours perfect place. The chairman of our practising this step on a silicone department, Professor Bart Leroy, model, and she was ready. has built a well-known genetics On the morning of the surgery, department, receiving retinal we entered the OR together. degeneration referrals from across Along the left wall, the three the country and beyond. Until nurses readied the enormous recently, none of these patients amount of necessary material. could be treated. But recent Along the back wall, the developments in gene therapy and two representatives from surgical implants have changed SecondSight were setting up the the landscape. So, Prof Leroy, computer equipment required needing an experienced retinal to final-check the implant’s surgeon to help him take the next software. A technician from step, reached out to Dr Nerinckx.

Zeiss was final-checking the It has been a perfect match. microscope’s built-in OCT. Two Seeing her chance, Dr Nerinckx DORC vitrectomy employees decided to set her sights on an were double-checking the epiretinal implant. However, vitrectomy machine so nothing cutting-edge treatment doesn’t unexpected would occur. just organise itself. Yes, there On the medical end, we are patients who are eager to had recruited the head of our participate; yes, the necessary OR’s anaesthesia department, But there’s a lot of co-ordination expertise is present; yes, the Professor Marc Coppens, to manufacturer is always keen make sure the patient’s vital required to make it all fall into place. to supply an implant or genesigns, particularly the blood Co-ordination and teamwork therapy meds. But there’s a lot of pressure, stayed perfectly stable co-ordination required to make it throughout the procedure. all fall into place. Co-ordination and teamwork. A lot of teamwork.

Dr Pierre-Olivier Barale of Paris, a veteran of 12 implants Communication had to be opened between the genetics/ and trainer of many others, was ready to go, while Sandra electrophysiology department and the vitreoretinal department.

Vermeirsch, a third-year ophthalmologist-in-training, helped Of the many patients in follow-up by the genetics team, a patient co-ordinate many of the details. My role as Dr Nerinckx’s had to be selected who suffered from retinitis pigmentosa with light vitreoretinal colleague was to maintain an overview of all that perception in both eyes and had otherwise normal optic nerves. No was going on in the operating room so that she could focus on problem. But this was just the tip of the iceberg. the procedure.

SecondSight, the producer of the Argus II retinal implant, also The atmosphere in the OR seemed tense as the surgery got had to invest time, money and expertise. The university hospital’s under way, but Dr Nerinckx was relaxed and assured. The surgery ethics committee had to approve the surgery. And the hospital’s proceeded flawlessly. There was a palpable release of tension as financial department had to agree to cover the surgical costs, the implant was tacked to the retina and the intraoperative OCT which are not yet reimbursed by the national health service for this showed perfect approximation of the electrode array. A year of indication. We would need a special microscope with intraoperative preparation had gone into this moment and it had all come down OCT capabilities. A surgeon with implant experience would have to this: success. to be present to guide Dr Nerinckx through the procedure. And Dr Nerinckx looked at me and I could see her smile behind her Dr Nerinckx selected the anaesthesia team and the operating room mask. It had all clearly been worth the effort. nurses who would assist on the day of the surgery.

The surgery was the first such in Belgium, and made the The work wouldn’t end with implantation. The hospital’s national news headlines soon thereafter. Since the implantation, Low Vision department had to be willing and prepared to teach the patient has learned to identify objects that are high-contrast the patient how to use the implant, and our ophthalmology compared to the background, such as tableware and door department’s personnel had to be instructed how to direct the handles. She can recognise pedestrian crossings and observe phone calls, inquiries and patient referrals that would suddenly moving objects, which will allow her to cross the street safely and appear after news of the implantation had reached a wider audience. independently. Fascinating.

After many months of preparation, the big day had finally arrived. The surgery itself would be a multi-step combination of Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at scleral buckling, vitrectomy, ILM-peeling and implant placement.

Ghent University, Belgium Illustration by Eoin Coveney

40

EUROTIMES | SEPTEMBER 2018

ESCRS NEWS

Dr Sheng Lim addresses the panel at the ESCRS Academy in Katowice

ESCRS

NEWS

ESCRS Academy visits Katowice The ESCRS Academy in Katowice, Poland, took place on Saturday 8 June during the XLIX Congress of Polish Ophthalmologists. After an introduction by Prof Ewa Mrukwa-Kominek, six speakers presented on cataract surgery in glaucomatous eyes, corneal disease, diabetic patients, patients with loose zonules, previous refractive surgery and multifocal IOLs in co-existing ocular disease.

Dr Sheng Lim gave a talk on optimising cataract surgery in patients with various types of glaucoma. He discussed different scenarios of patients with glaucoma and cataracts with their management algorithms. There was an excellent interactive discussion from the panel following his talk about lens-based surgery in narrow-angle glaucoma.

After that Prof Thomas Kohnen gave a talk on the use of multifocal IOLs in patients with co-existing ocular disease. He touched upon various types of multifocal IOLs including extended depth-of-focus (EDOF) IOL use in patients with stable glaucoma, mild drusens, etc.

This was a very good talk with interesting discussion from the panel.

Prof Béatrice Cochener gave an excellent presentation on cataract surgery in patients with corneal disease. Her talk included managing patients with Fuchs’ endothelial dystrophy and keratoconus with cataracts. This was followed by a very insightful discussion from the panel.

Dr Paul Rosen talked about cataract surgery in diabetic patients.

His talk focused on the prevention of cystoid macular oedema and the use of co-existing medications such as intravitreal steroids, topical NSAIDs, etc for these patients. He gave a very good overview of the management and also touched upon the ESCRS PREMED study part II in relation to cataract surgery in diabetic patients.

I presented on the topic of cataract surgery in eyes with loose zonules. This was a presentation of my surgical videos, giving examples of cases with loose zonules and its surgical management, giving tips for anticipation and prevention of potential complications. This was followed by a very interactive discussion on tips on surgical management in such cases from the panel.

This was followed by Prof Roberto Bellucci’s talk on cataract surgery after previous refractive surgery. He discussed the dilemmas with biometry in such patients and the choice of appropriate IOLs. This was followed by a discussion on choices of IOLs (multifocal, including EDOF and monofocal) in such cases from the panel.

I had the opportunity to meet ophthalmologists from Poland.

The Polish Ophthalmological Society organised a fantastic annual dinner evening for us and for the delegates with a presentation of traditional Polish dance sequences. It was great to meet the members of the scientific and programme committee of the Polish Ophthalmological Society and we were very impressed with their hospitality all throughout the meeting.

Mr Mayank A. Nanavaty, MBBS, DO, FRCOphth, Consultant Ophthalmic Surgeon, Brighton & Sussex University Hospitals NHS Trust.

23rd ESCRS Winter Meeting

ath ens In conjunction with the 33rd HSIOIRS International Congress

15 – 17 February 2019 Megaron Conference Centre, Athens, Greece

Abstract Submission Deadline: 31 October 2018

www.escrs.org

EUROTIMES | SEPTEMBER 2018

41

CHARITY RUN

Winning the race against

PREVENTABLE BLINDNESS Join a charity race to fight blindness while the ESCRS visits Vienna.

Aidan Hanratty reports

V

ienna is a beautiful city by day. By night, under the stars, it shines even brighter. Every year in September, thousands take part in the erste bank vienna night run. Established in 2007, when 3,700 participants were registered, the 5km run takes place along the city’s iconic Ringstrasse, around the historic Old Town. Last year more than 20,000 runners registered for the event.

This September, when the 36th Congress of the ESCRS takes place in Vienna, delegates are encouraged to register and take part in this special event, taking in some of the city’s most famous sights in an unexpected style. Runners will see the Vienna State Opera, Austrian Parliament Building, University of Vienna and more by the autumn moonlight.

The run is organised by Light for the World, a global disability and development organisation established in 1988. With a focus on inclusivity and development, they seek to enable crucial eye health services and empower people with disabilities in some of the poorest

regions of the world. This entails work in the areas of eye health and blindness prevention, as well as advocating for the rights of the blind and vision-impaired in development policies at UN, WHO and EU level.

The charity group has its own team, creating a kind of beacon of hope with its yellow t-shirts, and this year the team will feature Kenyan Paralympians Henry Wanyoike and Francis Karanja. Wanyoike has won medals at three consecutive Paralympic games (golds in Sydney 2000 and Athens 2004 and bronze in Beijing 2008) as well as setting records in marathons and half-marathons worldwide.

Karanja won silver at the Beijing Paralympics in 2008.

Reflecting the inclusivity of the charity, the race is intended to be a fun activity to

be shared with others, especially those with disabilities. There is no prize money as the race is for charity, but the winners will receive a symbolic small statute of a runner with a picture of Vienna.

Since its inauguration the race has raised €800,000 and helped Light for the World give sight back to nearly 27,000 people worldwide. Last year, Light for the World provided medication for nearly 13 million people and provided eye surgery for 93,000 people. Charity tickets are tax-deductible and cost €35.

Joining the race will help contribute to the fight against preventable blindness.

Make this trip to Vienna one to remember by taking part in the erste bank vienna night run 2018!

Please visit www.licht-fuer-die-welt.at/ vienna-night-run-2018 to sign up.

The 5km run takes place along the city’s iconic Ringstrasse, around the historic Old Town EUROTIMES | SEPTEMBER 2018

43

PRACTICE MANAGEMENT

A guide to social media What you don’t say is as important as what you do say.

Aidan Hanratty reports

W

hy should ophthalmologists use social media? A more important question might be: why should ophthalmologists not use social media? Rod Solar, Client Services Director at LiveseySolar Practice Builders, says social media is the place to be to capture all corners of the market. “If you’re not on social media you are definitely missing an opportunity to communicate with a large segment of the population,” he told Kristine Morrill, Founding Partner at consultancy firm medeuronet, in a EuroTimes Eye Contact interview.

From millennials on Twitter to Generation Xers and boomers on Facebook, a social media presence is vital for attracting potential patients. Many traditionalists (aged 73 and older) will ask their children for advice when contemplating surgery, and these will be sure to check out a practice’s social media profile.

When it comes to the character of your profile, your desired market will determine your approach. Millennials love authenticity, but older patients might prefer a more straightforward approach. “They want that professional distance, they’re used to that and they’re comfortable with that,” said Mr Solar.

What you don’t say is as important as what you do say, he adds. “Imagine that you’re sitting in your waiting room, and you’ve got a whole bunch of patients, and you’re answering some questions. Imagine that everything that’s being discussed is being broadcast on every single radio station in the area. Not only that, but there are also cameras, and they’re broadcasting everything that’s happening on television as well.” That gives a hint of the potential reach of your social media platform.

“We’ve all seen things that we laugh at, and sometimes groan and grimace at; this is

not something that we want if it’s something we don’t want representing our practice properly. With that rule in mind, they really can’t go wrong,” Mr Solar explains.

Finally, once you’ve got your head around all the current options, what’s next?

Social messaging, live video and virtual reality. It may seem far off, but don’t be surprised if patients start asking for advice over WhatsApp in the not-too-distant future. After that, you may be guiding patients through your practice while they remain in the comfort of their own home.

“Inviting someone into your practice and having them walk around it, goes well beyond a virtual tour. This creates a virtual reality kind of experience, which might lead to more adoption,” Mr Solar concluded.

This article is based on an EuroTimes Eye Contact interview. See here for more: http://bit.ly/eurotimes-pm-rs

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45

EXPLORING ATHENS

The Acropolis is a sight to behold, especially from the dinner table

ATHENS

3

TO KNOW

AN INTIMATE EXPERIENCE IN THE COMFORT OF SOMEONE ELSE’S HOME Attending a dinner party in a private home is a relatively new concept taking hold in cities around the world. One of the most popular experiences in the Greek capital is dinner with Dimitris and Savvas in their Monastiraki Square apartment, which features a rooftop terrace and a breathtaking view of the Acropolis.

The menu usually includes seven or eight courses, with substitute courses provided for vegetarians. Wine, chat and a traditional Greek welcome assured. If you would prefer lunch, a similar meal is offered by Michail in his apartment, also ‘with a view’. Sometimes Michail is available to pick you up and return you to your hotel. Private dining booking: www.eatwith.com

CLEARING THE AIR ON A SMOKING BAN THAT IS IN FORCE BUT NOT ENFORCED Smoking in Athens restaurants was officially banned in 2009. It’s a regulation widely ignored. In fact, it has been described as a ‘ban on ashtrays’; small plates or other makeshift receptacles are pressed into service and smokers continue to light up. If a non-smoking restaurant is an absolute requirement for you, consider Makalo, which offers fine cuisine at affordable prices. Smoke-free, they initially met with a lot of opposition from smokers but held their nerve and now have regular clients who prefer taste over smoke. Open 12:00 to 23:00.

On Facebook but no website. Nikis 23, Athina 105 57. Phone: +30 21 1406 7032

BE PREPARED TO PAY EXTRA FOR BREAD AND WATER – EVEN IF YOU DON’T EAT IT Check your bill before tipping in a Greek restaurant to see if it has already been rounded up. If not, give between 5 and 10% directly to the waiter (don’t leave it on the table). In a small local restaurant, a tip of 20% is not unusual. You may note that a ‘cover charge’ of a Euro or two has been added. This is for the bread and water – and it’s a standard charge even if you didn’t want them. In any restaurant you may have to ask for the bill – it won’t be presented until you signal you’re ready. Years ago, Greek taxi drivers didn’t expect a tip but nowadays a tip of 5 to 10% or rounding up the bill is appreciated.

Dine like a god

Delegates to the ESCRS Winter Meeting can dine under the (Michelin) stars in Athens. Maryalicia Post reports A fine-dining enthusiast with only a few nights in Athens has to make some hard choices. A city once better known for street food has become a firm favourite with gourmets. High on any connoisseur’s list is a meal at Spondi’s; this long-established restaurant with two Michelin stars is indeed considered ‘worth a detour’. For 12 years it has been listed as the top restaurant in Athens. Its signature dishes include langoustine and lamb. Open for dinner every day. www.spondi.gr Ettore Botrini, the innovative Italian chef at the one-star Botrini’s, has his own faithful following. His attention to detail extends to sourcing many of the oils, salamis and wines used at Botrini’s from the family farm. The restaurant, in a converted suburban school, serves dinner only. Closed Monday. www.botrinis. com. For a night on the glamorous side, try the one-star Hytra in the Onassis Cultural Centre. Two menus are offered; one catering to sophisticated tastes, the other based on simpler ingredients. Dinner served daily. www.hytra.gr For many, however, an evening at Funky Gourmet would be the priority. From its hard-to-find location to its hard-to-describe tasting menus, the theme here is ‘surprise’.

FG’s two young chefs were awarded their first star in 2012 and their second in 2014.

They are of the molecular school of cooking so expect smoke and mirrors with your meal. What looks like a hard-cooked egg is one of the desserts, A round of Greek caviar is coated with chocolate. One of the courses on the 13-course tasting menu is a picnic – the ingredients come to you in a basket; a chequered tablecloth is included along with stones with which to hold the cloth down against an imaginary breeze. There are three menus, with and without wine pairing.

Bookings open a month in advance of your proposed date. Dinner only, closed Monday www.funkygourmet.com All of these restaurants are ‘vegetarian friendly’.

The Varoulko Seaside, one of Athens’ best known and best loved restaurants, is actually in the port town of Piraeus, a 25-minute taxi ride from town. Chef Lefteris Lazarou opened his doors in 1987. At the time, creative cooking and seafood were a novelty in Athens, where meat was the star on every menu. His crayfish moussaka and basil pesto squid on a potato nest made the restaurant an overnight success. A Michelin star followed in 2002. The setting on the Mikrolimano marina is particularly enchanting at night as the maritime-themed dining room opens on to the water. The menu features Greek and Mediterranean dishes, with squid and octopus figuring strongly. The restaurant serves lunch and dinner daily. www.varoulka.gr There are many options to choose from in Athens

EUROTIMES | SEPTEMBER 2018

47

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LASER PULSES

OD-OS has announced that it has achieved the revocation of the MicroPulse™ Patent (Patent no EP1856774) by Iridex Cooperation in oral proceedings at the European Patent office.

Winfried Teiwes, Managing Director, OD-OS GmbH said: “We fully respect the effort Iridex Cooperation has put into the clinical development how tissue-sparing, shorter laser pulses can be effective for retinal treatments. With Navilas®, we are providing a contact-free, easy-to-use and transparent delivery technique of these laser pulses, which allows standardised treatment protocols. We will work with Navilas® users to make microsecond pulse treatment a non-contact, non-damaging but long-lasting treatment in clinical practice, and a viable addition to often chronical injections.” www.od-os.com

ICL LOADING SYSTEM In partnership with MST, Sheraz Daya MD has co-created an ICL loading system that ensures true confidence in loading and positioning, according to a press release announcing the development.

The design of the forceps allows the user to pull the ICL into the injection cartridge, providing safe handling of the implant and allowing for proper positioning, said a spokeswoman for Centre For Sight.

“The rounded edges of the forceps ensure gentle contact with the ICL and the injection cartridge,” said the spokeswoman, “and the viewing window allows for maximum visibility of the optic during loading.” www.centreforsight.com

KATENA ACQUISITION Katena Products has announced the purchase of Blink Medical Ltd, a UK-based provider of primarily single-use ophthalmic instruments.

Founded in 2004, Blink Medical currently distributes its products within Europe and the Middle East.

“The acquisition of Blink Medical strengthens and expands Katena’s offering in highquality ophthalmic instrumentation. Singleuse instruments are important to our strategy and the addition of Blink also offers Katena the benefits of a physical presence in Europe,” said Mark J. Fletcher, CEO of Katena Products. www.katena.com

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TRAINING

Giving trainees ultimate patience

True Dry Eye & Surgical Solutions

Dr Sorcha Ní Dhubhghaill talks about helping ophthalmologists through the learning process. Colin Kerr reports

M

aking the transition from trainee to trainer poses a number of challenges, according to Dr Sorcha Ní Dhubhghaill, anterior segment ophthalmic surgeon, at the Department of Ophthalmology, University Hospital Antwerp, Belgium.

“As a trainee, you are always looking for another case, looking for all of your numbers, but as a trainer you shift very much to being a patient advocate and making sure that all of your training is performed very safely,” said Dr Ní Dhubhghaill.

“While the trainees may be very hungry and enthusiastic, the trainers can sometimes appear rigid and cold,” she said.

“Bridging that divide is so important” Dr Ní Dhubhghaill said that as a trainer she can empathise with the nervousness of her trainees, but she also has to allow her trainees freedom to learn from their mistakes while making sure that she is the guardian of her patients’ safety.

“I feel their nerves, but I’m also very aware that I have to sit on my own hands, because my instinct is to say ‘stop, I’ll take over’. Nobody will ever learn anything if you keep taking it out of their hands.

“Trainees will never be calm from the first surgery. That would be abnormal,” she said. “It’s a new challenge, but managing that stress is very important.”

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BIGGEST CHALLENGES When she was a trainee, said Dr Ní Dhubhghaill, one of her biggest challenges was learning how to focus on what she was doing, without distractions.

“You can spend a lot of time looking around at your other colleagues, but the reality is that you shouldn’t look outside,” she said. “You should look to your own trainer and your own skills and basically run your own race.”

Learning how to be a teacher also requires a new set of skills, says Dr Ní Dhubhghaill.

“It may be a set of skills that wasn't covered in your own training. You have to learn patience and communication, but sometimes you also have to learn how to pick a trainee up from the ground if he or she feels devastated. Sometimes you need to tell them more about what they did well and less about what they did badly to make sure that they turn up to the next surgical session.”

Dr Ní Dhubhghaill says the characteristics of a good trainer are infinite patience and supportiveness.

“You get nowhere by making your trainee more stressed and you should never say: ‘Do it faster!’

That comes with time and experience.”

This article is based on an EuroTimes Eye Contact interview. See here for more: http://bit.ly/ eurotimes-yo-snd

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Dr Sorcha Ní Dhubhghaill EUROTIMES | SEPTEMBER 2018

51

5-8 September 2019

Le Palais des Congrès, Paris, France

www.euretina.org

MY MENTOR

Like father, like son Lampros Lamprogiannis MD reflects on the effect his father had on his career choice

T

he relationship between father and son is thought to be a complicated one, especially when they follow the same profession. A fatherâ&#x20AC;&#x2122;s desire to guide his son into the world of his trade is often at conflict with the sonâ&#x20AC;&#x2122;s lust to set his own path, questioning the past and being drawn to all novelties. Should mutual understanding and respect aid to resolve this inevitable conflict, a father can be a mentor like no other. This is, more or less, the story of the Lamprogiannis family of ophthalmologists.

Since my early childhood, it had become obvious to me that my father enjoyed the respect of his community. Being an ophthalmologist in a small public hospital during the first steps of the Greek National Health Service, not only did he have the opportunity to offer good quality treatment to his patients, regardless of their socioeconomic status, but he also won their hearts, with his warm, downto-earth approach.

His dedication set a paradigm for the role of a physician and led me to the decision to Lampros Lamprogiannis follow in his footsteps.

MD, MSc, FEBO Throughout the following years, he provided his generous support and guidance, helping me to stay on my course and to eventually complete my undergraduate medical training. A milestone in our relationship was my specialty training in ophthalmology under his supervision, as he was the clinical lead of the first department of my rota. During that period, I had the opportunity to observe his work and obtain valuable lessons, not only on a clinical and surgical level but also on the management of patients and maintaining a healthy professional environment.

Unfortunately, this period of our cooperation was abruptly terminated by his death; however, I consider it to have shaped my beliefs and to have deeply affected my future choices.

Hardly a day goes by that his presence is not dearly missed. It is, especially, in times of celebration for academic and professional progress that I particularly wish he was there. I find consolation in the thought that he may have foreseen a promising future for a dedicated young ophthalmologist with solid foundations.

Yet, I cannot help but visualise him holding the latest issue of EuroTimes, in his favourite armchair as he often would, only to see a familiar name among the authors.

I had the opportunity to observe his work and obtain valuable lessons

Reach the peak.

Belong to something impressive. Join us. www.escrs.org

Lampros Lamprogiannis MD, MSc, FEBO Senior Clinical Fellow in Paediatric Ophthalmology Cambridge University Hospitals NHS Foundation Trust

EUROTIMES | SEPTEMBER 2018

53

10th EuCornea Congress

13 â&#x20AC;&#x201C; 14 September 2019 | Paris Expo Porte de Versailles

www.eucornea.org

CALENDAR

↙

LAST CALL

SEPTEMBER 2018

ALACCSA-R LASOA

The 9th EURETINA Winter Meeting will take place in Prague, Czech Republic

6–8 September Santiago, Chile www.alaccsasantiago2018.com

18th EURETINA Congress 20–23 September Vienna, Austria www.euretina.org

9th EuCornea Congress 21–22 September Vienna, Austria www.eucornea.org

2018 WSPOS Subspecialty Day 21 September Vienna, Austria www.wspos.org

36th Congress of the ESCRS 22–26 September Vienna, Austria www.escrs.org

OCTOBER

2019

4–6 October Alexandria, Egypt www.egvrs.org

NEW

6th Egyptian Vitreoretinal Society (EGVRS) Training School

International Annual Course and Workshop on Diagnostic Ultrasound in Ophthalmology 8–11 October Munich, Germany www.echography.com

Ophthalmic Imaging: from Theory to Current Practice 12 October Paris, France www.vuexplorer.com/en/congres

AAO Annual Meeting 2018 27–30 October Chicago, USA www.aao.org

DECEMBER

Arab International Ophthalmology Congress

7–8 December Dubai, UAE www.menaophthalmologycongress.com

FEBRUARY

Cataract Surgery: Telling It Like It Is

6–10 February Florida, USA www.CSTellingItLikeItIs.com

23rd ESCRS Winter Meeting 15–17 February Athens, Greece www.escrs.org

Snowmass Retina & Eye 2019 25 February – 1 March Colorado, USA www.snowmasscme.com

MARCH

9th EURETINA Winter Meeting

1–2 March Prague, Czech Republic www.euretina.org

NEW Retina World Congress

21–24 March Florida, USA www.RetinaWorldCongress.org

The 23rd ESCRS Winter Meeting will take place in Athens, Greece

EUROTIMES | SEPTEMBER 2018

55

CALENDAR

APRIL

The ASCRS•ASOA Symposium and Congress will take place in San Diego, USA

International Meeting of the Egyptian Vitreoretinal Society (EGVRS) 10–12 April Cairo, Egypt www.egvrs.org

NEW 46th EFCLIN Congress Exhibition 25–27 April Brussels, Belgium www.efclin.com

MAY

ASCRS•ASOA Symposium and Congress 3–7 May San Diego, USA www.ascrs.org

JUNE

SEPTEMBER

SOE Congress 2019

10th EuCornea Congress

13–16 June Nice, France www.soevision.org

13–14 September Paris, France www.eucornea.org

SEPTEMBER

19th EURETINA Congress

14-18 September Paris, France www.escrs.org

WSPOS Subspecialty Day

5–8 September Paris, France www.euretina.org

13 September Paris, France www.wspos.org

OCTOBER

AAO Annual Meeting 12–15 October San Francisco, USA www.aao.org

9th EURETINA Wi n ter Meet i n g

Prague 2019 1–2 March 2019 Clarion Congress Hotel Prague, Czech Republic

www.euretina.org EUROTIMES | SEPTEMBER 2018

SEPTEMBER

37th Congress of the ESCRS

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