EuroTimes Vol. 22 - Issue 5

SPECIAL FOCUS CATARACT & REFRACTIVE LASER CORNEA

ENHANCING CORNEAL CROSSLINKING SAFETY

RETINA

THE FUTURE OF IMAGING

GLAUCOMA

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Conor Ward Senior Designer Lara Fitzgibbon

CONTENTS

Designer Monica De Iscar Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Pippa Wysong Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird Printers 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

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS CATARACT & REFRACTIVE LASER 4

Cover Story: FLACS – What lies ahead?

8 ESCRS FLACS study is yielding useful and interesting data

9 OCT technology is the future for ocular biometry

11 Topography-guided PRK and CXL

FEATURES CATARACT & REFRACTIVE 12 Everything you ever wanted to know about white cataract phacoemulsification

14 Conventional biometry methods less predictable

16 Six requirements

for reducing error and eliminating refractive surprise

17 JCRS Highlights

CORNEA 19 Visual acuity and

quality of vision after ultra-thin DSAEK and DSAEK

20 New presbyopia 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.

treatments should be grounded on solid understanding of accommodation

21 Epi-on appears to be safe but provides no added benefit

www.eurotimes.org

22 CXL for keratoconus

effective in vast majority of patients

23 New metrics for CXL should lead to better treatment

RETINA 25 The future of imaging for vitreoretinal surgeons

26 3D imaging provides

better retinal diagnostics

28 Researchers

looking for more effective additive treatments

29 Ophthalmologica Update

P.43 OCULAR 36 Study looks at link

between cataract and depression

GLAUCOMA 31 Evidence-based dietary, exercise and sleep practices can reduce glaucoma risk

32 Unique value of clinical examination has cornerstone role in glaucoma patient care

33 Neuroprotection, enhancement and regeneration agents entering clinical trials

P.12

REGULARS 38 Research 41 Ask The Experts 43 Random Thoughts 44 ESCRS News 45 Book Reviews 46 Exploring Lisbon 47 Calendar CME MONOGRAPH

FOCUS ON GLAUCOMA MANAGEMENT:

IOP Control and Quality of Life Improvement

FACULTY

Original Release: May 1, 2017

Norbert Pfeiffer, MD (Chair and Moderator) Gábor Holló, MD Cindy M. L. Hutnik, MD, PhD Tarek M. Shaarawy, MD, MSc, PD

Last Review: April 14, 2017 Expiration: May 31, 2018

Visit http://tinyurl.com/IOPcontrol for online testing and instant CME certificate.

Distributed with Jointly provided by New York Eye and Ear Infirmary of Mount Sinai and MedEdicus LLC.

This continuing medical education activity is supported through an unrestricted educational grant from Santen Pharmaceutical Co, Ltd.

Included with this issue...

MedEdicus supplement EUROTIMES | MAY 2017

2

EDITORIAL A WORD FROM PROF THOMAS KOHNEN

FLACS – WHERE ARE WE? We have many questions to answer and need more trials before we establish a clear verdict on the efficacy of the procedure

H

ow quickly the time goes! It is already May and Our Editorial Board includes many of the key opinion in five months’ time we will convene the XXXV leaders in ophthalmology and I think this new feature will be a Congress of the ESCRS in Lisbon, Portugal. valuable addition to the magazine.

I am delighted to accept the invitation to As chairman of the ESCRS Publications Committee and write the editorial in this issue of EuroTimes European Editor of the Journal of Cataract and Refractive which looks at some of the hot topics we will be Surgery, I am also very pleased to announce that our journal discussing in Lisbon. has been redesigned to make it easier to read and more The Cover Story reviews the progress of attractive to our readers. femtosecond laser-assisted cataract surgery The journal is the official ... as FLACS enters its 10th (FLACS), almost 10 years after my friend and publication of the American Society colleague Zoltan Z Nagy performed the first of Cataract and Refractive Surgery year, we still have many femtosecond laser-cut anterior capsulotomy in a (ASCRS) and the ESCRS and the questions to answer and human patient in August 2008. continued co-operation of the two we will need more trials So where are we now? As Howard Larkin points societies will ensure the continued before we can establish out in a very thought-provoking article, FLACS success of the publication. looked like it could be the biggest innovation in Finally, I would like to pay a a clear verdict on the cataract surgery since foldable intraocular lenses warm tribute to my good friend long-term efficacy of (IOLs) 20 years earlier. and colleague Rudy Nuijts who the procedure But as FLACS enters its 10th year, we still have earlier this year stepped down many questions to answer and we will need more trials from his position as Treasurer before we can establish a clear verdict on the long-term efficacy of the ESCRS. I have the honour of succeeding Prof Nuijts as of the procedure. treasurer and would like to thank him for the excellent work My colleague Rudy MMA Nuijts suggests that for routine he has done during his term in office. His will be big shoes to cataract surgery FLACS is not a game changer in the way that fill, but I look forward to taking on the challenge of this very phaco was, but he also notes that it is still in its infancy and is prestigious position. likely to develop further in years to come.

Large-scale randomised trials are needed to clarify the issue, so it will be interesting to see where we are in another five years’ time.

EuroTimes, as the official news magazine of the ESCRS, will play a major part not only in reporting on the latest developments in FLACS, but also looking at the bigger picture of how cataract and refractive surgery evolves in the future.

Even for the most experienced surgeon, there are often more questions to be asked than answers to be delivered. For that reason, we are introducing a new series, “Ask The Experts”, Prof Thomas Kohnen is Treasurer of the ESCRS, Chairman of the ESCRS Publications Committee and European Editor of the where we ask readers of the magazine to put questions forward Journal of Cataract and Refractive Surgery. to our International Editorial Board.

MEDICAL EDITORS

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), Alaa El Danasoury (Saudi Arabia), Oliver Findl (Austria), I Howard Fine (USA), Jack Holladay (USA), Soosan Jacob (India), Vikentia Katsanevaki (Greece), Anastasios Konstas (Greece), Dennis Lam (Hong Kong), Boris Malyugin (Russia), Marguerite McDonald (USA), Cyres Mehta (India), Thomas Neuhann (Germany), Rudy Nuijts (The Netherlands), Gisbert Richard (Germany), Leigh Spielberg (The Netherlands), Sathish Srinivasan (UK), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Emrullah Tasindi (Turkey), Marie-José Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy), Roberto Zaldivar (Argentina), Oliver Zeitz (Germany)

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4

COVER STORY: CATARACT & REFRACTIVE LASER

A DECADE OF

Precise capsulotomies, complicated cases and premium lenses may be best uses, though costs and limited advantages keep it a niche player for now.

Howard Larkin reports

or years after Zoltan Z Nagy MD performed the first femtosecond laser-cut anterior capsulotomy in a human patient in August 2008, femtosecond laserassisted cataract surgery (FLACS) pulled standing-room-only crowds at ophthalmology meetings around the world. With its ability to create perfectly round, precisely centred capsulotomies far more predictably than could skilled surgeons, and reducing EUROTIMES | MAY 2017

harmful phaco ultrasound energy by fragmenting the nucleus, FLACS looked like it could be the biggest innovation in cataract surgery since foldable intraocular lenses (IOLs) 20 years earlier.

Yet scepticism ran as high as interest.

Forty years of development had transformed manual phacoemulsification cataract extraction into one of the most elegant and successful of all surgical procedures. Visual outcomes and patient satisfaction were excellent, as were safety, efficiency and costeffectiveness – setting a very high bar for clinically meaningful improvement.

Moreover, while FLACS could reduce

the need for phaco, a phaco machine was still required to liquefy and aspirate the nucleus and cortex. FLACS lasers also needed extra floor space and a modified surgical flow, adding to procedure time.

So, the question arose, why spend €400,000 for a complicated laser that decreased operating room efficiency, but didn’t deliver patient outcomes measurably better than some forceps or bent needle?

As FLACS enters its 10th year of human use, this question remains pertinent.

Despite hundreds of studies, clear evidence of a clinically meaningful advantage for FLACS remains elusive, at least for its

COVER STORY: CATARACT & REFRACTIVE LASER

CAPSULOTOMY Anterior capsulotomy was the first FLACS capability demonstrated in humans, and may still be the one most commonly used.

In the ESCRS-EUREQUO study, the laser was used in 99% of the FLACS cases, followed by nucleus fragmentation in 95%, corneal incisions in 35% and arcuate astigmatic incisions in 5%.

Dr Nuijts uses FLACS primarily for premium IOL cases, both multifocal and toric. “The big advantage is the capsulotomy is more predictable in shape and size, and with premium lenses you want to have the capsule edge completely covering the optic.”

This prevents the capsule from healing asymmetrically, with the anterior and posterior leaves fibrosing together where the capsulotomy runs off the IOL optic,

POSTOPERATIVE COMPLICATIONS 

Any reported postoperative complication – – – – – – –

Cornea edema Early PCO reducing vision Uveitis with need of treatment High IOP with need of treatment Explantation Endophthalmitis “Other” vision-threatening compl.

113 (3.3%) 15 (0.4%) 26 (0.8%) 13 (0.4%) 4 (0.1%) 3 (0.1%) 0 58 (1.7%)

Table 1

which can tilt or rotate the lens, Dr Nuijts explained. While this doesn’t affect the performance of a monofocal lens much, it can introduce optical aberrations in multifocal lenses and astigmatism with toric lenses. “The incidence is quite low, but you want to prevent that, especially in people who have contributed extra to their own treatment. It takes predictability to the next level.”

In studies conducted by Dr Nagy, of Semmelweis University, Budapest, Hungary, lenses implanted in eyes with FS capsulotomies showed less tilt than those in eyes with manual capsulorhexes, as well as less coma and total higher order aberrations.

However, this did not have a big impact on visual outcomes, he said in an interview in the EuroTimes’ Eye Contact podcast series.

Large studies comparing outcomes with the same lens implanted in manual and FLACS eyes are needed to demonstrate the difference, he noted.

Dr Nuijts said that FS laser capsulotomy is useful for treating capsule phimosis.

“You size the capsulotomy and cut out the phimosis, make an incision, put in viscoelastic and remove the rim.”

FS capsulotomies are also an advantage in patients with Marfan’s, subluxated lenses or other capsule instability because there is no movement of the lens that might affect circularity, which can be a problem attempting a manual capsulorhexis, said Boris Malyugin MD, PhD, Professor of Ophthalmology at the S. Fyodorov Eye Microsurgery State Institution, Moscow, Russia. Laser capsulotomy is also useful for white cataracts with less risk of a large capsular tear often seen when attempting a manual capsulorhexis.

Dr Malyugin noted that while precisely sized and centred FS capsulotomies promote even healing for premium lenses, they might also be more prone to anterior capsule tears.

Dr Nagy said that the problem can be decreased by reducing laser power resulting in a smoother capsulotomy edge. Tearing the cap in a circular motion around the edge as with a capsulorhexis, rather than trying to pull it off from the centre may also help avoid tears in cases where the laser cut leaves attached tags, Dr Nagy said.

LENS FRAGMENTATION Laser lens fragmentation helps reduce stress on weakened ocular structures in eyes with Marfan’s and pseudoexfoliation, Dr Malyugin said. Reduced phaco time enabled by pre-fragmentation may also be helpful for eyes with compromised endothelium, such as Fuch’s, which make up about 4% of cataract patients.

Dr Agarwal finds the FS laser especially useful for hard brown cataracts, though not so much for white cataracts, which reflect the laser light. He also uses the FS laser for intumescent cataracts, paediatric cases and patients with shallow anterior chambers.

Studies by H Burkhard Dick MD, Bochum, Germany, and others have shown that laser fragmentation can completely eliminate the need for phaco in softer cataracts, and even speed up the procedure.

However, fragmenting softer lenses can actually make cortex removal more difficult, adding as much as five minutes to the procedure overall, noted Dr Agarwal, who recently published a review on FLACS with Soosan Jacob MD (Curr Opin Ophthalmol. 2017;28(1):49-57.)

CORNEAL INCISIONS Dr Nagy noted that the corneal multiplanar incisions were more central at the beginning than was intended. This lead to a redesign of the patient interface, so that it is now possible to place the corneal incisions where the surgeon wants to put them.

Dr Malyugin noted that studies show multiplanar corneal incisions cut by FS lasers are less prone to leakage than manual incisions. However, current FLACS systems may not give enough flexibility in where these incisions are placed, which could result in greater induced astigmatism.

“The lasers place the incisions on a circle, but in most cases the cornea is an oval with horizontal diameter bigger than vertical,” Dr Malyugin said. As a result, if the main incision is closer to the limbus, the paracentesis is a little closer to the centre than is ideal, or vice versa. He looks forward to a new generation of software that will allow correction of this issue, but for now he prefers to use disposable metal blades.

EUROTIMES | MAY 2017

Courtesy of Mats Lundström MD, PhD

routine use in uncomplicated cases of implanting monofocal lenses.

For example, a large case-control study using data from the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) compared visual, refractive and safety outcomes of 2,814 patients undergoing FLACS procedures with 4,987 patients undergoing conventional phaco cataract surgery matched for age, preoperative visual acuity, and similar number of ocular co-morbidities and surgical difficulty variables. It found conventional outcomes were slightly better than FLACS on average. (Manning S et al. J Cataract Refract Surg Dec 2016; 42:1229-1790.)

Similarly, small differences, though mostly favouring FLACS, were found by a meta-analysis of 42 studies comparing outcomes of 9,400 eyes undergoing FLACS with 8,779 undergoing conventional manual phaco conducted by Thomas Kohnen MD, PhD, Professor and Chair of the Department of Ophthalmology at Goethe University, Frankfurt, Germany.

“It appears for routine cataract surgery there is not a very big difference [with FLACS]; it is not a game changer in the way that phaco was,” said Rudy MMA Nuijts MD, PhD, Professor of Ophthalmology at the University Eye Clinic Maastricht, The Netherlands. Largescale prospective randomised clinical trials are needed to nail down what, if any, advantages FLACS offers for routine cataract care, and these are under way in France and the UK. However, many surgeons find FLACS valuable for certain niche applications, said Ashvin Agarwal MD, Dr Agarwal’s Eye Hospital, Chennai, India. These range from improving the performance of multifocal and toric IOLs to lens pre-fragmentation reducing risk in complex cases involving zonular dehiscence, intumescent cataracts, very hard nuclei or traumatic injury. A summary of some current productive uses – and limits – of FLACS follows, by surgical stage.

5

COVER STORY: CATARACT & REFRACTIVE LASER

ARCUATE INCISIONS Correcting astigmatism with FS-cut arcuate incisions can be much more precise than manual incisions, in part because the incisions made at surgery do not penetrate, and can be opened up as needed after surgery. Iris registration helps ensure incisions are not displaced due to cyclotorsion, though issues with alignment and even corneal perforation and misregistration leading to grid profile incisions have been reported, Dr Agarwal noted.

Dr Nuijts has used arcuate incisions, but prefers toric IOLs as an astigmatism solution. “In our hands, toric IOLs are more predictable,” he said.

COMPLICATIONS While FLACS complication rates are similarly low compared with manual cataract surgery, some complications are more common. Pupil contraction, apparently resulting from the release of prostaglandins due to FS laser exposure, is one. A team led by Dr Nagy analysed the reason of pupillary constriction and they found that the reason behind it is partly due to significant increase in the prostagladin level (PG-E) in the aqueous. “This can be completely prevented by dropping nonsteroid anti-inflammatory drops (NSAIDS) a day before. Other reasons for pupillary constriction might be the mechanical effect of the bubbles created during the capsulotomy,” said Dr Nagy.

Dr Malyugin said that in an early series of FLACS in his clinic, he was surprised to see a significant proportion of patients having pupil constriction after femtosecond laser application. Dr Malyugin now manages this problem by giving FLACS patients topical NSAIDS for one to two days before surgery.

Iris hooks or a Malyugin ring may also be used, though small pupils generally are a contraindication for surgery, Dr Agarwal said. Bubbles trapped in the capsule also can lead to posterior capsule ruptures if not allowed to dissipate before nucleus removal.

ESCRS-EUREQUO STUDY In an ESCRS-EUREQUO study examining all 3,379 FLACS procedures collected for the case-control study, including 562 that were excluded for lack of a control match, FLACS procedures had a total complication rate of 3.3%, compared with 2.3% for conventional surgery.

However, only 1.0% of these were “classic” complications, such as posterior capsule ruptures, while 1.9% were directly related to the FLACS procedure, said Mats Lundström MD, PhD, at the XXXIV Congress of the ESCRS in Copenhagen, Denmark. “Some of these complications are not a problem; they are not visionthreatening. They were complications we were looking for with this new technique.”

(See Table 1.)

EUROTIMES | MAY 2017

Courtesy of Rudy MMA Nuijts MD, PhD

6

Case #2: M, 61 yrs, OD: Toric IOL Tilting

THE FUTURE Dr Nuijts noted that FLACS is still in its infancy and is likely to develop further in years to come. He looks forward to the results of large-scale controlled trials that may shed more light on theoretical FLACS advantages, such as better lens stability that might improve visual outcomes.

Dr Malyugin believes routine cataract surgery will one day be completely automated. “Computers are smarter than humans. They play chess, they drive cars, why not teach them how to do surgery?”

A skilled surgeon would still be required to run the machine and intervene in case of complications, he noted.

What really holds back FLACS technology, however, is the cost, Dr

Agarwal believes. FS systems also need to be easier to use and small enough to fit in existing surgical theatres. “A lot of new machines break through immediately, but the femtosecond laser was not one of them. People still have a lot of questions. If it was quarter of the price a lot of people would say it helps in some cases,” he said.

Sonia Manning: sonia.sofia1@gmail.com Zoltan Nagy: Zoltan.nagy100@gmail.com Boris Malyugin: boris.malyugin@gmail.com Rudy Nuijts: rudy.nuijts@mumc.nl Ashvin Agarwal: agarwal.ashvin@gmail.com Mats Lundström: mats.lundstrom@ karlskrona.mail.telia.com

Eye Contact l Dr Oliver Findl interviews

Dr Zoltan Nagy on FLACS.

http://player.escrs.org/eurotimeseye-contact/femtosecond-laserassisted-cataract-surgery

l Sean Henahan interviews

Dr Boris Malyugin on FLACS. http://player.escrs.org/eurotimes-eye-contact/where-are-wenow-with-flacs-boris-malyugin

LISBON2017 7–11 OCTOBER

XXXV Congress of the ESCRS FIL – Feira Internacional de Lisboa, Portugal

Main Symposia The Irregular Cornea



Changing Pharmaceutical Treatment Patterns in Cataract Surgery



Building a New Eye



Intrastromal Lenticule Extraction: To smile or to Cry?



Six Years On: Is FLACS a Better, Safer Operation than Phaco?



Binkhorst Medal Lecture Boris Malyugin RUSSIA

Cataract Surgery in High-Risk Eyes: Lessons Learned

Scientific Programme, Registration & Hotel Bookings

www.escrs.org

8

SPECIAL FOCUS: CATARACT & REFRACTIVE LASER

ESCRS FLACS STUDY Femtosecond Laser-Assisted Cataract Surgery Study continues to yield useful and interesting data. Dermot McGrath reports

D

elving deeper into the ESCRS Femtosecond Laser-Assisted Cataract Surgery (FLACS) Study yields some interesting data concerning visual and refractive outcomes as well as complications related to the procedure, according to Mats Lundström MD, PhD. “Analysis of the data showed that visual and refractive outcomes with FLACS were good overall, and that the cases with a poor outcome seem to be related to the indications for surgery rather than the technique itself. We also found that some surgical complications were related to the technique, but most of these were minor and had no consequence on the visual outcomes,” said Dr Lundström.

Designed to evaluate the outcome of FLACS from the patient’s perspective in terms of visual outcome, refractive outcome and complications, the prospective ESCRS FLACS Study drew on the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) online platform for collecting surgical outcome data, explained Dr Lundström, of Lund University, Sweden.

The main finding from the study, presented at the XXXIII Congress of the ESCRS in Barcelona, Spain, was that FLACS was as good as routine phacoemulsification but did not outperform it.

Dr Lundström said that parameters significantly related to the visual outcome included preoperative visual acuity (VA), ocular comorbidity, postoperative complications and surgical difficulties.

“These are all aspects familiar to us from phaco studies. Parameters significantly related to a worse visual outcome, defined as two logMAR units or more in

Analysis of the data showed that visual and refractive outcomes with FLACS were good overall...

Mats Lundström MD, PhD

37 cases, were related to postoperative complications, ocular comorbidity, and preoperative VA,” he said.

While the overall refractive outcomes were good, detailed analysis of each clinic’s results showed room for improvement in terms of predictability, added Dr Lundström.

“Some clinics made their patients more myopic or hyperopic than intended. This is something we need to remember when we plan to use multifocal or trifocal intraocular lenses (IOLs) for such patients,” he said.

Surgical complications occurred in 99 cases overall (2.9%), broken down into classical complications such as capsular rupture and vitreous loss in 33 cases (1%) and laser-related complications in 66 (1.9%).

The laser-related complications included 27 incision-related complications (0.8%), capsulorhexisrelated complications in 18 cases (0.5%), minor anterior capsule complications in 19 (0.5%), and the laser approach had to be abandoned in three cases (0.1%).

“It is important to emphasise, however, that some of these complications are not a problem for vision but were identified as part of the study protocol to evaluate this new technique,” he said.

COMPLICATIONS The rate of postoperative complications with a follow-up of two months from time of surgery was 3.3% or 113 cases:

NEW EuroTimes India Website Now Live!

www.eurotimesindia.org EUROTIMES | MAY 2017

persistent corneal oedema in 15 (0.4%); early posterior capsule opacification reducing vision in 26 (0.8%); uveitis with need of treatment in 13 cases (0.4%); high intraocular pressure with need of treatment in four (0.1%); explantation in three (0.1%); and other vision-threatening complications in 58 (1.7%).

Overall, patients with worse visual outcome tended to be young (mean age 60), with good preoperative VA and a high percentage of ocular comorbidity, said Dr Lundstrom. Patients with poor refractive outcome were also characterised by young age (mean 62), a high percentage of previous corneal refractive surgery (14.1%), and poorer preoperative VA (median 0.3). Patients with postoperative complications were characterised by over-representation of glaucoma, other coexisting eye disease, surgical complications and multifocal IOLs. Dr Lundström emphasised that the study was not a clinical trial and was not designed to evaluate the performance of different laser platforms. “This is a registry study of what is happening in the real world. If we want to go into more detail and get more information, we need more randomised clinical trials,” he concluded.

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

SPECIAL FOCUS: CATARACT & REFRACTIVE LASER

OCT BIOMETRY SS-OCT more accurate and informative than older optical biometry technologies. Roibeard Ó hÉineacháin reports

N

ew swept-source optical coherence tomography (SS-OCT) biometry devices such as the IOLMaster® 700 (Zeiss) can successfully scan axial lengths in denser cataracts than was possible with previous optical biometry devices, and can confirm fixation and screen for macular disease at the same time, according to Nino Hirnschall MD, PhD, Vienna Institute for Ocular Surgery, Hanusch Hospital, Vienna, Austria.

“I think that OCT technology is definitely the future for ocular biometry,” he said.

He noted that, among the more than one million cataract surgeries in the EUREQUO database, 12% were more than 1.0D off target. A large part of that has been due to the inability of optical biometers to successfully scan dense and subcapsular cataracts. In such cases cataract surgeons have often relied on ultrasound measurements, which are much less reliable than a successful optical biometry scan.

Newer optical biometry devices using SS-OCT are bringing the number of eyes that cannot be successfully scanned ever closer to zero. He noted that, in a study conducted by Dr Oliver Findl’s team at Hanusch Hospital involving 1,226 consecutive eyes, 6.4% could not be measured with an IOLMaster 500 partial coherence interferometry (PCI) optical biometer, whereas all but 0.5% could be successfully scanned with SS-OCT technology.

Poor fixation is another source of error in biometry measurements which SS-OCT devices can correct. Its B-scans provide a crosssectional image of the entire eye including the retina. Therefore, if the fovea pit is not visible in the image it means the patient is not fixating properly, and consecutive scans will be less accurate and consistent.

He described the case of an eye where the foveal pit was not visible in two consecutive scans with the IOLMaster 700 and the measurements differed by 190μm in axial length and by 0.5D in keratometry. However, in a different eye where the foveal pit was visible, two consecutive scans differed by only 10 microns in axial length and 0.02D in keratometry.

The longitudinal scans provided by SS-OCT also enable the surgeon to check for macular disease in their cataract patients.

He noted that he and his associates found the IOLMaster 700 to have a moderate sensitivity (between 42% and 68%), high specificity (89% to 98%) for detecting the condition among 55 healthy eyes and 65 with macular disease. The conditions were definitively diagnosed by dedicated spectraldomain retinal OCT (RTVue OCT, Optovue). Intra-observer reproducibility with the biometry device was 88.3% among the three examiners participating in the study.

IMPROVING TORIC IOL CALCULATION The new SS-OCT devices also offers two new intriguing possibilities for the improvement of toric intraocular lens (IOL) calculation, namely the detection of lens tilt and the

We still have the problem of shift of the lens during the first weeks after surgery but this is minor in most modern lenses

measurement of the posterior corneal surface, Dr Hirnschall said.

Regarding the measurement of the cornea’s posterior surface, Dr Hirnschall noted that while there have been devices available in recent years credited with that ability, their accuracy is limited by their speed. He noted that a study, which Dr Peter Hoffmann from Germany conducted together with Dr Findl and Dr Hirnschall himself, showed that SS-OCT outperformed the Scheimpflug rotating camera, automated keratometry with the Lenstar, and topography in predicting residual astigmatism after cataract surgery.

INTRAOPERATIVE BIOMETRY However, even the best preoperative measurements can provide only an estimation of the position of the implanted IOL. That is because the combination of accurate axial length, anterior chamber depth and lens thickness values still leave uncertainty regarding the equatorial plane of the empty capsule and therefore the haptic plane of the implanted lens.

Yet once again, OCT may provide a partial solution, thanks to the relative ease with which it can be employed intraoperatively. He noted that he and his associates have been working with a prototype set-up for intraoperative measurements using a Visante anterior segment OCT combined with a surgical microscope.

So far, in a study involving 164 patients, they have found that had they used the intraoperative OCT anterior chamber depth measurements as the haptic plane in their IOL calculation they would have had a better refractive outcome than those achieved using preoperative measurements.

“We still have the problem of shift of the lens during the first weeks after surgery but this is minor in most modern lenses. So the main problem with predicting the position of the lens is definitely improved,” he added.

Nino Hirnschall: nino.hirnschall@gmail.com

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SPECIAL FOCUS: CATARACT & REFRACTIVE LASER

POST-LASIK ECTASIA Topo-guided PRK and CXL effective for progressive cases.

Howard Larkin reports

T

opography-guided partial photorefractive keratectomy (PRK) combined with corneal crosslinking (CXL) has proven an effective treatment for progressive post-LASIK ectasia and visual rehabilitation over 12 years, A John Kanellopoulos MD told Refractive Surgery Day at the 2016 American Academy of Ophthalmology Annual Meeting in Chicago, USA. Known as the Athens Protocol, the combined procedure is therapeutic rather than corrective for refractive error. It commonly has minimal refraction added as the normalisation alone reaches the 50µm maximum tissue removal from the cone apex, said Dr Kanellopoulos, of Athens, Greece, and New York City, USA. Over the past 12 years, he and his colleagues have treated more than 3000 keratoconus and post-LASIK ectasia patients with the Athens Protocol, and have trained hundreds of surgeons globally on technique and potential complications management.

ENDO The real ARGON experience

REVISED PROTOCOL Dr Kanellopoulos now performs the customised partial-PRK first, because it is cyclorotation-sensitive. Phototherapeutic keratectomy (PTK ) is then performed second to remove the tissue amount relating to the epithelium (this is not cyclorotation-sensitive), followed by application of mitomycin-C, and 15 minutes of accelerated CXL at 6mW/cm2.

The Athens Protocol has advantages over alternatives such as CXL alone, which does little to address corneal aberrations, thus a great and growing number of surgeons have adapted it globally, Dr Kanellopoulos added. "We have reported detailed outcomes for over 1000 cases so far, both short term and long term, along with potential complications of delayed epithelialization, overcorrection and scarring," he said.

"However, it should be optimally used in progressive ectasia patients intolerant to contact lenses, and preferably not in stable patients successfully managed with gas-permeable, and/ or scleral contact lenses," said Dr Kanellopoulos.

Post-LASIK ectasia can appear years after corneal refractive surgery and can progress at any age in contrast to keratoconus that usually slows down after 40. Dr Kanellopoulos credits screening criteria, including the Randelman ectasia risk score, for reducing ectasia rates. “Proper screening is the best management, hands down,” he said. "We have additionally reported some more complex screening landmarks that derive from corneal epithelial mapping and anterior corneal power asymmetry indices." However, some patients with no risk factors develop ectasia, which is puzzling. “There is a lot we don’t know about corneal biomechanics escpecially after laser vision correction,” Dr Kanellopoulos said.

Eye-rubbing may be an under-appreciated cause. “In my personal experience of over 100 post-LASIK ectasia cases evaluated, it’s almost always associated with eye-rubbing.

We have to caution patients that eye rubbing is a strict contraindication for laser refractive surgery, and for LASIK in particular,” he said.

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John Kanellopoulos: ajkmd@mac.com EUROTIMES | MAY 2017

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CATARACT & REFRACTIVE

WHITE CATARACT PHACOEMULSIFICATION Everything you ever wanted to know about white cataract phacoemulsification part 1.

Dr Soosan Jacob reports

A

white cataract may be age related or otherwise. Senile white cataract can be mature intumescent cortical cataract, hypermature cataract or hypermature Morgagnian cataract. A traumatic cataract with broken lens capsule may also present as a white cataract as also membranous traumatic/ congenital cataracts with resorption of lens proteins. Senile white cataracts can be intumescent white with cortex liquefaction, white with large nuclei and less cortex or white with fibrosed anterior capsule (Brzitikos et al). White cataracts are challenging at numerous points of surgery.

CHALLENGES WITH RHEXIS A soft eye with a good peribulbar block, pinkie ball application and preoperative intravenous mannitol is important. Tight speculum and bridle suture should be avoided. Lack of red glow and release of milky fluid on creating the initial puncture makes visualisation of the leading edge of rhexis difficult. The anterior capsule may be thin and fragile or fibrosed, both of which further compound difficulty. Increased intra-lenticular pressure makes the anterior capsule convex, increasing the risk of a rhexis run-out. The intra-lenticular pressure in an intumescent white cataract is quite high and the initial nick on the anterior capsule can extend rapidly to both sides resulting in the “Argentinian flag sign�

- a potentially dangerous situation.

The rhexis is done through a partially opened main port or a side port in order EUROTIMES | MAY 2017

to prevent escape of viscoelastic and better maintain a taut anterior chamber (AC). Trypan blue dye injected under a small air bubble is used for staining the capsule to enhance visualisation. A trisoft shell technique may also be used where a viscodispersive ophthalmic viscosurgical device (OVD)(eg. Viscoat) is first injected on the anterior capsule for approximately 25% fill, followed by viscoadaptive OVD (eg. Healon5) under this which pushes the viscodispersive upwards to coat the endothelium. A small amount of Trypan blue is then painted in a back-and-forth manner over the anterior capsule. An endoilluminator also helps improve visualisation.

High molecular weight/cohesive OVD is used to increase AC pressure and prevent a radial run-out of the rhexis. For initiating rhexis, an initial

puncture into the anterior capsule with the cystitome followed immediately by aspiration of liquefied cortex through the cystitome needle helps rapidly decompress the cataract and decrease intra-lenticular pressure. Gentle rocking of nucleus helps release both anterior and posterior liquefied cortex. The initial cut should not be initiated with forceps as a large cut can be uncontrolled and result in a rapid run-out. Milky fluid released in the AC is aspirated after decompressing the lens. After the initial puncture and aspiration with cystitome, it is easier to continue the rhexis with a microforceps as the liquefied cortex does not offer support to the cystitome tip. A two-step rhexis can be done where an initial small CCC/ mini-rhexis is secondarily enlarged just prior to IOL implantation. OVD is refilled when

A,B: Initial puncture on the lens capsule in intumescent white cataract resulting in Argentinian flag sign

CATARACT & REFRACTIVE

HYDRO PROCEDURES:

C - Milky fluid released obstructs visualisation; D - A forceps is better than cystitome to complete rhexis

necessary to keep the anterior capsule flat. The Little rhexis trick is employed in case of outwards extension of rhexis.

The capsule flap is unfolded to lie flat.

While holding it as close to the root of the tear as possible, it is first pulled backwards in a horizontal plane along the circumference of the completed segment of rhexis and then with the flap held stretched, directed more centrally to initiate the tear. If the rhexis runout is irretrievable, it may be attempted to be completed by creating a cut on the flap and continuing forwards or by creating a nick on the opposite side and completing it backwards. Alternatively, a can-opener capsulotomy can be done in the incomplete area. All precautions for phacoemulsification with a torn rhexis should be employed. Phacocapsulotomy utilises the phaco tip to simultaneously create an initial anterior capsular puncture and remove some of the lenticular material following which a forceps completes the rhexis.

An Argentinian flag sign is seen in intumescent white cataract. Risk factors

include diabetes, UV exposure, steroid usage etc. As Trypan blue stiffens and makes the capsule brittle, it has also been proposed as a risk factor. If a split is seen, the AC pressure should be immediately increased with cohesive OVD to prevent a wraparound tear.

A perpendicular relaxing cut is made on one of the leaflets which is then joined on the other side as a partial circular tear.

A fibrosed and calcified anterior capsule may be seen in some hypermature cataracts, membranous congenital cataracts or as post-traumatic sequelae – the rhexis is started in a normal area and circumnavigated around the affected area to include it. If not possible, microscissors or vitrector may be used in the affected zone in which case, subsequent manoeuvres should be as described for torn rhexis.

Femtosecond laser assisted cataract surgery (FLACS) may be utilised for rhexis. Milky fluid released may interfere with subsequent cuts resulting in microadhesions that need to be manually released. A fibrosed capsule needs higher energy levels to be cut.

In mature white cataracts that have large nuclei and less cortex, hydrodissection may result in the fluid wave being trapped behind the nucleus. Further injection of fluid can cause fluid to build up within the capsular bag resulting in capsular block syndrome and a capsule blow-out with resultant risk of drop of a large nucleus into the vitreous cavity. This should be avoided by very gentle, multi-quadrant hydrodissection using a low volume of fluid as well as by gently rocking the nucleus to allow fluid trapped behind the nucleus to flow out. A thorough cortical cleaving hydrodissection is not mandated as there are generally very little cortical fibres that are adherent to the capsule and most cortex if present is either in a liquefied form or can be easily washed out.

Hydrodelineation need not be attempted as there is generally no epinucleus. In cases of traumatic white cataracts, there should always be the suspicion of a posterior capsular break and hydro manoeuevres may be avoided.

Nucleus management will be discussed in Part 2 of this series.

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.

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CATARACT & REFRACTIVE

ENHANCE PRECISION Conventional biometry methods are less predictable in eyes with prior refractive surgery. Dermot McGrath reports

I

ntraoperative wavefront aberrometry can help enhance precision and accuracy of refractive outcomes in patients undergoing cataract surgery, as well as providing a useful tool in eyes that have previously undergone corneal refractive surgery.

“The use of intraoperative aberrometry [IA] improved the spherical equivalent [SE] outcomes in our series of cataract patients. IA successfully reduced the mean absolute value of prediction error [MAVPE] for intraocular lens [IOL] power selection and the distribution of mean absolute error [MAE] also shifted to lower errors compared to preoperative power predictions, with more eyes falling within ± 0.50 D of target,” said Michael Breen OD. Planning for refractive cataract surgery demands precise preoperative measurements to achieve accurate IOL powers in order to obtain desired refractive outcomes, noted Dr Breen.

Current systems typically employ optical biometry, advanced keratometry and topography together with latest-generation IOL power calculation formulas, yet refractive outcomes are still not always as precise as expected, he said.

“Errors in biometry, the contribution of the posterior cornea and the limitations of some IOL power formulas can result in refractive misses. While refractive outcomes in cataract surgery are definitely improving, a recent study of refractive outcomes in Sweden showed that only 71% of eyes ended up within ±0.50D of predicted postoperative SE,” he said.

Dr Breen’s prospective, masked comparative study included 162 eyes of 149 cataract patients who underwent surgery at eight different sites in the USA. The IA device used was the ORA System® with VerifEye™ (Alcon Laboratories), a microscopemounted aberrometer which allows surgeons to evaluate refractive findings, refine IOL power, cylinder power, and IOL alignment in real time during the surgery.

IOL POWERS Evaluators were masked to the use of ORA, IOL type (toric IOL, non-toric, presbyopic) and treatment type. The surgeons calculated IOL powers and predicted postoperative SE based on preoperative measurements. The lens power formula used for preoperative calculation was chosen by the surgeon.

A total of 84 toric lenses were implanted in this series of patients, with a mean IOL power of 19.22 D (range 6.00 D - 30.00 D). The Holladay 2 formula was used in 94 eyes, SRK-T in 64 eyes, Holladay 1 in 3 eyes and the Haigis formula in 1 eye.

In terms of results, the MAVPE pre-op power was 0.35D (±0.37) and MAVPE using IA was 0.29D (± 0.26). The use of IA increased the proportion of eyes Catia Azenha MD

Conventional biometry methods are less predictable in eyes with prior refractive surgery, so these patients represent a particular challenge...

EUROTIMES | MAY 2017

Errors in biometry, the contribution of the posterior cornea and the limitations of some IOL power formulas can result in refractive misses Michael Breen OD with a postoperative SE within 0.50D of predicted postoperative SE compared to the outcomes that might have occurred had preoperative calculated IOL powers been implanted in both the overall group and in the most frequently implanted subset group, said Dr Breen.

In the future, a randomised contralateral eye, observer masked study comparing newer IOL formulas to IA would be an appropriate next step, said Dr Breen. Those studies should be IOL mode specific and preoperative formula specific in order to reduce variation, he added.

USEFUL TOOL Catia Azenha MD said that IA may prove to be a useful tool in cataract surgery patients who have undergone prior laser refractive surgery.

“Conventional biometry methods are less predictable in eyes with prior refractive surgery, so these patients represent a particular challenge for accurate IOL power calculation. IA is intended to reduce residual refractive error through aphakic refraction, revise preoperative biometry and IOL power choice, optimise lens location and tailor arcuate corneal incisions in eyes with astigmatic needs,” she said.

Dr Azenha’s retrospective study carried out at the University Hospital of Coimbra, Portugal, included nine patients who underwent cataract surgery after a prior myopic LASIK procedure.

All patients underwent IOL power estimation for a monofocal lens using the mean preoperative value obtained using the ASCRS online calculator, and during the surgery using the ORA System®.

The surgeon was free to select the IOL power based on either measurement method.

Comparative effectiveness analysis was carried out to evaluate the accuracy of IOL power determination between both methods. The IOL power prediction error was obtained by taking the originally targeted refraction minus the eventual postoperative outcome.

The IA achieved a median absolute error of 0.38 (range 0.03–0.83) and a mean absolute error of 0.40 (± 0.28). The ASCRS online calculator showed a median absolute error of 0.36 (range 0–1.25) and a mean absolute error of 0.39 (±0.34).

“The IA and ASCRS online calculator did not reveal significantly different capability to determine the estimated IOL power, although the IA showed a minor range of median absolute error.

However the patient numbers in our study were very small so we need further studies with greater numbers to try to establish statistical significance,” she said.

Michael Breen: michael.breen@alcon.com Catia Azenha: c.azenha@hotmail.com

CATARACT & REFRACTIVE

BRIGHT PATH AHEAD Examining six requirements for reducing errors and eliminating ‘refractive surprise’. Howard Larkin reports

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ven under optimal conditions, using the best measurement tools and corneal power formulas available, post-cataract surgery refractions are still off by more than 0.5D in one out of 11 patients with uncomplicated corneas – and in many more cases among patients who have had corneal refractive surgery, keratoconus or keratoplasty, Douglas D Koch MD told the American Academy of Ophthalmology (AAO) 2016 Annual Meeting in Chicago, USA. Further improvement in cataract surgery refractive outcomes will require better corneal measurement instruments, Dr Koch said in the Jackson Memorial Lecture at the AAO opening session. These will permit calculation of intraocular lens (IOL) power based on individual patients’ observed anterior and posterior corneal curvature rather than on constants for the presumed relationship derived from population studies, eliminating a significant source of error.

“Regression approaches have maxed out; we are not going to get formulas that do much better. We need to be able to accurately measure all our key parameters, preferably preoperatively,” said Dr Koch, of Baylor University, Houston, USA. Measurement is especially important in aberrated corneas, where posterior topography cannot be reliably extrapolated from anterior topography.

In the meantime, however, careful patient preparation and biometry can minimise the chance of “refractive surprise”, Dr Koch noted.

He reviewed six requirements for reducing and managing corneal measurement errors before, during and after surgery, as well as emerging technologies that will further improve performance.

HEALTHY CORNEAS AND TEARS Corneal curvature and astigmatism measurements can easily vary 0.5D or more from day to day using the same machine, and even more among different modalities, Dr Koch noted. Poor tear film quality is frequently the major cause of variability. Dr

Courtesy of Douglas D Koch MD

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Koch emphasised stabilising tear film and corneal surface disease as much as possible before measuring for cataract surgery.

WELL-TRAINED TECHNICIANS Consistent measurement processes are essential to generate reliable corneal measurements. Technicians must be trained in properly preparing patients and conducting tests.

SCEPTICAL SURGEONS Surgeons should critically evaluate measurement data, and obtain multiple readings from more than one device, Dr Koch said.

“We as clinicians have to look at the quality of the refractive data, whether we look at the reflected mires or numerical values such as standard deviations, and we need to ask why variations occur and address potential causes,” he said.

BETTER DEVICES Devices that better measure posterior corneal surfaces and aberrated anterior corneas are needed. Already Scheimpflug and OCT devices using elevation data, and a new instrument using coloured LED lights to measure the second Purkinje image reflected off the posterior corneal surface, can

Regression approaches have maxed out; we are not going to get formulas that do much better Douglas D Koch MD EUROTIMES | MAY 2017

provide posterior curvature data. Formulas using this data support more accurate IOL power calculations for post-myopic LASIK and photorefractive keratectomy (PRK) patients, with up to 68% within 0.5D of target (Wang L et al. Ophthalmology.

2015;122:2443-9). Dr Koch expects this will improve rapidly. Posterior corneal data also is helpful for calculating toric IOL power, even in uncomplicated corneas, because the orientation of posterior astigmatism varies and can add or subtract up to 1.0 D, leading to over or under correction and even flipping the astigmatism axis.

INTRAOPERATIVE ABERROMETRY Studies have found up to 74% of postmyopic refractive surgery patients within 0.5D of target using this technology (Fram NR et al. Ophthalmology. 2015;122:1096101), Dr Koch noted.

POST-OP IOL POWER ADJUSTMENT Technologies that can change IOL power in the eye after surgery are also promising, Dr Koch said. These include the Calhoun Vision lens, which reshapes a special lens material by selectively polymerising monomers, and a femtosecond laser device that alters the refractive index of a small region of conventional acrylic IOLs, imparting a pattern that changes lens power.

“We are blessed with a wonderful collaboration among physicians, scientists and industry. I am very confident that with the work we are doing we will have great success. There is a bright path ahead toward better outcomes for our patients,” Dr Koch concluded.

Douglas D Koch: dkoch@bcm.edu

CATARACT & REFRACTIVE

JCRS SYMPOSIUM JCRS HIGHLIGHTS VOL: 43 ISSUE: 2 MONTH: FEBRUARY 2017

IOL POWER CALCULATION AFTER HYPEROPIC LASIK Investigators evaluated seven intraocular lens (IOL) calculation formulas in patients with previous hyperopic LASIK or excimer laser photorefractive keratectomy (PRK).

Formulas included the adjusted Atlas 0-3, Masket, Modified Masket, Haigis-L, Shammas-PL, Barrett True-K, and Barrett True-K No-History.

The Masket and Modified Masket were calculated using the single-K version of Holladay 1 and Hoffer Q formulas; the adjusted Atlas 0-3 was calculated using the double-K version of Holladay 1 and Hoffer Q. The study found no significant differences in the median absolute refractive prediction error or percentages of eyes within ±0.50D or ±1.00D of the predicted refraction between newer and older formulas or methods. The IOL mean prediction errors were comparable between the Holladay 1 and Hoffer Q calculations for all formulas except for a greater error for the double-K version of the Hoffer Q of the adjusted Atlas 0-3. E Hamill et al. JCRS, Intraocular lens power calculations in eyes with previous hyperopic laser in situ keratomileusis or photorefractive keratectomy, Vol. 43, No. 2, p189–194.

Controversies in Anterior Segment Surgery Monday, May 8, 2017 1:00–2:30 PM

IOLS AND THE CAPSULE What effect would different optic edge designs of acrylic IOLs have on posterior chamber opacification (PCO)? To address this question, researchers conducted a randomised controlled prospective study of 50 patients who received an AcrySof SA60AT IOL implanted in one eye and a Tecnis ZCB00 IOL implanted in the fellow eye. Both lenses are one-piece hydrophobic acrylic IOLs. The AcrySof IOL has a continuous square optic edge whereas the Tecnis IOL has an interrupted edge. At five-year follow-up there was no significant difference in the PCO rate between the two types of IOL. However, there were significant differences with respect to anterior capsule opacification (ACO) development and anterior capsule retraction between both IOLs. Significantly less ACO and capsule phimosis were observed with the Tecnis IOL. Glistenings were observed in all patients with the AcrySof IOL and in no patient with the Tecnis IOL. G Kahraman et al., JCRS, Intraindividual comparison of capsule behaviour of 2 hydrophobic acrylic intraocular lenses during a 5-year follow-up, Vol. 43, No. 2, p228–233.

CME POST-CATARACT SURGERY Topical NSAIDs are beneficial in treating chronic cystoid macular oedema (CME) after cataract surgery, although CME may recur after cessation of treatment, concluded a comprehensive literature review. The authors report that it remains unclear which pharmacologic treatment is most effective in improving CDVA and retinal morphology. Noting that the evidence regarding the optimum treatment is of moderate-to-low quality, they call for large well-designed multicentre studies to investigate the optimum pharmacologic treatment of acute and chronic CME after cataract surgery. LHP Wielders et al., JCRS, Treatment of cystoid macular oedema after cataract surgery, Vol. 43, No. 2, p276–284.

THOMAS KOHNEN European editor of JCRS

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Management of Residual Refractive Errors After Cataract Surgery Best Refractive Procedure for Moderate to High Myopia Intraocular Antibiotics for Cataract Surgery Moderators: Nick Mamalis, MD Sathish Srinivasan, MD During the ASCRS Symposium on Cataract, IOL and Refractive Surgery Los Angeles, California, USA

EUROTIMES | MAY 2017

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ltra-thin Descemet’s stripping automated endothelial keratoplasty (UT-DSAEK) offers faster and better visual recovery compared to traditional DSAEK, according to Mor Dickman MD, PhD, of Maastricht University, The Netherlands.

“Our randomised, multicentre study showed that there was faster and better recovery of best spectaclecorrected visual acuity (BSCVA) and faster recovery of contrast sensitivity with UT-DSAEK compared to standard endothelial keratoplasty,” said Dr Dickman.

Recent years have seen a massive increase in the number of endothelial keratoplasty procedures for diseases such as Fuchs dystrophy in The Netherlands, said Dr Dickman, mirroring the wider international trend.

“In the last two decades, not only did endothelial keratoplasty replace penetrating keratoplasty as a treatment of choice, but the total number of grafts continues to rise steadily. Recovery of visual acuity, however, after endothelial keratoplasty is unpredictable.

At the same time, we are seeing a paradigm shift towards earlier surgical intervention at lower levels of visual disability,” he said.

To test the hypothesis that thinner grafts result in better vision, a randomised controlled trial of 66 patients was carried out in four tertiary ophthalmology clinics in The Netherlands comparing visual acuity and quality of vision in patients undergoing UT-DSAEK (defined as grafts thinner than 100 microns), and standard DSAEK which were grafts 200 microns in thickness.

Looking at the visual acuity results, there was a high, statistically significant difference in BSCVA in favour of UT-DSAEK at three and six months. “At 12 months we found a difference of 0.07 logMar in favour of UT-DSAEK which equates to almost one Snellen line of vision,” said Dr Dickman.

For contrast sensitivity, results were better at three months for patients in the UT-DSAEK group, but there was no difference between the groups at six and 12 months.

Preoperative straylight values did not differ between groups, but younger patients were found to have significantly higher straylight scores compared with agematched phakic controls.

“Post-op straylight values in younger patients returned to normal compared to age-matched pseudophakic controls, suggesting that elevated straylight may play a role in the decision of young Fuchs’ patients to seek surgical treatment,” said Dr Dickman.

Another key finding was that early posterior corneal higher order aberrations were lower after UT-DSAEK, perhaps contributing to faster recovery of visual acuity.

“Vision-related quality of life continued to improve after the operation at three and 12 months irrespective of the technique used or patient age, thus giving hope to both younger and older patients with Fuchs dystrophy who need to undergo endothelial keratoplasty,” said Dr Dickman.

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CORNEA

THE FINAL FRONTIER New presbyopia treatments should be grounded on solid understanding of accommodation. Leigh Spielberg MD reports

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ffective treatment of presbyopia remains the last frontier of refractive surgery, but important progress has been made in recent years, Günther Grabner MD told delegates attending the Refractive Surgery Course at the 21st ESCRS Winter Meeting in Maastricht, The Netherlands.

“There are currently two anatomical locations amenable to treatment for presbyopia: the cornea and the natural lens,” said Dr Grabner, Chairman Emeritus, University Eye Clinic Salzburg, Paracelsus Medical University, Salzburg, Austria.

A third location, the anterior chamber, has long been abandoned. New treatment modalities are emerging, although some appear to be of questionable quality, he noted.

“Beware of any potential procedures that aim to treat presbyopia based on disproven theories of accommodation, such as the effect of increasing equatorial zonular tension or the proposed piston-like movement of the crystalline lens,” he warned.

It is only Helmholtz’s theory of accommodation, in which optical change in the dioptric power of the lens is the driving force, that has been experimentally and clinically proven in almost all aspects, he asserted.

Further, there are several types of true accommodation. The first is 'blur-driven', which is stimulated by defocus. The second, 'vergence-driven', is controlled by the accommodation-convergence reflex. The third is due to pharmacologic stimulation by a muscarinic cholinergic agonist such as pilocarpine.

Before delving into surgical solutions to presbyopia, however, Dr Grabner reminded delegates that the conservative treatment modalities for presbyopia, namely reading glasses and contact lenses, remain excellent choices.

“They are easily adjustable, very stable, fully reversible and offer high contrast, making them especially ideal for very critical patients.”

Currently, the most frequently performed surgical presbyopia treatment

is the creation of monovision in which the non-dominant eye is targeted to mild myopia. This can be performed with various surgical procedures, including lens exchange, LASIK, LASEK and photorefractive keratectomy (PRK).

A pre-surgical test with contact lenses is mandatory. People in professions that require good stereopsis at near distance, such as plumbers, are not good candidates for monovision, he reminded delegates.

Corneal surgical options abound, with the advantage that they are extraocular and at least partially reversible, as opposed to lens surgery. Possibilities include laser and intracorneal inlays or implants.

“PresbyLASIK is a proven technology that has been around for a long time, of which the most promising is the so-called global optimum technique,” said Dr Grabner.

Central presbyLASIK is particularly good for near vision while distance vision suffers slightly, whereas peripheral presbyLASIK performs the opposite, he reported.

Dr Grabner is particularly enthusiastic about non-linear aspheric micromonovision, which maintains functional stereo acuity. Intracor, an intrastromal femtosecond laser correction, is an irreversible procedure, that seems less promising, with up to 20% of patients left unsatisfied, he said.

CORNEAL INLAYS What about corneal inlays? This tissuesparing, removable modality includes microlens systems such as the Raindrop, Icolens and Flexivue, as well as the “small aperture” Kamra.

“The corneal inlays, which are microlenses that are placed in the nondominant eye’s cornea, offer a wide range of defocus and good bilateral uncorrected distance visual acuity [UDVA] with no decrease in binocular contrast sensitivity. However, a drop

The search for solutions with fewer side effects, better depth of focus and more natural ‘accommodating’ properties has led to the development of alternatives Günther Grabner MD EUROTIMES | MAY 2017

of DVA in the operative eye has to be stated,” said Dr Grabner.

The Kamra inlay is not a lens but rather a central aperture that improves near vision by extending depth of focus. A study with one year follow-up in nearly 1800 patients reported 95% satisfaction rate, and it has been FDA-approved since 2015.

However, complications such as epithelial ingrowth, decentred inlays and hyperopic shift are potential, albeit rare, problems.

Moving more posteriorly, anterior chamber phakic multifocal IOLs have largely been abandoned due to complications, and surgical procedures that target the sclera have never taken off as viable options.

More promising are lenticular solutions. Lens corrections offer the promise of established surgery with wellknown materials and optical principles, large series and known side effects such as some glare, halos, loss of contrast sensitivity and insufficient intermediate vision, said Dr Grabner.

The optical quality of multifocal IOLs has gotten much better than even several years ago, but Dr Grabner finds that they need to improve further.

“The search for solutions with fewer side effects, better depth of focus and more natural ‘accommodating’ properties has led to the development of alternatives,” he said.

“The IC-8 is a small-aperture, singlepiece hydrophobic acrylic IOL from AcuFocus that generates added depth of focus in the same manner as the Kamra corneal inlay,” explained Dr Grabner.

Accommodating IOLs have been introduced and more than a half dozen models have been produced.

The contrast sensitivity is equal to that of a monofocal IOL, but they are rather complex. As no peer-reviewed publications have been published to date, accommodating IOLs have a long way to go before they are widely accepted, he told the session.

Topical drops that increase lens elasticity via reduction of lens protein disulfides have also been tested, but are unlikely to be clinically available for quite some time. Until then, multifocal IOLs will remain the primary option for most surgeons.

“No technique is perfect. There is always a compromise,” Dr Grabner concluded.

Günther Grabner: g.grabner@grabner-augen.at

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orneal crosslinking (CXL) performed with the corneal epithelium intact (epion) does not appear to provide any therapeutic advantage in the treatment of progressive corneal ectasia, reported Frederik Raiskup MD, PhD, FEBO, Dresden, Germany, at the 21st ESCRS Winter Meeting in Maastricht, The Netherlands.

“The epi-off (with epithelial removal) technique has been extensively investigated in prospective, randomised, controlled trials. Nevertheless, The Cochrane Collaboration Review Study had concerns regarding the size of the studies and the quality of their evidence,” said Dr Raiskup.

Complications after CXL were also a concern. These include persistent epithelial defects, melting processes, infections and the development of permanent stromal scars.

This led to researchers asking whether the safety of CXL might be enhanced with a transepithelial (epi-on) procedure that keeps the epithelial barrier function intact and avoids wound-response reactions in the stroma. Keeping the epithelium intact might avoid early postoperative pain as well as complications, he explained.

However, intact epithelium serves as a barrier for the riboflavin required in the stroma for CXL, he noted. Thus, new methods were developed to draw riboflavin into the stroma. These include pharmacological cleavage of epithelial tight Frederik Raiskup junctions, iontophoresis and the use of enhanced riboflavin solution.

The results of a recent study of transepithelial CXL published by Dr Raiskup et al. were not particularly encouraging. “Although there were no cases of infection, sterile infiltrates or haze, there were postoperative epithelial defects in nearly half of the eyes treated, and marked superficial punctate keratitis or loose epithelium in nearly a quarter,” said Dr Raiskup.

Furthermore, nearly half of the procedures were 'failures', as defined by an increase of >1.0D in Kmax at 12 months postoperatively.

These results reflected those of previous studies, which looked at both clinical results and corneal morphology. There were also questions regarding whether the epi-on procedures truly maintained intact epithelium, considering the extensive application of topical preserved anaesthetic and antibiotic solutions prior to the instillation of riboflavin.

“To date, the majority of comparative studies strongly suggest that although epi-on CXL is a safe procedure, epi-off CXL is significantly more effective in halting the progression of keratoconus,” said Dr Raiskup.

“However, considering the many variables involved in epion CXL studies, better designed randomised controlled trials are necessary to prove its efficacy, safety and predictability,” concluded Dr Raiskup.

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Frederik Raiskup: frederik.raiskup@uniklinikum-dresden.de EUROTIMES | MAY 2017

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CORNEA

CXL FOR KERATOCONUS Standard procedure effective in vast majority of patients.

Howard Larkin reports

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he standard Dresden protocol for corneal crosslinking (CXL) provides stable long-term improvements in visual acuity and keratometry for about 90% of patients, Rudy MMA Nuijts MD, PhD told Refractive Surgery Day at the 2016 American Academy of Ophthalmology Annual Meeting in Chicago, USA. Moreover, epithelium-off CXL also provides persistent improvement for up to four years in 80-90% of children, and may reduce need for corneal transplants by 25%, he reported.

EFFICACY DEMONSTRATED A 2015 meta-analysis of six CXL trials found decreases of -1.65D mean K-max, and -2.05D in mean astigmatism in CXL-treated patients compared with controls. Best spectacle-corrected vision improved by -0.10 logMAR, or one Snellen line, and cylinder by -0.39D. (Li. PLoS One 2015;10:e0127079.)

A second paper analysing 75 studies found a small amount of regression after 24 months (Meiri. Cornea 2016;35:417). In Dr Nuijts' own series, CXL outcomes were stable over four years, with mean K, K-max and steep K values all continually declining out to 48 months.

Best-corrected vision was also stable over four years in this study at the Maastricht University Medical Centre, The Netherlands.

Looking at long-term follow-up studies of five years or more, CXL outcomes are quite stable on average, with failure rates, defined as progression of 1.0D or more, of 0-11%, Dr Nuijts noted. In children, studies with four years or more follow-up show a continuous effect of decreased K-max and improved corrected distance vision, with failure rates from 6-22%. Mean regression in K-max and improvement in distance vision were both greater in children than in adults.

Preliminary data from The Netherlands corneal transplant registry suggests CXL may reduce the need for transplants by 25%, Dr Nuijts said.

However, assessing CXL outcomes has been hampered by a lack of well-designed Rudy MMA Nuijts MD, PhD randomised clinical trials,

...assessing CXL outcomes has been hampered by a lack of well-designed randomised clinical trials...

Courtesy of Rudy MMA Nuijts MD, PhD

22

due in part to variable definitions of progression, Dr Nuijts said.

Among the varied indications for progressive keratoconus are K-max increase of 1.0D or more in one year; significant change in myopia and/or astigmatism in six months; and three consecutive topographies in six months showing a mean central K increase of >1.5D or mean central corneal thickness decrease of >5.0%. Uniform outcome measures and better trials are needed to prevent delays in bringing innovations to patients, he emphasised.

Rudy MMA Nuijts: rudy.nuijts@mumc.nl

РОССИЙСКИЙ ВЫПУСК

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EUROTIMES | MAY 2017

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CORNEA

23

NEW METRICS FOR CXL Refining measurement should lead to better treatment.

Leigh Spielberg MD reports

Courtesy of David Touboul MD

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ew metrics for following keratoconus progression will help to refine treatment strategies, said David Touboul MD during a symposium on corneal crosslinking (CXL) at the 21st ESCRS Winter Meeting in Maastricht, The Netherlands.

“Prior to CXL, keratoconus was classified by severity scales based on the macroscopic appearance and thickness of the cornea. However, now that it is possible to halt the progression, progression rate indices are needed that rely less on macroscopic data," said Dr Touboul, CHU, Bordeaux, France.

Progression rate is a ratio that can vary according to patient age and biomechanical, morphological, optical and functional ocular metrics, said Dr Touboul. In order of precocity, metrics for keratoconus progression start with biomechanical anisotropia; then posterior bulging; then anterior bulging & thinning; and lastly, refractive changes and visual acuity symptoms.

But applying all of this to clinical practice is difficult.

Biomechanical metrics such as in vivo elastography are not yet useful in the clinic. Morphological metrics such as slit lamp changes are difficult to quantify. And although central corneal bulging remains the main criterion for CXL treatments, it represents neither peripheral nor epithelial changes.

What about corneal thinning? “Increasing 1D of keratometry can correspond to a corneal thinning below the repeatability threshold measured with optical coherence tomography (OCT) or Scheimpflug technologies. So, based on a recent Cochrane review, corneal thickness was too inconsistent to assess CXL effectiveness,” warned Dr Touboul.

Measuring optical metrics, which describe optical aberrations, seem like a logical method, but there are important fluctuations between aberrometers, and both pupil aperture and accommodation are confounding factors. The same applies to functional metrics such as visual acuity, which is also too variable.

So, what’s new? Dr Touboul finds the development of pachymetry mapping promising.

“Using OCT, corneal structure can be analysed by separating stromal changes and epithelial compensation, making this modality very interesting. The dominant method to rate progression is topographical and tomographical analysis,” said Dr Touboul.

This is strongly correlated with worsening of keratoconus in terms of biomechanics, retinal image quality as defined by the point spread function, and with quality of life. Indeed, the decision to intervene in order to halt progression surgically is best made based on this morphological metric, he said.

But clinicians cannot focus too much on a single metric.

Defining keratoconus progression rates requires the analysis of the entire patient’s profile. There is no magic number to determine therapeutic indications, he emphasised.

David Touboul: david.touboul@chu-bordeaux.fr

WSPOS

Friday 6 October 2017

World Society of Paediatric Ophthalmology & Strabismus

Lisbon, Portugal

SUBSPECIALT Y DAY

Preceding the XXXV Congress of the ESCRS 7–11 October 2017

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EUROTIMES | MAY 2017

17th EURETINA Congress 7–10 September 2017 CCIB, Barcelona, Spain

11 EURETINA Updates (Main Sessions) 30 International Society Symposia 25 Free Paper Sessions 45 Instructional Courses 4 Surgical Skills Courses Keynote Lectures EURETINA Lecture

Francine Behar-Cohen SWITZERLAND

Richard Lecture

Borja Corcóstegui SPAIN

Kreissig Lecture

Jackson Coleman USA

III

WORLD RETINA DAY

Saturday 9 September

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17th EURETINA Congress, Barcelona

RETINA

THE FUTURE OF IMAGING Digitalised assistance set to create a new paradigm in vitreoretinal surgery. Cheryl Guttman Krader reports

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itreoretinal surgeons in the not-too-distant future will find themselves operating like pilots flying an airplane because they will be pre-planning their entire operative 'route' and will be able to execute it precisely and efficiently thanks to assistance from digital informatics technology.

“We are on the precipice of a revolution that will close the loop between what we are able to see in the office and what we see in the OR,” said Pravin Dugel MD, Managing Partner, Retinal Consultants of Arizona, Phoenix, and Clinical Professor of Ophthalmology, University of Southern California, Los Angeles, USA. “Now, all of the information we have from multimodal diagnostic imaging is left behind in the office and we go blindly into surgery. The change that is coming is all about developments in informatics. With implementation of digitalised assistance, vitreoretinal surgery will be much safer and much more efficient, and our patients will have much better outcomes,” he said.

Dr Dugel noted that he personally has not used an operating microscope over the past two years. Instead, he wears three-dimensional (3D) glasses and looks at an image that is captured with a 3D highdynamic range camera appearing on a highPravin Dugel definition large screen monitor.

“The reason why I am using this system is not because of its ergonomics and teaching opportunities, although those are both big advantages. Rather, it is all about the informatics,” said Dr Dugel.

NEW OPPORTUNITIES While that hardware is in place, the transformation in vitreoretinal surgery still hinges on advances in registration and navigation that will allow image overlay and compensation for eye movement. When those elements are available, full implementation of digitally assisted vitreoretinal surgery will lead to new opportunities.

For example, it will allow for automated, navigated tissue sparing laser photocoagulation procedures in which the treatment density, spot parameters, and location will be defined in the preoperative plan based on preoperative diagnostic imaging and completed automatically intraoperatively with the press of a button. Real-time digitalised assistance will also enable intraocular distance monitoring through instrument guidance and feedback.

Other technologies that are currently in development will further enhance digitally assisted vitreoretinal surgery planning.

For example, 3D optical coherence tomography that can provide precise anatomic information will allow surgeons to plan exactly where to position their forceps and where to cut with their scissors when operating on an eye with vitreomacular traction or a tractional retinal detachment.

Pravin Dugel: pdugel@gmail.com EUROTIMES | MAY 2017

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RETINA

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ENHANCED DIAGNOSTICS New 3D imaging technology provides better retinal diagnostics and enhances posterior segment surgery visualisation. Roibeard Ó hÉineacháin reports

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University, Durham, North Carolina, USA, Dr Binder noted. However, she suggested that 3D intraoperative OCT may not realise its full potential until the noise in the images can be filtered out in real-time.

Currently, the post-processing of raw OCT data into a noise-free virtual 3D rendering takes about 30 minutes.

FANTASTIC VOYAGE In the meantime, the post-processed images allow the clinician to take virtual flights through the macular tissue at a microscopic level. The improved visualisation reveals many features not visible with two-dimensional (2D) OCT and can help guide treatment decisions and provide further insight into the recovery processes of retinal tissue, Dr Binder said.

In one video clip, Dr Binder showed a case where an eye with vitreomacular traction appeared to be a good case for enzymatic vitreolysis when viewed by conventional 2D OCT. However, 3D post-processed rendering showed the presence of many vitreomacular adhesions, which is a strong contraindication for the treatment.

She also presented cases of retinal detachment where one could differentiate much more clearly whether or not the macula was attached than was possible with conventional clinical examinations.

“For the future, I strongly believe we will have full 3D intraoperative OCT and that will provide an overview of the eye. Later on we can move to a cellular level and use adaptive optics,” Dr Binder said.

Courtesy of Matthias Becker MD, PhD

ew three-dimensional (3D) digital imaging technologies are providing enhanced diagnostics of macular disease and greater ease in the visualisation and performance of vitreoretinal surgery.

Among the new 3D imaging tools becoming available are enhanced 3D optical coherence tomography (OCT) systems that allow the detailed exploration of the macular region at a microscopic level, and heads-up surgery visualisation systems that allow not only the surgeon but the whole surgical team to observe ophthalmic surgery in high-definition 3D. Susanne Binder MD noted that OCT imaging of the retina has revolutionised the field of retinal disease treatment. It provides the ability to perform in vivo histology on retinal tissues before and after treatment.

In addition, when used intraoperatively, OCT enables better membrane peeling, reduces the need for dyes, and allows better visualisation of vitreomacular traction and subretinal fluid behaviour. It can also be used in hazy media.

“The fusion of the microscope and the OCT image adds a new dimension to vitreoretinal surgery – we can see more, we can perform better and it actually does simplify our work flow,” said Dr Binder, Rudolf Foundation Clinic, Vienna, Austria.

The addition of 3D imaging to intraoperative OCT is the logical next step and this has been employed with some success by Cynthia Toth MD at Duke

Dr Becker performing surgery with the aid of imaging technology. With heads-up surgery, surgeons do not use the eyepieces of the microscope anymore. Through 3D glasses the surgeon and staff can watch the microscope view with a 3D monitor

EUROTIMES | MAY 2017

HEADS-UP 3D Another new 3D approach is the new heads-up NGENUITY® (Alcon) 3D surgical viewing systems, where instead of the surgeon looking directly through the surgical microscope, the surgeon and the nurse wear 3D glasses and view the surgery on a 3D monitor. The system consists of a high-dynamic-range surgical camera with a three-megapixel resolution and a highdefinition monitor.

This new approach offers the potential advantage of facilitating surgery using lower light levels than when using a surgical microscope. It also has a high dynamic range that provides increased colour contrast and comparable depthof-field, said Matthias Becker MD, PhD, Triemli Hospital, Department of Ophthalmology, Zurich, Switzerland.

Dr Becker described the experience he and his associates had with the new heads-up 3D visualisation system over a three-week testing period. During that time, they used the system in 21 consecutive patients and 25 patients undergoing posterior segment surgery. Their retinal conditions included 10 cases with retinal detachment, six with epiretinal membrane, one with macular hole and four undergoing silicone oil removal.

He noted that the system was fairly simple to use, although it requires an additional staff member to manage the camera-monitor interface controls. In two cases the surgeon had to return to the surgical microscope for safety reasons. He added that it definitely improves training.

Moreover, the improved visualisation of the vitreous it provides could reduce the need for triamcinolone and dyes for that purpose.

However, although the light sensitivity of the camera reduces light toxicity to the retina, it also means that the camera is more sensitive to media opacities. There is also a delay of about a tenth of a second between real-time and the image on the monitor, which means that instruments can appear to be 'floppy' when performing surgical manoeuvres quickly.

“My personal summary is that there is nothing like a trained human eye-brain visual system which can compensate and extrapolate from foggy reality to clear visualisation, so don't get lured into a false sense of security,” said Dr Becker.

Susanne Binder: susanne.binder@extern.wienkav.at Matthias Becker: matthias.becker@zuerich.ch

WCPOS IV

4th World Congress of Paediatric Ophthalmology and Strabismus

See You in Hyderabad, India 1-3 December 2017 Registration Available Online Early Bird Registration Closes: 31 May 2017

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RETINA

BEYOND ANTI-VEGF Researchers are looking for effective treatments.

Leigh Spielberg MD reports

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s it becomes clear that antivascular endothelial growth factor (anti-VEGF) agents are not sufficient by themselves to provide long-term treatment of neovascular age-related macular degeneration (AMD), researchers are looking for effective additive treatments.

“We have more or less reached the ceiling of anti-VEGF efficacy. Aflibercept, bevacizumab and ranibizumab have similar efficacy, and increasing the dosage or regimen does not substantially enhance visual outcome for most patients,” said Marco Zarbin, of the New Jersey Medical School, Rutgers University, New Jersey, USA. Dr Zarbin made these comments at a symposium, entitled 'Neovascular AMD: Novel Insights & Lessons Learned', which featured a series of presentations that provided both a coherent overview of the current state-of-the-art in neovascular AMD and a detailed examination of what has been learned to date. Dr Zarbin led attendees through the current state of the so-called 'pathway-based' therapy of AMD-related choroidal neovascularisation.

“Every step of the angiogenesis sequence is being examined for potentially clinically relevant targets. The anti-VEGF molecules bind the angiogenic factors that have been released, but researchers have investigated molecules, such as sirolimus, bevasiranib and everolimus, intended to decrease the factors’ production in the first place,” he reported.

Once the angiogenic factors have been produced, and if they make it past the anti-VEGF treatment, they bind to specific receptors on the vascular endothelial cells in order to initiate intracellular signalling.

Squalamine, pazopanib, and vatalanib are intended to target this step, he said.

CELL MEMBRANES Squalamine, an angiostatic steroid derived from the dogfish shark (Squalus acanthias) binds to cell membranes and interferes with signals initiated by the binding of growth factors to the cell.

“A phase 2b trial by Ohr Pharmaceutical of 128 patients studied combination therapy of squalamine eye drops plus ranibizumab,” said Dr Zarbin.

This study showed potentially beneficial results in terms of both letters gained and subsequent ranibizumab injection frequency. The phase 3 study is under way, with data expected in December 2017.

Other steps being targeted include endothelial cell activation and proliferation, directional migration, extracellular matrix remodelling, vascular formation and, finally, vascular stabilisation.

“At this relatively late point in the cascade, pericytes are protecting the endothelium, leading to one mechanism of resistance to anti-VEGF treatment,” said Dr Zarbin.

A study in 1998 identified a 'plasticity window' for blood vessel remodelling, defined by pericyte coverage of the preformed endothelial network and is regulated by platelet-derived growth factor B (PDGF B). Once pericytes have intimate interactions with vascular endothelial cells, the pericytes become a source of VEGF that allows tumour vasculature to sidestep VEGF blockade mediated by exogenous anti-VEGF agents. Research into oncologic treatments outlined the benefits of targeting both pericytes (via PDGF B blockade) and endothelial cells (via antiVEGF agents) in tumour vasculature.

COMBINATION THERAPY “That’s where Fovista® comes into the equation,” he said. Fovista (pegpleranib) is an aptamer directed at PDGF B that is undergoing trials by Ophthotech. The goal is to antagonise both endothelial cell activation and vascular stabilisation using combination therapy.

In a large phase 2 trial, among patients treated with 1.5mg Fovista plus 0.5mg Lucentis, the mean visual acuity of patients at week 24, a prespecified primary endpoint, showed 62% additional benefit when compared to Lucentis monotherapy.

...pericytes are protecting the endothelium, leading to one mechanism of resistance to anti-VEGF treatment Marco Zarbin EUROTIMES | MAY 2017

In any case, combination therapy should be both pathwayspecific and synergistic, allowing us to break through the ceiling of efficacy that we currently encounter A recently completed phase 3 trial compared combination of Fovista plus anti-VEGF versus anti-VEGF monotherapy using ranibizumab. In contrast to the phase 2 results, there was no significant difference in visual outcome among patients treated with combination therapy versus ranibizumab monotherapy. The phase 2 trial was of six months duration, whereas the phase 3 trial was of one year duration. Additional phase 3 trials involving combination therapy of Fovista with aflibercept or bevacizumab are in progress.

VEGF has a potent enhancer, angiopoietin 2 (Ang2). This molecule increases the responsiveness of retinal vessels to VEGF and promotes vascular leakage and neovascularisation. With this in mind, both Genentech/Roche and Regeneron are targeting Ang2, he said.

Now that new molecules are in the pipeline, further questions will arise as to how they should be used. “Should we try to block several molecules simultaneously, as RG7716 does with VEGF-A and Ang2?

Or should treatment focus on sequential targeting, as suggested by Dr Pravin Dugel and colleagues based on a study using Fovista and ranibizumab?” asked Dr Zarbin.

In any case, combination therapy should be both pathway-specific and synergistic, allowing us to break through the ceiling of efficacy that we currently encounter, he concluded.

Marco Zarbin: zarbin@rutgers.edu

RETINA

OPHTHALMOLOGICA VOL: 237 ISSUE: 3

BEST RESULTS FOR MYOPIC CNV ACHIEVED WITH EARLY ANTI-VEGF THERAPY Early anti-vascular endothelial growth factor (VEGF) treatment of myopic choroidal neovascularisation (CNV) can decrease the recurrence rate and improve visual outcome, according to the findings of a new study. Among 106 eyes with myopic CNV included in a retrospective review, the recurrence rate following initiation of anti-VEGF treatment was only 19% among eyes with a pre-treatment CNV duration of less than two weeks, compared to 25% among those with a pre-treatment CNV duration of two-to-eight weeks, and 52% among those with a pre-treatment duration of eight-to-24 weeks. In addition, CNV duration was a significant predictor of a better final best-corrected visual acuity, even after controlling for other factors (p = 0.042). B.G Moon et al, “Improved Visual Outcome and Low Recurrence with Early Treatment with Intravitreal Anti-Vascular Endothelial Growth Factor in Myopic Choroidal Neovascularization”, Ophthalmologica 2017, Volume 237, Issue 3.

The OCULUS Pentacam® AXL Always an Axial Length Ahead

LUTEIN SUPPLEMENTATION IMPROVES VISION AND REDUCES SUBFOVEAL FLUID IN EYES WITH CCSC Antioxidant supplementation containing lutein can significantly improve vision and reduce subfoveal fluid height in eyes with chronic central serous chorioretinopathy (CCSC), the findings of a randomised study indicate . Among 79 patients randomised who received either the lutein-containing supplement or placebo, those in the supplementation group had significant improvements in their best corrected visual acuity (p = 0.003), but there was no significant change in the placebo group (p = 0.589). In addition, the mean subfoveal fluid height was reduced by 28.6% in the supplementation group (p = 0.028), compared to only to 3.3% in the placebo group (p = 0.898). A Shinojima et al, “A Multicenter Randomized Controlled Study of Antioxidant Supplementation with Lutein for Chronic Central Serous Chorioretinopathy”, Ophthalmologica 2017, Volume 237, Issue 3.

OCT ANGIOGRAPHY SHOWS CHORIOCAPILLARY CHANGES FOLLOWING PDT FOR CCSC An optical coherence tomography angiography (OCTA) study of eyes with chronic central serous chorioretinopathy (CCSC) before and after undergoing photodynamic therapy (PDT) appears to confirm the treatment’s theorised mechanism of action. The study involved 33 eyes of 28 patients who underwent OCTA with the splitspectrum amplitude-de-correlation angiography before and after undergoing half-dose PDT. Using the new technology, the study’s authors detected choriocapillary changes that corresponded to an improvement in mean BCVA from 0.29 logMAR to 0.1 logMAR at three months’ follow-up. Y Xu et al, “Effect of Photodynamic Therapy on Optical Coherence Tomography Angiography in Eyes with Chronic Central Serous Chorioretinopathy”, Ophthalmologica 2017, Volume 237, Issue 3.

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29

ESCRS

Glaucoma Day 2017 Friday 6 October FIL – International Fair of Lisbon, Portugal Registration Open glaucomaday.escrs.org

Scientific Programme organised by

GLAUCOMA

IOP AND LIFESTYLE Evidence-based dietary, exercise and sleep practices can reduce glaucoma risk. Howard Larkin reports

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ecent research shows that following maternal guidance such as eating vegetables, regular exercise and maintaining healthy body weight reduce the risk of developing open-angle glaucoma in patients with high intraocular pressure (IOP), Cynthia Mattox MD, of New England Eye Center, Tufts University, Boston, USA , told the 2016 American Academy of Ophthalmology Annual Meeting in Chicago, USA. Higher consumption of dark green, leafy vegetables and other dietary sources of nitrates can lower glaucoma risk by 30% overall and as much as 50% in patients prone to paracentral visual field loss, Dr Mattox said. Nitrates and nitrites are precursors of nitric oxide, which plays an important role in aqueous outflow signalling and has emerged as a therapeutic target for regulating IOP. (Kang JH et al.

JAMA Ophthalmol. 2016;134(3):294-303.)

Higher intake of fresh oranges and peaches, and collard greens and kale, is associated with lower glaucoma rates among older African-American women (Giaconi JA et al. Am J Ophthalmol 2012;154(4):635-644). A similar diet is associated with less glaucoma in older women (Am J Ophthalmol 2008;145(6):1081-1089), as is intake of retinol equivalents and beta-carotene.

(Ramdas WD et al. Eur J Epidemiol. 2012 May; 27(5): 385–393.)

Commencing regular aerobic exercise can lower IOP and glaucoma risk in previously sedentary patients (Passo MS et al. Arch Ophthalmol. 1991 Aug;109(8):10968), and may increase when regular exercise ceases, Dr Mattox noted. However, isometrics, Cynthia Mattox heavy weight lifting and prolonged Valsalva forced exhalation are associated with increased IOP, as are inversion manoeuvres on tilt tables or back swings.

Encouraging healthy body weight also helps reduce IOP. However, low body mass index is associated with paracentral visual field defects.

Mineral supplements generally are not beneficial, and high doses of iron and calcium can increase glaucoma risk (NHANES 2015), as can magnesium (Passo MS et al. Arch Ophthalmol. 1991 Aug;109(8):1096-8). Generally, supplements should be avoided in the absence of nutrient deficit, Dr Mattox said.

Some evidence exists for the beneficial effects of herbal antioxidants, such as allium, bilberry, wolfberry, crocetin in saffron, gardenia fruit and resveratrol, Dr Mattox said.

Astragalus, foeniculeum and brown algae seaweed have been shown to reduce IOP in animal models.

Sleep position also influences IOP. In patients with a preferred sleeping side, IOP is higher on the side on which they habitually sleep, Dr Mattox said. Alternating sides or using a head-up wedge pillow mitigates supine IOP elevation (Buys YM et al. Ophthalmology. July 2010;117(7):13481351). Overtreatment of hypertension and nocturnal antihypertensive dosing also should be avoided, she advised.

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GLAUCOMA

THE HUMAN TOUCH Unique value of clinical examination supports its cornerstone role in glaucoma patient care. Cheryl Guttman Krader reports

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ata derived from imaging tools can be helpful for the diagnosis and prognosis of glaucoma, but should only be used as a supplement to and not as a substitute for a competent clinical examination, according to George L Spaeth MD “I am not opposed to the introduction of better technologies, and I have worked towards that goal. But, as physicians and patients increasingly rely on indirect and machine-driven markers of health and disease, I have witnessed the deterioration of physicians’ abilities to take histories, examine patients, and perceive and understand patterns,” said Dr Spaeth, Esposito Research Professor of Ophthalmology, Kimmel Medical College, Jefferson University, Philadelphia, USA.

The development of a relationship between the doctor and the patient is most likely to result in the person being fully engaged in his or her own care “I believe we need to preserve, teach, and research the skills of direct physical examination. Every step away from data that result from touching the patient – touching physically, emotionally, and spiritually – is a step away from understanding the essence of the patient, engaging the patient in his or her own care, and the promotion of health that is the primary objective of the patient encounter. What we are interested in is what happens to the patient as a result of our examination, and guiding the patient so that he or she can heal himself or herself is what we are really trying to do. What comes out of a machine is only data, and EUROTIMES | MAY 2017

Statistically-derived outputs based on population averages may not be applicable to the individual George L Spaeth MD

it has no relevance to patient engagement.

The development of a relationship between the doctor and the patient is most likely to result in the person being fully engaged in his or her own care,” he said.

LIMITATIONS AND STRENGTHS Whether information is obtained using technology or by physical examination, it is critical to consider its accuracy and its relevance to the patient. Accuracy depends in part on the method of obtaining the data. Dr Spaeth noted that there can be accuracy problems with both imaging and clinical examination.

For example, physicians may pay no attention to signal strength when reviewing images obtained by optical coherence tomography (OCT). Or, a machinederived readout can be simply erroneous, as demonstrated by Dr Spaeth’s personal experience where the Disc Damage Likelihood Scale score calculated by a spectral-domain OCT device wrongly indicated he had glaucoma.

“Statistically-derived outputs based on population averages may not be applicable to the individual,” he said.

Clinical examination can also yield invalid information. For example, optic disc examination is often done without pupil dilation, or physicians performing applanation tonometry may fail to confirm that the mires are properly aligned.

When it comes to relevance to the patient, however, clinical examination has the advantage. Relevance is judged against what patients care about most, which is how they feel and function, and those aspects are best ascertained through history and observation.

“What we are looking for is whether the data will tell us about quality of life and ability to act,” said Dr Spaeth.

Relevant data include the patients’ comments and temporal patterns recorded through personal observation of such things as how patients walk into the examining room, whether they are happy or depressed, and if change in the optic

nerve appearance corresponds to a new visual field defect.

Measurements that allow accurate prediction of disability development are also important, and the rate of change in the optic disc or visual field are probably most helpful. However, the data still need to be interpreted, and then the interpretations need to be individualised, said Dr Spaeth.

QUALITY OF LIFE He illustrated his latter point with findings from studies showing that the relationship between visual acuity and quality of life differs between urban- and rural-dwelling populations, while the impact of visual field loss on function also varies among individuals.

A search of the literature identified no studies comparing the accuracy of clinical examination alone with machine- or laboratory-derived data for glaucoma diagnosis or prognosis.

However, Dr Spaeth said it did uncover numerous articles consistent with his beliefs about the need for conducting an accurate clinical examination and the fact that too many physicians lack the necessary skills.

Resurrection of the necessary skills may be difficult, however, because the personal examination takes time and effort, and habits are hard to change.

“It is much easier to look at a coloured labelled printout than at an optic disc, and the course chosen is often that which is economically and/or emotionally more beneficial for the physician than for the patient,” said Dr Spaeth.

“So, how are you going to keep someone down on the farm once they have seen Paris? When the data acquisition material is readily available, how can you convince physicians to look at the optic disc? The answer is to make them understand that when they look at the optic disc, the patient is going to do better,” he added.

George L Spaeth: gspaeth@willseye.org

GLAUCOMA

REVERSING GLAUCOMA Neuroprotection, enhancement and regeneration agents entering clinical trials. Howard Larkin reports

S

everal treatments that protect from loss of retinal ganglion cells (RGCs), regenerate axon cells and enhance retinal function are at, or near, the clinical trial stage, Jeffrey L Goldberg MD, PhD told a session of the American Academy of Ophthalmology Annual Meeting in Chicago, USA. In rodent tests, the topical rho-kinase (ROCK) inhibitor Rhopressa (Aerie Pharmaceuticals) showed neuroprotective and neuroregenerative effects, said Dr Goldberg, Professor and Chairman of the Byers Eye Institute at Stanford University, Stanford, California, USA. After traumatic optic nerve injury, treated animals had higher RGC survival rates and more optic nerve axon regeneration than did animals receiving a placebo (Exp Eye Res 2016).

However, it is uncertain if topical administration would be effective in humans since topical drug penetration is better in rodents than in primates, Dr Goldberg added.

The treatment’s long-term effects, any neuroprotective effect beyond intraocular pressure (IOP) lowering, and its effectiveness across different diseases also are unknown.

Adenosine receptor agonists also are in human testing, Dr Goldberg said. Preclinical data suggest Trabodenoson (Inotek Pharmaceuticals) may have a direct neuroprotective effect on RGCs. Stem cells may help treat the retina in two ways. First, they can continuously produce neuroprotective survival and growth factors. Even putting them in the vitreous might slow the course of glaucomatous degeneration, he noted.

Second, induced pluripotent stem cells can be implanted in the retina and turned into RGCs using gene therapies like Sox4 and Math5, Dr Goldberg said.

“Not only do they look like retinal ganglion cells, they act electrophysiologically like RGCs.” In a rodent model, RGCs transplanted into uninjured retinas have integrated into the retina, with axons extending back along the optic nerve across the optic chiasm to the lateral geniculate nucleus and superior colliculus, the two major synaptic targets in both rodent and human brains, Dr Goldberg said. The transplanted RGCs grow tree-like branches and respond to light stimulation (Venugopalan P et al. Nature Comm 2016. http://www.nature.com/articles/ncomms10472).

In a Phase I trial testing ciliary neurotrophic factor (CNTF) in non-arteritic ischemic optic neuropathy and glaucoma, a semi-permeable membrane loaded with cells from a human retinal pigment epithelium (RPE) cell line that secreted CNTF was inserted into the vitreous.

In 11 patients with various visual acuities, demographic characteristics and disease states, no serious adverse effects were seen while improvement was observed in some patients’ Humphrey visual field indices (VFI), including VFI and mean deviation, in one to three months, Dr Goldberg said. Retinal fibre layers also thickened significantly, though the benefit of this is uncertain. A larger controlled trial began recruiting in late 2016.

REGISTRATION & HOUSING OPENING

MAY 2017 THE LARGEST U.S. MEETING DEDICATED EXCLUSIVELY TO THE NEEDS OF THE ANTERIOR SEGMENT SPECIALIST THE LEADING PRACTICE MANAGEMENT PROGRAM IN OPHTHALMOLOGY

AnnualMeeting.ascrs.org

Jeffrey Goldberg: smkohler@stanford.edu EUROTIMES | MAY 2017

33

ESCRS

Practice Management

& Development

8–9 October 2017 Lisbon, Portugal

Grow Your Practice Manage Your Business

Programme Practice Management Masterclass Sunday 8 October 09.00 – 18.00

Masterclass in Ophthalmic Practice Management with John Pinto and Corinne Wohl The effective management of an ophthalmology practice is nearly as intellectually challenging – and interesting – as the practice of ophthalmology, itself. This practical day long course will be taught by two of America’s most active practice management advisors, with a combined 70 years of healthcare experience and hundreds of publications. John Pinto is the founder of J. Pinto & Associates, Inc., a 38-yearold ophthalmic management consulting firm based in San Diego, California. Corinne Z. Wohl, MHSA, COE, is President of C. Wohl & Associates, Inc., a practice management consulting firm.

Practice Management & Development Workshops Monday 9 October 08.00 – 18.00 Chairman: Paul Rosen UK Moderators: Kris Morrill FRANCE, Rod Solar

UK,

Ed Toland IRELAND, Paul McGinn IRELAND

Topics Include... 

Search engine optimisation and reviews to grow your practice

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All digital practices

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Presbyopia: How to increase your share of the market

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Social media for ophthalmologists

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Need-based marketing



Ambulatory surgeries: Your next step?



Influencer marketing for progressive ophthalmologists

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The Top 10 most common Human Resources mistakes

For full programme visit www.escrs.org

OCULAR

CATARACT DEPRESSION Study explores link between presence of cataract and depressive symptoms and lower cognitive function. Dermot McGrath reports

T

he presence of cataract was examined as a possible risk factor for depressive symptoms and for lower cognitive function, it has been reported in a large-scale Irish study.

“Cataract is common, with previous studies in Western Europe estimating prevalence at 30% of over 65-year-olds, with a further 10% in this age group having had prior cataract surgery. Cataract has been associated with depression in several epidemiologic studies, a link which was reiterated in our own study,” said Clare Quigley MD, Mater Misericordiae University Hospital, Ireland.

Dr Quigley’s study included 8,146 adults over the age of 50 enrolled in The Irish Longitudinal Study on Ageing (TILDA), a nationally representative longitudinal study of ageing in Ireland.

The breakdown was 54% female and 46% male, with a mean age of 64 years.

The presence of cataract was reported as present in 371 patients (5% of the total sample), with an additional 513 (6%) being pseudophakic.

Predictor variables, measured at baseline, included self-reported cataract and prior cataract surgery; participants who reported presence of other vision problems, including glaucoma and agerelated macular degeneration, were excluded. Other relevant covariates included sex, age, place of birth in Ireland versus elsewhere, polypharmacy (use of four or more medications), and selfreported visual impairment.

Outcome variables included symptoms of depression, assessed via the Center for Epidemiologic Studies Depression (CES-D) scale, at baseline and two years later, and cognitive function, assessed via The MiniMental State Exam (MMSE) at baseline only, said Dr Quigley.

Courtesy of Clare Quigley MD

36

EUROTIMES | MAY 2017

...we want to determine what effect cataract surgery has, as this could be hoped to ameliorate mood problems...

Clare Quigley MD While the presence of cataract was associated with significantly higher depressive symptoms at baseline and at follow-up two years later, the association was removed after adjustment for relevant covariates. Other variables significantly associated with depression score at baseline and two years later included positive association with female sex, visual impairment, and polypharmacy, and inverse association with age and place of birth in Ireland.

Cataract was also associated with lower cognitive function in unadjusted analysis at baseline and at follow-up two years later, but this association was removed after adjustment for covariates.

“Pseudophakic, versus phakic, status of study participants did not show strong evidence of association with depression, or cognitive function. Unfortunately, we could not determine an effect of cataract surgery, as we did not follow depression score in participants before and after surgery. This could be an area for further research,” said Dr Quigley. "The fact that the presence of cataract was lower than previous studies may be due to self-reported nature of the data, said Dr Quigley.

“The strengths of the study were a large sample, and that multiple variables were assessed, while the weaknesses were the likely underestimation of cataract incidence, and the lack of visual acuity data or slit lamp examination,” she said.

Dr Quigley said the study picked up a signal which may be important, as with our currently ageing society, the burden of cataract is increasing. "An association with increased depressive symptoms is troubling. Recently, on 30th March 2017, the World Health Organization (WHO) described depression as the leading cause of ill health and disability worldwide," said Dr Quigley.

"Previously, studies have found an association of lower mood with presence of cataract. However, our analysis is

the first to show this in a nationally representative cohort. The advantage of a large-scale study such as ours is that a positive association is drawn from a diverse sample, showing likely importance. One disadvantage is the lack of detail," she said.

"It would be very useful to determine why those with a diagnosis of cataract had more depressive symptoms; so far we know that it is partially, but interestingly, not fully driven by visionrelated quality of life. Especially we want to determine what effect cataract surgery has, as this could be hoped to ameliorate mood problems. Prior prospective studies have shown either no change in mood, or a small improvement. Further research, which examines in more detail what underlies the association, and examines the effect of surgery, are needed," said Dr Quigley.

A shorter version of this article was published on www.eurotimes.org in April 2017. This article has been updated.

Clare Quigley: quigleyclare@gmail.com

ASCRS

38

RESEARCH

GENE THERAPY Big Pharma is interested in gene therapy, but technical difficulties and regulatory barriers remain.

Howard Larkin reports

M

oving gene therapy out of the lab and into the clinic requires support from Big Pharma.

No one else has the massive resources and expertise needed to develop, manufacture, market and gain regulatory approval of new conventional drugs, let alone an entirely new drug category, José-Alain Sahel MD told the Ophthalmology Futures European Forum 2016.

Interestingly start-up companies have led the path and provided the most relevant proof-of-concept studies.

After years on the sidelines, major players are now stepping up, said Dr Sahel, who is Director of The Vision Institute, Paris, France, Professor at Pierre and Marie Curie Faculty of Medicine in Paris, Professor and Chairman of the Department of Ophthalmology at the University of Pittsburgh School of Medicine, USA, and a founder of GenSight Biologics.

However, significant technical and economic challenges remain that will take time to overcome, several presenters said.

These include the rarity of many genetic diseases, difficulties developing safe viral delivery vectors and precisely delivering EUROTIMES | MAY 2017

them, and scaling up production to commercial levels.

The good news is ocular applications are particularly attractive in part because they require only minute doses, said Vivian Choi PhD, Head of Gene Therapy Research, US, Shire Pharmaceuticals, Lexington, Massachusetts, USA. The action of ocular therapies also can be readily observed in a segregated, relatively immune privileged, anatomical space.

research candidates and potential market size, posing challenges to the financing of the high development and testing costs.

For ethical reasons, human tests are usually initiated in patients with advanced disease, presenting another challenge, said Simon Chandler PhD, Head of Clinical Research and Regulatory Operations at Ora Inc, London, UK. “Most of the cells we need to treat aren’t there anymore,” he said, which may make it impossible to restore vision to levels detectable with traditional acuity or visual field tests.

José-Alain Sahel RARE DISEASES Therefore, surrogate endpoints Diseases treatable with gene therapy must be developed, Dr Chandler said. tend to be rare genetic disorders, such These include biochemical and anatomical as Leber’s congenital amaurosis and markers, as well as newly developed vision choroideraemia, which attack the retina, function tests, such as one developed by Dr Choi said. Low volume of ultra-orphan Spark Therapeutics, Philadelphia, USA. indications limits both availability of

Replacement genes are delivered by modified viruses, and these must be carefully developed...

Simon Chandler PhD

RESEARCH

VECTORS AND DELIVERY Replacement genes are delivered by modified viruses, and these must be carefully developed for each therapy to ensure they both work and do not provoke immune reactions or other severe side

effects, Dr Chandler said. The technology to measure the quality of these vectors also has to be invented from scratch, customised for each therapeutic vector. The requirements can be punitive – for example in one Ora trial, a vector required the development of 24 quality control assays.

Gene therapy must also be delivered precisely to be effective. For example, a choroideraemia treatment developed by Robert MacLaren FRCOphth at Oxford University, UK, must be injected into the subretinal space.

“Very skilled surgeons such as Dr MacLaren can get back to the same hole and put it in the same space, but for the typical surgeon that is much more difficult,” said Marc de Smet MD, PhD, co-founder and Chief Medical Officer of Preceyes BV, Eindhoven, The Netherlands.

Disseminating the procedure requires development of instruments that make it easier, such as robotic injectors or specially designed needles.

Very skilled surgeons such as Dr MacLaren can get back to the same hole and put it in the same space...

Marc de Smet MD, PhD

ESCRS

Practice Management

& Development

Competition

Courtesy of Institut de la Vision, Paris/Dalkara, Deniz

The test measures patients’ mobility improvements due to the restoration of enough vision to detect light sources and orient themselves in space.

Changes in how clinical trials are designed, allowing patients involved in early safety and efficacy trials to roll seamlessly into later dose-finding and pivotal clinical trials, will also help by reducing the total number of patients required for discrete phase 1, 2 and 3 trials, Dr Chandler said. In recent years, the US FDA has been increasingly supportive of such adaptive trial designs. This includes the enrolment of earlier stage patients, who have no other treatment options, into safety trials, he noted.

A high magnification zoom on AAV-transduced cones outside the fovea

Industrial organisations that had experience in developing traditional biologics can leverage their knowledge to tackle the challenge of producing gene therapies which meet industry standards for consistency and volume, Dr Choi said.

“Manufacturing for gene therapy has been a continuous challenge in the field, but much progress has been made to develop manufacturing technologies and to build capacities to support clinical testing and commercial supplies,” she said José-Alain Sahel: j.sahel@gmail.com Vivian Choi: vivian.choi@shire.com Marc de Smet: mddesmet1@mac.com Simon Chandler: schandler@oraclinical.com

CALLING ALL MARKETERS! WIN A €1000 BURSARY. ESCRS Practice Management and Development Marketing Case Study Competition Enter now to win a €1000 bursary.

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EUROTIMES | MAY 2017

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CLINICAL QUESTIONS

ASK THE EXPERTS

Welcome to a new EuroTimes feature where our medical editors answer readers’ questions Prof Sorcha Ní Dhubhghaill University Hospital Antwerp, Belgium Q. Learning cataract surgery can be really stressful for both the trainee and the teacher. Do you have any tips for trainees to help them create the best environment for learning?

Dr Soosan Jacob MS, FRCS, DNB Director and Chief, Dr Agarwal’s Refractive and Cornea Foundation (DARCF), Senior Consultant, Cataract and Glaucoma Services, Dr Agarwal’s Group of Eye Hospitals, Chennai, India A. The most important thing that trainees can do to make learning cataract surgery easier is to prepare themselves for surgery – step by step.

A mental checklist should be prepared from multiple sources which includes didactic learning, watching live surgeries performed by seniors, watching surgical videos and finally performing surgery, step by step, under supervision.

Each has its advantages and disadvantages. Didactic lectures and the excellent reading material available, both in the form of books and online articles, helps trainees learn all about the topic.

However, though some concepts are better explained, some are better understood when seen. Watching live surgery by seniors allows one to see his or her technique of surgery and how problems are handled in real time.

Nevertheless, it may not be possible to see all types of surgical situations or different methods of management of the same scenario.

Watching surgical videos online is another great technique to observe, as many interesting videos can be watched in a short time.

A combination of these three methods will help the trainees to become successful in the last and most important way of learning, which is performing under supervision, both with simulators as well as on the patient.

All the above measures should help the trainee to formulate a step-by-step plan as to the sequence of events to be followed when things are going as planned, as well as when they are not.

Thomas Kohnen MD, PhD, FEBO Professor and Chair, Dept of Ophthalmology, Goethe-University, Frankfurt, Germany; Editor, JCRS in collaboration with Anna Slavík-Lenčová MD Ophthalmology Consultant (for) Cornea, Cataract and External Eye Disease, Dept of Ophthalmology, GoetheUniversity, Frankfurt, Germany A. It is essential to be well prepared. Hard work pays off. Gain as much possible theoretical knowledge about cataracts, IOLs, phacoemulsification and its possible complications. Attend the phaco-courses and video sessions that are offered at congresses. Read books to increase your knowledge on principles and techniques.

Hands-on training is a necessary step.

Nowadays, cataract simulators are useful tools for preoperative preparation. You can train your bimanual coordination, preciseness, and go through all the steps of cataract surgery. It is a perfect tool for capsulorrhexis exercise. You can train your skills, repeating each step of a surgery. After each session, you receive an evaluation. The latest simulators also offer training for complicated situations, and provide a unique possibility to train for actual real-life surgery.

It is important to be cautious about your patient selection for your first surgeries. It is recommended to start with easy cataracts and cooperative patients.

Deep-set eyes or narrow lids are not good to start with. Think about anaesthesia (anaesthetic block instead of topical drops if preferred).

Familiarise yourself with your microscope, instruments, and the phacomachine that you are going to use. Adjust your chair and microscope before a surgery. Record videos of your cases and learn from your mistakes. Complications at the beginning are common; do not lose your courage to improve.

Finally, take the opportunity to watch other experienced surgeons. If you compare how they handle the case, it should help you to improve your own surgery.

Boris Malyugin MD, PhD Professor of Ophthalmology, Deputy Director General (R&D, Edu), S. Fyodorov Eye Microsurgery State Institution, Russia A. Many great surgeons are perfectionists by nature. That is why observing somebody who is doing things that are generally right, but not as perfect as they have to be, may be really stressful.

To relieve that stress, from both the student and the teacher, it is a good idea to divide the procedure into relatively small but crucial steps (capsulorhexis, irrigation/ aspiration, IOL implantation and OVD removal, etc).

These steps are relatively short and do not generate prolonged stress.

On the contrary, during one surgeon session, the student will focus on one certain manoeuvre at a time. By doing it repeatedly 10 to 12 times in a row, the student can master the manoeuvre in a fast and efficient way.

If you have a clinical question regarding a straightforward or complex case, send it to EuroTimes Executive Editor Colin Kerr at: colin@eurotimes.org EUROTIMES | MAY 2017

41

WINNER e B2B Magazin 16 20 & ar 2015

of the Ye

0 (more than 5,00 circulation)

THE

TO BE REACH

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*

CUSTOMERS IN OVER 150 COUNTRIES WITH YOUR AD Advertise with the highest audited circulation for any ophthalmic news magazine in Europe 59 per cent of our readers surveyed in an independent research survey have decision-making power when it comes to the purchase of surgical/medical equipment or supplies. A further 20 per cent are usually consulted before a final decision is made**

* Average net circulation for the 10 issues circulated between 1 January 2016 to 31 December 2016. See www.abc.org.uk ** Results from the

EuroTimes Readership Study 2011

RANDOM THOUGHTS

43

RISK BENEFIT At home or at work, ophthalmologists must decide what is an acceptable level of risk. Leigh Spielberg MD reports

Illustration by Eoin Coveney

W

hat is the risk-benefit trade off for a particular situation? That seems to be the primary question in my life these days, wherever I am and whatever I’m doing. The question poses itself when I’m in the clinic. It’s in the back of my mind in the operating room. It is a recurring theme when I’m at home with my kids. It pops into my mind when I’m doing any of my hobbies.

In the clinic, I can usually manage the question quite well. Most of the surgical indications are fortunately quite straightforward, so the risk of operating is usually clearly outweighed by the expected benefits. But what about vitreous floaters in a middle-aged phakic patient with -5D myopia? Is the decision to operate too risky? Who’s to say?

Similarly, in the operating room, almost every step of a vitrectomy is the result of calculating the risk. How closely should I shave the vitreous in this eye to make sure enough is removed but not so much that I risk an iatrogenic retinal tear. How much peripheral laser do I apply? Just a little, to absolutely minimise the risk of macular pucker, or a bit more, to allow me to sleep better at night, knowing that a micro-tear won’t end up as a retinal detachment. Do I suture the sclerotomies, with the knowledge that sutures can irritate for days to weeks, or do I risk the potentially dangerous but very unlikely postoperative hypotony?

METAL OR PLASTIC? The risk-benefit calculations continue at home too. Do I allow my little chefs-in-themaking use a metal knife to slice a banana for breakfast? Or do I insist on them using a plastic kid’s knife? Can Philippa (5 years old) and Raphael be trusted with metal scissors?

Ocular trauma, whether personal or professional, gives me nightmares. And, on a less serious and dangerous note, can I accept the risk of them dropping my (wife’s) iPad while they watch a video that keeps them busy long enough to allow me to finish writing this article?

My hobbies all pose some level of risk.

Do I always have to protect my big camera and its fancy lenses if it not only decreases the chance of an expensive fall but also the

chance of capturing that perfect shot? A nasty fall off my mountain bike could result in a broken hand or wrist, with serious implications for my operating future. But riding ultra-cautiously somewhat defeats the purpose of riding at all. Is riding a motorcycle an acceptable risk for someone with a wife and two young children?

Clearly, not if it’s rush-hour and raining.

But what if I only ride down country roads on sunny Sunday afternoons?

I’ve made it to where I am now, so I guess I’ll continue as I’ve done since day one.

Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent University Hospital in Belgium * This article was first published on www.eurotimes.org in March 2017

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44

ESCRS NEWS

ESCRS speakers at the 31st International congress of the Hellenic Society of Intraocular Implant and Refractive Surgery

Membership POWERFUL DATA | CLINICAL TRENDS

ASCRS Members receive the latest ophthalmic surgical news, research and resources.

YEAR-ROUND EDUCATION Annual meetings and the ASCRS Center for Learning (webinars, clinical reports, post-meeting resources, podcasts and CME 24/7)—NEW ascrs.org/learn

CLINICAL SURVEY DATA ASCRS is the only professional organization in ophthalmology offering access to the detailed clinical survey data provided by over 2,000 of its members

TOOLS

ESCRS

NEWS

ESCRS SYMPOSIUM AT HSIOIRS CONGRESS The ESCRS Academy organised a symposium at the 31st International congress of the Hellenic Society of Intraocular Implant and Refractive Surgery (HSIOIRS) in Athens, Greece on “Managing Astigmatism During Cataract Surgery”.

The symposium speakers included Drs Alja Črnej from Slovenia; Alex Day from England; Satish Srinivasan from Scotland; Pantelis Papadopoulos from Greece; José Guell from Spain; and Roberto Bellucci from Italy. The session was moderated by Dr Bellucci and Dr Vikentia Katsanevaki from Greece.

Topics including preoperative measurements, biometry and managing conflicting measurements between biometry and topography were discussed.

There were video-based discussions on incisional and femto-corneal relaxing incisions and several techiniques of intraoperative toric IOL alignment including the latest imageguided systems.

The symposium concluded with the final talk by Dr Bellucci on managing post-operative refractive error.

Post-refractive IOL and Barrett Toric Calculators, Toric Results Analyzer and more online tools

PUBLICATIONS Journal of Cataract & Refractive Surgery, Ophthalmology Business magazine and EyeWorld news magazine

CORNEA COURSES ON YOUR IPAD, MAC OR DESKTOP COMMUNITY Daily online discussions in EyeConnect and the EyeConnect 365 app

START YOUR MEMBERSHIP TODAY.

ascrs.org EUROTIMES | MAY 2017

Members of ESCRS iLearn can earn 12 CME credits with four courses dedicated to corneal diseases, diagnosis and surgery.

These courses will give ophthalmologists the opportunity to learn about key concepts in corneal anatomy and biomechanics as well as imaging

and laboratory testing methods for infectious and noninfectious, ectatic and ocular surface diseases.

Two surgical courses cover a range of procedures from crosslinking through PKP to anterior and endothelial lamellar keratoplasties. http://elearning.escrs.org

BOOK REVIEWS

WHAT TO DO IN AN OPHTHALMIC EMERGENCY

BOOK

REVIEWS

CHALLENGING CASES Cataract surgery remains the bread and butter of most ophthalmologists’ practices. Yet, despite the great advances in knowledge, experience, and technology available, challenging cases can still lead to complications, PUBLICATION even in the most CHALLENGES IN experienced hands.

CATARACT SURGERY Challenges in EDITORS: WAN SOO KIM Cataract Surgery AND KYEONG HWAN KIM (Springer), by Wan Soo Kim and Kyeong PUBLISHED BY SPRINGER Hwan Kim differs from most textbooks in that it covers only the most difficult aspects of phaco surgery. No time is spent discussing the basics of the phaco machine, the anatomy of the eye, or the standard steps involved in a normal procedure.

Instead, each chapter in this 125-page book covers one specific problem: intumescent, brunescent, posterior polar, post-traumatic

and uveitis cataracts; small-pupil surgery; lens and IOL (sub)luxation; and phaco in highly myopic, hypermetropic and vitrectomised eyes, among others. Several related advanced procedures, such as secondary IOL fixation and artificial iris implantation are also described. Preoperative, intraoperative, and postoperative considerations are discussed in every chapter.

The book is illustrated with many surgical photographs as well as schematic illustrations of, for example, the effect of irrigation flow blockage by a small pupil, leading to the collapse of the capsular bag and subsequent rupture by the phaco tip. When fine details are difficult to discern, such as those seen in a brunescent cataract in an eye with a brown iris, surgical photographs are accompanied by drawings illustrating the critical features of the anatomy and procedural steps.

Once we have finished our formal surgical training, we have to learn the rest on our own, and any help we can get is greatly appreciated.

This book is intended for cataract surgeons who have gained proficiency in standard phaco procedures and who are looking to elevate their skills to the next level.

ALL YOU WANT TO KNOW ABOUT COLOUR VISION “Colour vision is a marvellous sub discipline in vision research,” begins the preface to a new release in the Springer Series in Vision Research, Human Colour Vision.

Edited by Jan Kremers, Rigmor C Baraas, and N Justine Marshall, the book is not only a very comprehensive overview of our current knowledge regarding colour vision, with chapters like, “Colour Constancy and Contextual Effects on Colour Appearance.” It is also full of interesting titbits of information that some of us may have noticed in passing, but never gave much thought. For example, most children acquire a reliable knowledge of nine of the 11 basic colours around the age of 36 months. Brown and grey are more difficult, coming up to nine months later.

The most interesting chapter for most ophthalmologists is “Colour Vision in Clinical Practice,” which describes the diseases of colour vision, their causes, assessment methods, and management.

This 350-page, text-dense book is intended for vision researchers and for those of us with a healthy dose of curiosity.

“Facing an emergency situation where improper management can rapidly worsen the condition leading to blindness or even death of the patient is every ophthalmologist’s nightmare.” So begins Emergencies of the Orbit and Adnexa (Springer), by Bipasha Mukherjee and Hunter Yuen, a new handbook that covers a very broad spectrum of pathologies, from subluxated globes and adnexal injuries due to animal bites to more commonly encountered problems like dacryocystitis and orbital fractures.

For general ophthalmologists and those of us generally not called on to manage severe orbital and adnexal emergencies, the first two chapters are a great way to get started. They outline the general approach and the systemic management in trauma and other emergencies.

Each of the following 50 chapters covers a single, very specific topic such as the “Investigation of Eyelid and Lacrimal Injuries” and “Canaliculitis and Intracanalicular Foreign Bodies.”

This is an excellent reference text for general ophthalmologists and a good place to start reading for orbital and oculoplastic surgery fellows.

LATEST ON CXL FOR KERATOCONUS AND CORNEAL ECTASIAS Before 1998, when the first patient was treated with Corneal Collagen Cross Linking (CXL), the only options for keratoconus and corneal ectasias were observation and keratoplastic surgery. Since then, a wealth of knowledge has been accumulated.

Corneal Collagen Cross Linking (Springer),

by Mazen M Sinjab and Arthur B Cummings is a 280-page discussion on the current stateof-the-art of CXL and it aims to present the reader with all this information in one place.

All aspects of CXL are covered, including the diagnostic tools required to evaluate ectactic corneal diseases, the fundamentals of CXL, combinations of CXL with other procedures, the clinical results in both adults and children, and the potential complications. The future of CXL is discussed in the last chapter.

This book is intended for ambitious residents, cornea fellows, current cornea specialist, and general ophthalmologists who are considering incorporating CXL into their practice and would like up-todate information in a well-written and convenient package.

DR LEIGH SPIELBERG Books Editor 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 | MAY 2017

45

46

EXPLORING LISBON

LISBON

3

TO NOTE...

LISBON

CREDIT CARDS: SELDOM ACCEPTED AT CAFES OR PASTRY SHOPS TIPPING: SERVERS RECEIVE ABOUT 10% DINING HOURS: LUNCH 12.00 TO 15.00, DINNER 19.00 TO 23.00

Brasserie De L’entrecote: The popularity of the restaurant is based on offering just one menu – a green salad garnished with walnuts, followed by two servings of entrecôte smothered in a delicious secret sauce and accompanied by crispy French fries. There are tempting desserts, too. Note: vegetarians can order seitan – “wheat meat” – to replace the steak. Also, note that appetisers - olives, cheese, fish paste, bread - arrive at your table before you order. This widespread Portuguese custom surprises unwary diners. The starters are not complimentary; if you nibble, the charge will appear on your bill. You’re free to ignore them or better still, wave them away.

To book a table go to the website: www.brasserieentrecote.pt To enjoy a view of the Tagus, check out the possibilities on Rua da Pimenta, which runs between the Feira International and the river.

One suggestion is the Senhor Peixie at No, 35 for fresh fish and a vast selection of seafood served by a cheerful informative staff.

Details at: www.senhorpeixe.pt For a dazzlement of codfish, try D’Bacalhau at No. 45 Rua da Pimenta. There are said to be over 1,000 Portuguese recipes for codfish and this restaurant features many of them. Can’t decide which to sample? Order the “four in one” – four specialities in one serving. Details at: www.restaurantebacalhau.com If you like Chinese food, it would be a shame to be so near The Old House and not treat yourself to a meal. In China, there are 30 restaurants in this popular chain but the one at Rua da Pimenta 9 is the first to open outside China. The cuisine is Sichuan, normally highly spiced but here toned down slightly. The menu indicates how spicy the dish may be. The restaurant also has a special oven for preparing Peking duck. The restaurant accepts only cash or Portuguese Multibanco cards. Reserve a table on the Portuguese language website at: www.the oldhouseportugal.pt.

EUROTIMES | MAY 2017

Rua Neves Costa

APPETISING OPTIONS

Classic dining choices await delegates at the ESCRS Congress in Lisbon. Maryalicia Post reports A 20-minute taxi ride from Park of Nations, there’s a tiny area that has the feel of times gone by. Carnide is an ideal place to combine an evening stroll with a few glasses of wine and a good meal, One choice is the 100-year-old Adega das Gravatas, where you dine in a room decorated with 3,500 neckties (gravatas) left by happy customers. Reservations available at www.adegadasgravatas.com Another choice is Adega de Carnide, a traditional Portuguese restaurant with Alentejo regional specialities and an inner garden. Although Adega de Carnide has no website, your can make reservations through www.thefork.pt. Both restaurants serve lunch and dinner. Both close on Monday.

If either of those restaurants is full, amble down Rua Neves Costa and settle where fancy takes you.

To experience the most highly refined cuisine the city has to offer, just follow the Michelin Star trail. Since 2012, when chef José Avillez gained his first star at Belcanto, the restaurant has been synonymous with fine dining. His second star in 2014 kept him ahead of a pack that now includes two established one-star restaurants – Eleven and Feitoria – and two up-and-coming one-star restaurants – Loco and Alma.

Each restaurant reflects a different culinary point of view. Each offers a multi-course menu to show it off. It can take about threeand-a-half hours to sip and savour your way through an 18-course “discovery menu".

Belcanto offers tasting menus, described as “voyages of discovery” and featuring dishes like the Garden of the Goose who Laid the Golden Egg. “Revisited Portuguese cuisine” is served to 10 tables of appreciative diners at lunch and dinner daily except Sunday and Monday.

Another popular restaurant, Eleven,

specialises in Mediterranean cuisine in an elegant building with beautiful views. In addition to seasonal and tasting menus, the restaurant offers a lobster menu and black truffle menu.

Feitoria, which is located in the Altis Belém Hotel, has adopted discovery as its theme. Two tasting menus each year celebrate the exotic spices and ingredients that make traditional Portuguese dishes special. The Terra tasting menu is vegetarian. Details at: restaurantefeitoria.com Loco is a modern restaurant where you dine with a view of the kitchen. The restaurant serves dinner tasting menus only.

Choose either 14 or 18 courses, the latter described as “unpredictable and surprising like the restaurant itself ”. Closed Sunday and Monday. Details at: www.loco.pt Alma offers a variety of tasting menus, including a five-course menu based on seafood. Details at: www.almalisboa.pt

Adega de Carnide

CALENDAR

JUNE

LAST CALL

MAY 2017 Johns Hopkins University School of Medicine presents Retina Festival 2017 5 May Baltimore, Maryland https://hopkinscme.cloud-cme.com/aph. aspx?P=5&EID=7298

ASCRS · ASOA 2017 5–9 May Los Angeles, USA www.ascrs.org

SFO 2017

6–9 May Paris, France www.sfo.asso.fr

ARVO 2017 Annual Meeting 7–11 May Baltimore, USA www.arvo.org

MediterRetina Club International Meeting 11–13 May Parma, Italy www.mediterretina.com

1–3 June Hangzhou, China www.apacrs2017.org

SOE 2017

10–13 June Barcelona, Spain www.soe2017.org

↙

↙

30th APACRS Annual Meeting

World Glaucoma Congress 2017

28 June–1 July Helsinki, Finland www.worldglaucoma.org

17th ESASO Retina Academy

29 June–1 July Berlin, Germany www.esaso.org/17th-esaso-retinaacademy-2017

JULY

MaculArt Meeting

2–4 July Paris, France www.maculart-meeting.com

AUGUST

ASRS Annual Meeting 2017 11–15 August Boston, USA www.asrs.org/ annual-meeting

NEW EPOS 2017 43rd Annual Meeting of The European Paediatric Ophthalmology Society 31 August–2 September Oxford, UK www.epos-focus.org

SEPTEMBER

17th EURETINA Congress 7–10 September Barcelona, Spain www.euretina.org

SEPTEMBER

Echography Teaching Services International Annual Course and Workshop on Diagnostic Ultrasound in Ophthalmology 11–15 September Vienna, Austria www.echography.com

EVER – European Association for Vision and Eye Research Congress 2017 27–30 September Nice, France www.ever.be

DOG 2017

28 September–1 October Berlin, Germany www.dog.org

OCTOBER

8th EuCornea Congress

6–7 October Lisbon, Portugal www.eucornea.org

South East European Congress of Ophthalmology

6–8 October Sarajevo, Bosnia and Herzegovina www.ophthalmologia2017.com

XXXV Congress of the ESCRS 7–11 October Lisbon, Portugal www.escrs.org

3rd European Congress on Ophthalmic Imaging: From Theory to Current Practice 13 October Paris, France http://www.vuexplorer.fr

Barcelona, host city of the 17th EURETINA congress and SOE 2017

EUROTIMES | MAY 2017

47

48

CALENDAR

Vienna will host the XXXVI Congress of the ESCRS, the 9th Eucornea Congress and the 18th EURETINA Congress in September 2018

NOVEMBER

AAO 2017

11–14 November New Orleans, USA www.aao.org/ annual-meeting

DECEMBER

WCPOS IV 4th World Congress of Paediatric Ophthalmology and Strabismus

2018

JANUARY

9th International Course on Ophthalmic and Oculoplastic Reconstruction and Trauma Surgery

10–12 January Vienna, Austria http://www.ophthalmictrainings.com/ workshops

MARCH

NEW Frankfurt Retina Meeting 2018

24–25 March Mainz, Germany www.eckardt-frankfurt.de

JUNE

WOC 2018

16–19 June Barcelona, Spain www.icoph.org

9th EuCornea Congress

21–22 September Vienna, Austria www.eucornea.org

XXXVI Congress of the ESCRS

As part of our ongoing service to our readers, we are introducing a new feature to EuroTimes, the official news magazine of the ESCRS. 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 be sent to our Medical Editors and International Editorial Board.

We will publish a selection of their answers in the magazine.

EUROTIMES | MAY 2017

20–23 September Vienna, Austria www.euretina.org

22–26 September Vienna, Austria www.escrs.org

1–3 December Hyderabad, India wspos.org/india-2017

ask the experts

SEPTEMBER

18th EURETINA Congress

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