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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Content Editor Aidan Hanratty Senior Designer Lara Fitzgibbon


Designer Monica De Iscar Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg 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

We look at the latest technological innovations in vitreoretinal surgery

7 Laser therapy still has its place in the treatment of proliferative diabetic retinopathy


Polypoidal choroidal vasculopathy is a complex disease and may require a customised approach

10 OCT angiography is a valuable tool for retinal physicians

11 Anti-VEGF agents have revolutionised the management of ocular neovascularisation

13 Ophthalmologica update

CATARACT & REFRACTIVE 14 Everything you ever wanted to know about phacoemulsification in small eyes – Part 1

16 Small-incision lenticule extraction appears to be safe and effective for astigmatism correction

17 Many technological

advances have emerged that can improve toric IOL outcomes

18 Complications with 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.

SMILE are generally resolved with a good visual outcome for the patient



19 Intraoperative

aberrometry is a promising tool to aid surgeons in achieving better outcomes

20 Data from devices that

measure the posterior cornea improve power calculations

21 JCRS highlights 22 We look at the highlights from the 22nd ESCRS Winter Meeting in Belgrade

CORNEA 24 Corneal imaging tools continue to evolve, enhancing the ability for early keratoconus diagnosis

25 Blood derivatives have rich potential to treat a wide range of ocular surface diseases

26 Mapping the epithelium can help determine if patients are at risk of postoperative ectasia

27 New approaches to

difficult corneal pathologies follow anatomic discoveries

GLAUCOMA 28 A new study should help

clinicians to make more informed choices in daily patient management

29 Phacotrabeculectomy may offer an alternative to small-incision cataract surgery combined with trabeculectomy

PAEDIATRIC 30 Phakic posterior

chamber lens implantation is a good option for children with unilateral high myopia

31 Should multifocals be

used in the paediatric population, and if so, how should they be used?

REGULARS 33 Industry news 35 ESCRS News 37 Eye on history 38 Travel 39 Calendar Supplement March 2018

Included with this issue... ESCRS Education Forum supplement

Supported by an unrestricted educational grant from




PHENOMENAL GROWTH Developments in technology have been matched by the expansion of EURETINA over the past two decades


his year marks the 18th anniversary of the European The OCT technology not only allows for imaging retinal Society of Retina Specialists. EURETINA’s timeline structure, it also enables us to image the retinal blood flow. In the began in 2000, with its inaugural meeting welcoming field of treatments for retinal disease, the development of anti300 delegates. In the years since, it has experienced VEGF therapy revolutionised the treatment outcome in many phenomenal growth to almost 5,000 delegates, macular diseases. Since the approval of anti-VEGF therapy in establishing it as the largest retina meeting in the world. 2006, patients with exudative AMD, macular oedema secondary to EURETINA’s activities span outside of its main congress, and vascular disease and other pathologies can be treated successfully it also hosts a successful Winter Meeting, this year in Budapest in with intravitreal anti-VEGF drugs. This new treatment modality February. Another recent development for EURETINA saw the has resulted in increased interest in retinal disease, a growing launch of YOURS, a new initiative focusing on the pressing issues number of retinal specialists and a great need for exchange of and needs of Young Retina Specialists. Within the first few months knowledge and education. The EURETINA congresses have of this initiative being launched the society saw more than 300 new served this need by providing an excellent overview of new trainee subscriptions for YOURS membership. This demonstrates developments in retinal disease. the need for such an important initiative and secures the input We are very much looking forward to the 18th EURETINA of younger voices at the congress and across all society activities. Congress in Vienna, which is sure to provide an excellent In a world with an increasing focus on online education, the platform for education and knowledge transfer. The program EURETINA website is undergoing something of an upgrade. The will cover all important subjects in vitreo-retinal disease and online newsletter ‘EURETINA Brief’, On Demand and the popular will give an update on actual developments in retinal diseases. eLearning platform ‘inSight’ remain valuable features The 18th Congress will be held in of the society’s digital presence. Meanwhile, the newly combination with the 36th Congress We are very much looking launched ‘EURETINA Player’ allows visitors to enjoy of the European Society of Cataract studio-recorded video interviews with renowned and Refractive Surgeons (ESCRS) and forward to the 18th experts in retina. We are excited to unveil a new design the 9th EuCornea Congress, making EURETINA Congress in for the website very soon, which will offer improved the meeting in Vienna an exciting Vienna, which is sure functionality and a fresh and exciting user experience. platform for international exchange It is not just EURETINA that has experienced between sub-specialties. to provide an excellent phenomenal growth since the year 2000. The platform for education developments seen in diagnosis and treatment of and knowledge transfer retinal diseases have also been dramatic. One example of revolutionary development in retinal diagnostics during the lifespan of EURETINA is optical coherence tomography (OCT). In the year 2000 OCT instruments were available only in specialised centres and the discussion at the time was whether or not OCT technology would be helpful for managing patients with retinal disease. Today, OCT is used for diagnostic, monitoring and treatment decisions in a large variety of retinal diseases, including age-related macular degeneration (AMD), diabetic retinopathy, retinal vascular occlusion, vitreoretinal interface diseases and macular dystrophies. Sebastian Wolf is President of EURETINA


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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• Consistent folding • Small incision size Desired consistent leading Depth guard nozzle is designed to protect wound integrity and posthaptic configuration in implantation incision size1,6-8 98% of implantations†,5

*Prospective observational, multicenter, time and motion study comparing duration and economic efficiencies of cataract surgeries with different IOL delivery systems at three hospitals in France and two hospitals in Spain. Testing completed with UltraSert® 2 mm nozzle tip. †In porcine eyes where leading haptic configuration was evaluated when the IOL reached its dwell position, 98% of implantations resulted in tucked delivery configurations (deep tuck and tuck looped). Testing completed with UltraSert® 3 mm nozzle tip. 1. AcrySof® IQ UltraSert® Pre-loaded Delivery System Directions for Use. 2. Nanavaty MA, et al. Evaluation of preloaded intraocular lens injection systems: Ex vivo study. J Cataract Refract Surg 2017; 43:558–563. 3. Weston K, Nicholson R, Bunce C, Yang YF. An 8-year retrospective study of cataract surgery and postoperative endophthalmitis: injectable intraocular lenses may reduce the incidence of postoperative endophthalmitis. Br J Ophthalmol. 2015;99(10):1377-1380. 4. Mendicute J, Pablo L, Vélasque L, Martinez A, Asmar J, Schweitzer C. Multicenter evaluation of time, operational and economic efficiencies of a new pre-loaded IOL delivery system vs. manual IOL delivery. Paper presented at: ASCRS-ASOA Symposium and Congress; May 5-9, 2017; Los Angeles, CA. 5-6. Alcon data on file. 7. Wang L, Wolfe P, Chernosky A, Paliwal S, Tjia K, Lane S. In vitro delivery performance assessment of a new preloaded intraocular lens delivery system. J Cataract Refract Surg. 2016;42(12):1814-1820. 8. Alcon data on file.


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RETINA SURGERY Technological innovation is crucial to the continued improvement of vitreoretinal surgery. Leigh Spielberg reports


echnological innovation is crucial to the continued improvement of vitreoretinal surgery. This was abundantly apparent during the RetinaTech Bio-Engineering Session during the 17th EURETINA Congress in Barcelona, Spain. Subtitled “Where Surgery Meets Technology”, it featured a group of 12 highly experienced vitreoretinal surgeons who have dedicated their careers to developing the current and future equipment that we now EUROTIMES | MARCH 2018

have or can look forward to in the future. The session covered a wide range of topics, including 3D visualisation, ultrasonic vitrectomy, IOP control, robotics, informatics and a new type of retinal prosthesis, among others. A new concept that has garnered a great deal of attention during the past few years is 3D visualisation for vitreoretinal surgery. This provides a remarkable combination of both increased magnification and increased depth of field as compared to viewing

through the oculars of a microscope. Steve Charles MD, Charles Retina Institute, Tennessee, USA, is a great proponent of 3D surgery, but he baulks at the term “heads-up surgery”, which he finds a misleading concept. “There is no ergonomic benefit,” he says, as operating microscopes have had tilt oculars for decades. Instead, advantages can be found in the much lower endoilluminator levels required, which can be set at an


Courtesy of Pr

avin U Dugel M


by feedback mechanisms nor prevented by feedforward controls, but passive mechanisms such as valve may cut them, he noted. Carl Awh MD, Tennessee Retina, USA, presented delegates with devices from Katalyst Surgical that use newer manufacturing techniques to lower costs while maintaining, or improving, quality. He showed a vitreoretinal forceps tip in which the internal drive mechanism is manufactured with a 3D printer. This allows more rapid prototyping and modification, more complex internal geometries and substantial cost savings, said Dr Awh. A new endolaser probe utilises a reusable connector and handpiece, available with curved, flexible, or steerable tips, but with disposable, universal gauge optical fibres. Marc de Smet MD, MIOS, Lausanne, Switzerland, discussed Preceyes, the ophthalmic robotics company of which he is Chief Medical Officer. “We’re certainly not the first to approach the concept of vitreoretinal robotics, but we were the first to get into the eye,” he commented. He described the four different robotic concepts in eye surgery: the handheld tool, instrument co-manipulation, instrument telemanipulation and magnetic control. Each varies in the degree to which the robot can filter tremors, scale motion and allow automation. With telemanipulation, the intended goal is to use robotics to enhance existing procedures currently performed, and to allow surgeons to execute manoeuvres not possible with currently available technology.

astonishingly low 1-5% for macular surgery. This decrease has been made possible in part by the recent switch to OLED screens and high sensitivity CMOS camera pair. Pravin U Dugel MD, Managing Partner, Retinal Consultants of Arizona, Phoenix, Arizona and Clinical Professor, University of Southern California, Los Angeles, USA, has also focused on using advanced technology to improve visualisation during vitrectomy. “Once you digitalise images, you can do anything you want with them,” Dr Dugel, referring to the head-mounted displays used by fighter pilots, which provide information like flight data and video supplied by external cameras. Three primary concepts are guidance, overlay and enhancement. Guidance refers to digital indicators of an instrument’s intraocular location, helping to avoid inadvertent lens or retina touch. Overlay “makes the preoperative intraoperative”, overlaying preoperative images such as fluorescein angiography over the intraoperative retinal image. Enhancement permits reduced illumination and allows the surgeon to see otherwise invisible features such as the fine details of an epiretinal membrane. Kirk Packo MD, Rush University, Chicago, USA, continued this line of thought. The combination of dual 3D high-dynamic-range cameras, a high-speed digital graphics processor and a 4K ultra HD OLED display with rapid refresh has the potential to transform the way we see the retina during surgery. Colour tone mapping, by increasing the green channel of the display, can vastly enhance the effect of ICG colouring of the ILM, possibly allowing a lower ICG concentration. Dr Packo showed how red-free images could enhance the visualisation of membranes. Packo added that while these are all available now, it is the future of digital 3D imaging that holds even more excitement. Using the digital domain to visualise what is invisible optically opens up technologies such as overlay fluorescent microscopy, infrared imaging and fluorescent colour tagging of tissues, to name just a few.

A new prototype of a hypersonic vitrector was introduced by Prof Paulo Stanga MD, Manchester Royal Eye Hospital, England. A hypersonic vitrector needle tip’s up-and-down motion at 1.5 million times per minute creates an active zone in front of the needle’s port that “liquefies” the vitreous. This modifies the viscosity of the vitreous before it passes through the port. “Hypersonic vitrectomy breaks up the collagen fibres so small that it’s almost like blending,” said Dr Stanga. Further, the vitrector’s port is very close to the tip, which is ideal for aspirating preretinal haemorrhage or initiating a PVD. He reported the results of the first ever study in humans, which was designed to analyse its effectiveness and safety. Dr Stanga said that he “would consider this an additional tool, and not yet a replacement technology for the current standard guillotine model. This new technology allows for the fabrication of small-gauge hypersonic vitrectors with the efficiency of larger guillotine ones and also offers the potential for the removal of vitreous, silicon oil and soft lens matter, as well as the execution of retinectomies, all using the same needle.” Tommaso Rossi MD, San Martino Hospital, Genoa, Italy, discussed IOP control systems during vitrectomy. He told delegates that IOP estimation by the vitrectomy machine is of paramount importance in keeping the optic nerve and retina safe and sound and that significant improvements can be made to existing devices. Particularly, IOP spikes due to instantaneous surgical manoeuvres cannot be corrected

Steve Charles: scharles@att.net Pravin Dugel: pdugel@gmail.com Kirk Packo: kirk_packo@rush.edu Paulo Stanga: p.stanga@retinaspecialist.co.uk Tommaso Rossi: tommaso.rossi@usa.net Carl Awh: carlawh@gmail.com Marc de Smet: mddesmet1@mac.com

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PRP REMAINS EFFECTIVE Laser therapy still has its place in PDR treatment. Dermot McGrath reports


anretinal photocoagulation (PRP) is an established, effective therapy that should be used for treatment of proliferative diabetic retinopathy (PDR), according to Michaella Goldstein MD. “The long-term benefits and risks of treatment with anti-VEGF agents for PDR are currently unknown, whereas we have an abundance of data over many years for PRP,” Dr Goldstein told delegates attending the 17th EURETINA Congress in Barcelona. Left untreated, PDR is a leading cause of blindness, with more than 50% of eyes with high-risk PDR experiencing severe vision loss within five years. Although promising results have been attained in recent years with anti-VEGF treatments, adherence to follow-up is critical to success with these pharmacological agents. In the CLARITY clinical trial, 9% of participants did not complete the one-year visit, and in the DRCR.net protocols, 12% of participants did not complete the two-year visit, she said. “PRP is typically able to be completed in two-to-four visits, which is often sufficient for a long-lasting effect and requires no additional treatment in 50% of eyes. The Protocol S study, which compared intravitreal ranibizumab injections to PRP, suggests that approximately 45% of eyes in the Anti-VEGF arm were given additional PRP during the two-year study period,” she said. Another potential advantage of PRP is economic, pointed out Dr Goldstein, Head of the Retinal Vascular Unit at Tel Aviv Medical Centre, Israel. “PRP is significantly more cost-effective than anti-VEGF injections and thus may be more feasible in some health systems. Furthermore, there is no risk of endophthalmitis with laser treatment and no risk of systemic exposure to antiVEGF,” she added. While patients treated with intravitreal ranibizumab in the Protocol S study did have better final visual outcomes, with a gain of nearly eight letters compared to a two-letter gain for the PRP-treated group, this applied only to patients with baseline diabetic macular oedema (DME), said Dr Goldstein. “The eyes with PDR and without baseline DME showed no statistically significant difference in final visual acuity whether treated with intravitreal ranibizumab or PRP therapy,” she said. Another study by Dogru et al. on long-term outcomes in PDR patients after PRP treatment showed that complete regression could be successfully achieved and well preserved after 10 years. More than 28% of patients had 20/40 or better visual acuity after five years, and most cases maintained the same visual acuity at 10 years, she noted. “We need to bear in mind that this study was performed prior to the anti-VEGF era, and if performed nowadays the visual acuity outcomes would probably be much better by using anti-VEGF or steroid injections to treat the DME,” concluded Dr Goldstein. Michaella Goldstein: michgold@netvision.net.il EUROTIMES | MARCH 2018



PCV TREATMENT OPTIONS Polypoidal choroidal vasculopathy is a complex disease demanding a customised approach. Dermot McGrath reports


olypoidal choroidal vasculopathy (PCV) is a complex disease and may require a customised approach that draws on different treatment strategies to ensure the best patient outcomes in the long term, according to Won Ki Lee MD, PhD. “There are lots of unanswered questions in relation to PCV management. Is antiVEGF monotherapy or combination therapy with anti-VEGF and photodynamic therapy (PDT) better? Are there any prognostic factors in indocyanine green angiography (ICGA), optical coherence tomography (OCT) or choroidal morphology to guide our treatment choices? Is there an optimal antiVEGF drug, what is the ideal dosing and how can we determine a non-responder or poor responder to a given drug?” Dr Lee said at the 17th EURETINA Congress in Barcelona. Other relevant questions include at what point the clinician should consider switching to other drugs or PDT, and how many PDT sessions can be applied safely without significant complications, he added. Dr Lee said that anti-VEGF therapy is usually the first-line treatment of choice. He noted that the recent EVEREST II clinical trial found that ranibizumab and PDT was superior to ranibizumab monotherapy in improving visual acuity and achieving complete polyp regression at 12 months. However, bearing in mind that many clinicians remain concerned about PDTrelated complications, Dr Lee and co-workers decided to perform a retrospective study looking at the long-term outcomes of 47 treatment-naïve PCV eyes over nine years of treatment. Patients were treated initially using PDT alone or combination therapy between December 2004 to June 2008 followed by additional PDT and/or antiVEGF monotherapy on an as-needed basis. The study showed that initial PDT/antiVEGF combination therapy could reduce the injection frequency. However, patients treated with multiple PDTs initially received more anti-VEGF injections later and had poorer final visual acuity outcomes, implying either that multiple-session PDTs had a negative impact on the outcomes, or that poor responders to PDT also responded poorly to anti-VEGF treatment. “I believe that PDT is still a viable treatment option in PCV. However, multiple PDTs result in cumulative damage to the surrounding choroid, with choroidal ischaemia and VEGF upregulation, which induces more malignant or bizarre patterns of polyps and neovascularisation, fibrous scarring and RPE atrophy,” he said. EUROTIMES | MARCH 2018

Courtesy of Won Ki Lee MD, PhD


There is pronounced inter-individual variability in subfoveal choroidal thickness and values were distributed over a wide range.

For this reason, Dr Lee said that he endeavours to keep PDT sessions to the strict minimum. “If a repeat session can’t be avoided I try to use either selective PDT, which was also used in the EVEREST II study, or some reduced fluence or half-dose PDT. My own personal preference, however, is for deferred PDT, where it is reserved as a rescue therapy in patients with active polyps and a limited response to anti-VEGF injections,” he said. This strategy was tested in the PLANET study, in which 318 patients initially received three monthly aflibercept injections and were randomised into two arms at week 12, stratified by qualification for rescue treatments: one with aflibercept plus sham PDT or the other with aflibercept plus active PDT. The results showed that aflibercept monotherapy was effective in the treatment of PCV over 52 weeks, with mean improvement in best-corrected visual acuity (BCVA) of 10.7 letters. More than 85% of patients did not require any rescue therapy and more than 80% of patients had no active polyps. The authors concluded that the combination of intravitreal aflibercept with PDT did not appear to provide any additional functional benefits, and PDT therapy does not seem to be required for the vast majority of patients with PCV when treated with aflibercept. Nevertheless, Dr Lee said there was no “one size fits all” approach to treating PCV. “It is actually very heterogeneous in terms of polyp size, number, internal structure,

branching pattern, total lesion size and lesion location. There is also a lot of diversity in the choroidal features between patients,” he said. In general, PCV with small polyps and small lesion sizes respond well to antiVEGF treatments as well as combination therapy. By contrast, PCV lesions associated with choroidal hyperpermeability and/ or increased choroidal thickness do not respond favourably to anti-VEGF therapy. One recent study, however, reported that aflibercept induced significant reduction of choroidal thickness and was effective in eyes with choroidal vascular hyperpermeability. Summing up, Dr Lee said that his preference to treat PCV is anti-VEGF therapy and deferred PDT, starting with three loading doses of anti-VEGF and using aflibercept in cases with increased choroidal thickness. “I try to determine responsiveness to a drug, including switched drugs, at six-to-12 months. I maintain anti-VEGF treatment in good responders with an acceptable injection frequency and consider PDT in non-responders or cases requiring too frequent injections. For recurrent lesions after PDT, I recommend restricting the number of PDT sessions with anti-VEGF as first-line treatment. In refractory cases, I try selective PDT or laser, or half or reducedfluence PDT covering the whole lesion before considering standard PDT covering the whole lesion,” he said. Won Ki Lee: wklee@catholic.ac.kr

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OCT-ANGIOGRAPHY OCT-A is useful in detecting and tracking retinal disease. Dermot McGrath reports


Dr Spaide presented four case studies to illustrate the utility of OCT-A in clinical practice. The first example was a 71-year-old male patient with a central retinal vein occlusion in his right eye who had been treated in another clinic with anti-VEGF agents. Fluorescein angiography of his left eye showed nothing abnormal. An OCT-A exam of the same eye, however, showed multiple areas of nonperfusion in the superficial capillary plexus. “This was very curious, so I ordered a carotid Doppler ultrasound test which showed a huge ulcerated plaque on the left side. The patient underwent emergency surgery to remove the plaque and the vascular surgeon remarked afterwards that the eye examination had probably saved this patient’s life,” said Dr Spaide. The second case study was a 24-year-old patient with type 1 diabetes that had good overall visual acuity of 20/30, but with dark chequerboard disturbances in her field of vision. The structural OCT showed areas of disorganisation of the retinal inner layers, also known as DRIL. OCT-A showed these areas had absent flow in the deep vascular plexus, a feature common in DRIL that is not visible in fluorescein angiography. OCT-A images also showed microaneurysms surrounding areas of

Courtesy of Richard F Spaide MD

CT angiography (OCT-A) is a valuable and complementary addition to the imaging tools currently available to retinal physicians, according to Richard F Spaide MD. “OCT-A today can give us information that is not visible by other testing methods. It is useful for detection of retinal vascular disease and offers the opportunity to expand our knowledge of the physiology of the retina. It is also good for monitoring age-related macular degeneration and evaluating vision loss,” he told delegates attending the 17th EURETINA Congress in Barcelona. OCT-A visualises vasculature using motion contrast. No dye injection is required, unlike other imaging modalities such as fluorescein angiography. “It is a very quick test, which enables three-dimensional volumetric imaging of the retinal and choroidal vasculature and can provide information that is not visible by other imaging devices. However, there is a learning curve involved in interpreting the images correctly and identifying artefacts. It is not a plug-in replacement for fluorescein angiography (FA), but is really a separate way to learn how to image the eye,” he said.

This patient was being treated for a central retinal vein occlusion in the right eye with anti-VEGF injections. His fluorescein angiogram (top left) and OCT angiogram (above left) looked good. The left eye showed mild non-specific leakage (top right), but the OCT angiogram (above right) showed multiple small vessel occlusions. A carotid doppler was obtained


capillary non-perfusion could occur in areas where the deep vascular plexus seemed to anastomose with the superficial plexus. “In this case, OCT-A was really an excellent research tool to reassess information that we thought we knew about fluorescein angiography, but which were not giving us the full picture,” he said. The third case highlighted by Dr Spaide showed a patient with geographic atrophy who had loss of central vision because of the atrophy affecting the central part of the macula. Structural OCT imaging showed an increased amount of reflective material in the deep retina, which further OCT-A examination revealed to be areas of neovascularisation wrapped around the areas of atrophy. “The Sarks showed that unsuspected choroidal neovascularisation occurred in about 45% of patients with geographic atrophy. In this case, OCT-A demonstrated neovascularisation skirting around an area of central geographic atrophy and enabled us to make the diagnosis efficiently,” he said. The final case study presented by Dr Spaide was a patient with end-stage glaucoma who had undergone a filtering operation. One month after surgery his visual acuity dropped dramatically to 20/400. While structural OCT scans showed some epiretinal membrane, there was nothing present on either OCT or FA to really explain the vision loss. An OCT-A scan, however, showed an absence of blood flow in the radial peripapillary capillary network, as well as the loss of ganglion cells. “There was absent flow in the right eye and the left eye was not too good either. If you have someone with advanced glaucoma and particularly if the scotoma bisects the point of fixation and you do filtering surgery to reduce their pressure, they may lose their central visual acuity. This ‘snuff out’ phenomenon was first recognised by Von Graefe over 150 years ago. OCT-A and ganglion cell analysis may offer valuable clues to diagnosis as well as etiology,” he concluded. Richard F Spaide: rickspaide@gmail.com



TREATMENT OF MYOPIC CNV Anti-VEGF effects paradigm shift in myopic CNV treatment. Dermot McGrath reports

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Courtesy of Professor Adrian Koh MD, FRCS


he availability of antiVEGF agents, such as intravitreal ranibizumab (Lucentis, Genentech), has revolutionised the management of various forms of ocular neovascularisation, including myopic CNV (mCNV), according to Professor Adrian Koh MD, FRCS. “The current gold standard treatment of myopic CNV is anti-VEGF therapy, Figure 1: Myopic CNV with haemorrhage Figure 2: Pre-treatment myopic CNV which achieves good visual results with minimal number of treatments, unlike in age-related macular degeneration CNV,” Prof Koh said at the 17th EURETINA Congress in Barcelona. Myopic CNV is a sight-threatening complication of pathologic myopia characterised by neurosensory detachments and sub-retinal haemorrhage with fibrotic membrane formation, said Prof Koh. “In individuals with pathologic myopia, CNV will develop in approximately 5% of eyes in Caucasians and approximately 10% in Asians,” he said. Several theories have been put forward to explain the cause of mCNV, said Prof Koh. The mechanical theory posits that excessive elongation of the retina and associated changes cause an imbalance of angiogenic and antiangiogenic factors, thereby triggering the condition. The heredodegenerative theory argues that refractive errors are genetically predetermined, while the hemodynamic theory proposes perfusion changes in the choroidal circulation of Figure 3: Resolution after two aflibercept injections the myopic eye as a possible cause. Standard tests for diagnosing mCNV include fundus biomicroscopy, fluorescein angiography and optical coherence tomography (OCT). Fluorescein angiography, which demonstrates leakage from the CNV, demonstrated a 13-to-14 letter gain with a median of just two is still the current gold standard for diagnosis, said Prof Koh. injections, said Prof Koh. More than 50% of patients treated with Prior to the introduction of anti-VEGF agents, verteporfin ranibizumab gained more than 15 letters at month 12, and the photodynamic therapy (vPDT) was the only approved treatment proportion of patients with CNV leakage and intraretinal oedema for mCNV, said Prof Koh. “PDT was shown to have a benefit over decreased by more than 70% in ranibizumab groups. placebo for up to two years and may delay further visual acuity A recent trial of intravitreal aflibercept (EYLEA, Bayer Pharma deterioration. However, it does not improve vision, it may induce AG) for mCNV demonstrated clinically important visual and chorioretinal damage and leakage from CNV may persist,” he said. anatomic benefits with limited injections, concluded Prof Koh. The introduction of anti-VEGF treatments changed the paradigm for mCNV management. In the RADIANCE trial, ranibizumab Adrian Koh: dradriankoh@eyeretinasurgeons.com

4 th ESASO

Anterior Segment Academy 26 – 28 April 2018 | Milan - Italy Highlights


Main topics

Thursday 26 - Master Classes, Skill transfer courses and wet/dry labs aiming to develop professional skills on a specific topic

• • • • • •


Friday 27 - Main Sessions lectures by leading international Speakers

Clinical examination of patients with hyperopia Hyperopia and strabismus: what should I know Cataract Surgery Hyperopia: when lens surgery Surgery after previous surgery Video case presentation

Saturday 28 - Video surgery discussion on challenging cases

ESASO Anterior Segment Academy (ASA) is now on its fourth edition. It’s the second in a series of three on hypermetropia. We have chosen to offer our programme as a series in order to continue our training pathway in anterior segment diagnostics and surgery. Correcting hypermetropia is in fact much more complex than myopic vision correction, as the range of correction in diopters is more restricted and the possible complications are more serious. In cataract surgery, there are challenges in relation to limited spaces that make the results more difficult to achieve. The biometrics are more unpredictable, and there is a correlation to glaucoma. These patients present a further challenge, since they have often had good eyesight, at least in childhood, without needing glasses. The problem often arises of how well-accepted the correction will be,

apart from having to assess orthophoria, and cycolplegic exam effectively with each surgical or simply prescriptive intervention. Treatment and diagnosis are obviously highly complex, and we aim to address diagnostics in an integrative way, using modern techniques. As well as hypermetropia, ESASO Academy will also address another condition that is closely related: presbyopia. With ever greater possibilities for correction, and patients also requesting more, what choices should we make? These issues must also be considered at reintervention, as every time we operate, we must also assess the possible complications and consider possible solutions for them. This event will be attended by a top international panel.

Organising Committee Paolo Vinciguerra Scientific Director ESASO Anterior Segment Academy

Josep Güell Director ESASO Anterior Segment Academy

Director of the Ophthalmology Department Humanitas University, Milan, Italy

Director of Cornea and Refractive Surgery Unit Instituto Microcirugía Ocular (IMO) Barcelona, Spain

Congress Venue Humanitas University Humanitas Congress Centre Via Manzoni, 113 – 20089 Rozzano Milan, Italy

Congress Secretariat congress.asa@esaso.org Tel.: +39 02 56601-1 Fax: +39 02 56609045

Giuseppe Guarnaccia ESASO Global Executive Director Lugano, Switzerland




SLOW RESPONDERS TO ANTI-VEGF FOR DME CATCH UP WITH QUICK RESPONDERS OVER TIME Eyes with persistent diabetic macular oedema (DME) that have a delayed morphological response to anti-vascular endothelial growth factor (anti-VEGF) treatment tend to have a similar visual outcome in the longer term to those with an immediate morphological response, according to the results of a retrospective study. The study showed that, among 20 DME patients, those with a 25% or less reduction in central macular thickness (CMT) in the first three months of anti-VEGF treatment had an improvement in best corrected visual improvement that was not significantly different at 12 months from those with more than a 25% reduction of CMT in the first three months. However, those with no visual improvement in the first three months also had significantly less visual improvement at 12 months than those with an early visual improvement. Y Koyanagi et al, “Visual Outcomes Based on Early Response to AntiVascular Endothelial Growth Factor Treatment for Diabetic Macular Edema”, Ophthalmologica 2018, Volume 239, Issue 1-2.

TRIAMCINOLONE BEATS ANTI-VEGF IN IMPROVING RETINAL MORPHOLOGY IN DR Ranibizumab, bevacizumab and triamcinolone all appear to provide similar improvement in visual acuity in eyes with diabetic retinopathy, but triamcinolone provides better anatomical improvements, according to a new study. In 275 eyes of 208 consecutive diabetic retinopathy patients, the mean changes in visual acuity after six months’ treatment was a gain of 4.9 letters in eyes receiving bevacizumab, 4.3 letters in eyes receiving ranibizumab and 4.6 letters in eyes receiving triamcinolone (p=0.911). The triamcinolone group had significantly better improvement of central macular thickness at six and 24 months, but also had significantly more cataract and glaucoma. İ Koç et al, “Real-World Results of Intravitreal Ranibizumab, Bevacizumab, or Triamcinolone for Diabetic Macular Edema”, Ophthalmologica 2018, Volume 239, Issue 1-2.

Applications are open for the Peter Barry Fellowship 2018. This Fellowship commemorates the immense contribution made by the late Peter Barry to ophthalmology and to the ESCRS. The Fellowship of €60,000 is to allow a trainee to work abroad at a centre of excellence for clinical experience or research in the field of cataract and refractive surgery, anywhere in the world, for 1 year. Applicants must be a European trainee ophthalmologist, 40 years of age or under on the closing date for applications and have been an ESCRS member for 3 years by the time of starting the Fellowship. The Fellowship will be awarded at the ESCRS Annual Congress in Vienna in September 2018, to start in 2019. To apply, please submit the following: l

SILICONE OIL THINS THE CHOROID Silicone oil tamponade appears to thin the subfoveal choroid, and the longer the tamponade is in place the thinner the choroid becomes, new research suggests. The study showed that in 60 patients with unilateral pseudophakic macula-off rhegmatogenous retinal detachment, the mean difference in thickness of the subfoveal choroid between silicone oil-treated eyes and fellow eye was -14.8, -25.5 and -62.1µm for those three-to-six months, six-to-nine months and nine-to-18 months of the tamponade, respectively. Moreover, choroidal thinning did not improve three months after silicone removal. S Karimi et al, “Effects of Intravitreal Silicone Oil on Subfoveal Choroidal Thickness," Ophthalmologica 2018, Volume 239, Issue 1-2.




A detailed up-to-date CV A letter of intent of 1-2 pages, outlining which centre you wish to attend and why A letter of recommendation from your current Head of Department A letter from your potential host institution, indicating that they will accept you if successful

Closing date for applications is 1 May 2018 Applications and queries should be sent to Danielle Maher at danielle.maher@escrs.org

SEBASTIAN WOLF Editor of Ophthalmologica The peer-reviewed journal of EURETINA





PHACOEMULSIFICATION IN SMALL EYES Everything you ever wanted to know about phacoemulsification in small eyes – Part 1.


mall eyes can be part of microphthalmos (short anterior chamber [AC] depth and short axial length), relative anterior microphthalmos (short AC depth and normal axial length) or axial hyperopia (normal AC depth with short axial length). Part 1 of this series deals with a description of the challenges in the microphthalmic eyes, and part 2 will deal with hyperopia and IOL-related issues.

MICROPHTHALMOS Duke-Elder classified microphthalmos into nanophthalmos (short, otherwise normal eye); microphthalmos with coloboma and complex microphthalmos. Simple microphthalmos refers to a short eye. A nanophthalmic eye is less than two standard deviations below mean for age or <20.5mm in axial length. Nanophthalmos is bilateral and high hypermetropic errors (+8 to +20DS), an overall small eye with microcornea, small anterior segment, normal or increased lens thickness, marked iris convexity, crowding of the anterior chamber and shallow AC are seen. Blindness can occur if left untreated. Retinal problems such as macular hypoplasia can limit vision even after successful cataract surgery. Problems encountered during cataract surgery are secondary to microcornea (<10mm), shallow central and peripheral AC, peripheral anterior synechiae, chronic angle closure glaucoma (CACG), poorly dilating pupil and thickened choroid and sclera. The thick and inelastic sclera decreases trans-scleral passage of proteins EUROTIMES | MARCH 2018

Soosan Jacob MD reports and compresses the vortex veins, leading to spontaneous as well as postoperative uveal effusions and exudative retinal detachments. Uveal effusions can cause anterior rotation of the ciliary body with shallow AC. Microphthalmos with coloboma results from an incomplete closure of the embryonic fissure. This can range from small infero-nasal iris coloboma to orbital cyst. Retinal laser may be required preoperatively in eyes with choroidal colobomas. Iridoplasty may be required together with cataract surgery for coloboma repair. Complex microphthalmos is often associated with congenital cataract, other anterior/posterior segment malformations and systemic abnormalities. Additional surgery for glaucoma or corneal opacity may be required. Postoperative vision may be limited by associated ocular comorbidity. Relative anterior microphthalmos is more common. The normal-sized lens causes consecutive crowding of anterior segment, shallow AC and CACG. Since the eye is grossly normal, this may be missed on slit lamp. It is not associated with scleral abnormalities or uveal effusions.

CATARACT SURGERY Glaucoma if present may be managed by YAG peripheral iridectomy, laser gonioplasty, anti-glaucoma medications, sclerectomies, trabeculectomy or cyclodestructive procedures, depending on stage of the disease. Cataract surgery is challenging and carries risks, but has the benefit of decreasing anterior chamber

crowding. Preoperative indentation gonioscopy or ultrasound biomicroscopy and complete glaucoma evaluation are important. Dilatation can precipitate angle closure and prophylactic YAG PI may be necessary before dilatation. Fundus evaluation to look for uveal effusions and B-scan to measure thickness of choroid and sclera are important. Patients should be counselled regarding the increased risk of surgery and also about poor visual prognosis secondary to any associated retinal abnormalities or amblyopia. IOL implantation may be deferred in very severe microcornea where the IOL optic may cause crowding. IOL power calculation is difficult in these eyes, with a higher chance of errors. Both immersion and optical biometry should be used. Hoffer Q or Haigis formulas are more reliable. Special highpowered IOLs may need to be customised. An alternative option is to piggyback an IOL in the same sitting or at a second sitting after checking residual refractive error and available space in the sulcus. Preoperative acetazolamide, oral glycerol, IV mannitol and ocular pressure with Pinkie ball/Honan balloon should be used to decrease the IOP. General anaesthesia may be opted for to avoid an increase of the orbital volume from peribulbar anaesthesia. Blood pressure should be kept to the lower side during surgery. Intraoperatively, prophylactic sclerotomies or sclerectomies are placed to decompress the vortex veins and allow fluid drainage without causing uveal effusions. Well-constructed tunnels are

CATARACT & REFRACTIVE wound during phaco. Positive vitreous pressure and a shallow AC with inadequate manoeuvring space is tackled by increasing inflow by increasing bottle height or by using pressurised air infusion. Loose or defective zonules may cause vitreous hydration and further shallowing of AC. If inadequate AC depth does not allow surgery, limited dry anterior vitrectomy with high-speed 25-gauge vitrector allows iris and lens to fall backwards and thus deepens AC. However, pars plana dimensions may be different from normal eyes and care should be taken while placing the sclerotomy. The eye should not be made excessively soft. Cortex aspiration and IOL implantation are performed as usual. Implanting very high-powered IOLs via injector is difficult and wound may need to be enlarged. Tight wound apposition at the end of surgery is important and wound sutures may be applied.


A: Unilateral microcornea; B: Brown cataract with shallow AC; C: Choroidal coloboma in the same pt

necessary to prevent iris prolapse. Sudden changes in intraocular pressure should be avoided. Pharmacological dilatation, viscomydriasis, synechiolysis, pupil stretch, mini-sphincterotomies or pupil expanders are used if indicated. The B-Hex ring is particularly suited in these small eyes as compared to other pupil dilators because of its low profile and thin nature. Intraoperative challenges occur because of a lack of adequate manoeuvring space within the AC. Rhexis should be performed with microinstruments through a partially opened incision, using high molecular weight cohesive viscoelastics to maintain space and flatten the anterior lens capsule.

Bimanual phaco may be preferable in very small eyes. The soft-shell technique may be used using cohesive viscoelastic to maintain space and dispersive to protect endothelium. Soft nuclei may be partially hydroprolapsed and emulsified in parts. However, hard nuclei are often encountered because of propensity by both patient and surgeon to delay surgery. The bulk of the nucleus may be decreased by shaving away epinucleus within the bag and then using divide and conquer or crater and chop techniques. Nucleus is then broken into smaller fragments and emulsified. Wound burns should be avoided, and chilled BSS may be used for irrigating the

The risk of posterior capsular rent and endothelial damage is higher in these eyes because of positive vitreous pressure and a lack of surgical space. Uveal effusion, suprachoroidal haemorrhage, aqueous misdirection syndrome and prolonged uveitis are other complications. In case of a PCR, secondary IOL fixation may be done using a glued IOL (using small diameter optic and with trimmed haptics for tucking) or other preferred technique. 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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22–26 September 2018

ESCRS Practice Management and Development Marketing Case Study Competition


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Submission Deadline Monday 30 July 2018

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CORRECTING ASTIGMATISM Researchers report encouraging outcomes in initial experience of using SMILE for astigmatism correction. Cheryl Guttman Krader reports


mall-incision lenticule extraction (SMILE) appears to be safe and effective for astigmatism correction, although cyclotorsion could be an issue, according to two early studies presented at the XXXV Congress of the ESCRS in Lisbon, Portugal. Suphi Taneri MD reported outcomes from follow-up of up to three months for a consecutive series of 157 eyes with astigmatism of at least 1.0D treated at the Centre for Refractive Surgery, St Francis Hospital, Muenster, Germany, with the VisuMax femtosecond laser (ZEISS). They represent the first eyes in an ongoing observational case series treated with SMILE and having this level of astigmatism. The eyes had myopia between -0.5 and -10.0D and corrected distance visual acuity (CDVA) of 1.0 or better. The treatment target was plano in all cases. Preoperative marking of the axis was done only in eyes with astigmatism of greater than 3.0D, which accounted for 4.5% of the study cohort. Analysis of the refractive outcomes showed very good predictability and stability. Mean spherical equivalent was -5.52D preoperatively, +0.07D at one week and -0.06D at three months. Spherical equivalent at three months was ±0.50D of intended target in 85% of eyes and ±1.0D in 97%. An analysis of refractive astigmatism showed that at three months, 99% of eyes had less than 1.0D of astigmatism. “We found a tendency for undercorrection in the eyes with very high astigmatism, greater than 3.0D, but considering that we had so few such eyes in our series, we are waiting to adjust our nomogram because we do not want to risk overcorrection,” Dr Taneri said. Data on the refractive astigmatism angle of error showed the axis was well targeted. “Of course, you have to align the patient correctly before starting the treatment,” Dr Taneri said.

Courtesy of Suphi Taneri MD


Preparation of lenticule backside: Oval shape of opaque bubble layer for correction of high astigmatism

Snellen uncorrected distance visual acuity (UDVA) at three months was 20/25 or better in 90% of eyes and 20/20 or better in 76%. A loss of ≥2 lines of CDVA occurred in 2% of eyes. “SMILE outcomes may be improved in the future with automated compensation of cyclotorsional eye movements, but they are similar to those reported for modern femtoLASIK with automated eye tracking,” Dr Taneri said.

COMPARATIVE STUDY OUTCOMES Dr Taneri’s conclusion was supported by the findings of a comparative study presented by Sherif Tolees MD. The retrospective, non-randomised study analysed data from 43 SMILE eyes and 49 eyes treated with femto-LASIK (OPA software, Quest excimer laser; Nidek) at the Magrabi Eye Hospital, Jeddah, Saudi Arabia. The eyes had between -1.0 and -5.0D of astigmatism preoperatively, and they all completed follow-up to six months. In the femto-LASIK group, mean cylinder was reduced from -1.63±0.48D preoperatively to -0.38±0.32D. In the SMILE group, mean cylinder was -1.84±0.64D preoperatively and

was reduced to -0.47±0.35D at six months. Refractive astigmatism was ≤0.25Ds in 59% of femto-LASIK eyes and in 43% of eyes in the SMILE group, and it was ≤ 1.0D in 98% of femto-LASIK eyes and 96% of SMILE eyes. Angle-of-error analysis showed treatment alignment in about 70% of eyes in both groups. Spherical equivalent results were stable from month one to month six and showed mild undercorrection of about 0.5D in both groups. “We believe this undercorrection should be considered in our nomogram. In addition, eye marking is very important when performing SMILE because docking and suction manoeuvres may create cyclotorsion,” said Dr Tolees. No eyes lost more than one line of CDVA, and CDVA was unchanged or improved in 94% of femto-LASIK eyes and 91% of SMILE eyes. Uncorrected distance visual acuity at six months was 20/16 or better in 33% of femto-LASIK eyes and 19% of SMILE eyes, with 88% of femtoLASIK patients achieving of 20/20 or better compared with 81% in the SMILE group. Sherif Tolees: sheriff.tolees@magrabi.com.sa Suphi Taneri: taneri@refraktives-zentrum.de




OUTCOMES IN TORIC IOLS Adjustable lenses could render many current technologies obsolete. Howard Larkin reports


any technological advances have emerged that can improve toric IOL outcomes, David F Chang MD told the American Academy of Ophthalmology 2017 Annual Meeting in New Orleans, USA. Dr Chang generally prefers toric IOLs over limbalrelaxing incisions because they produce more predictable outcomes. “However, toric IOLs require proper selection of the cylindrical power and axis, and accurate surgical alignment that is maintained postoperatively”, he said. Accurate preoperative measurement of corneal astigmatism continues to be critical. Newer biometry platforms such as the Lenstar LS 900 (Haag-Streit) and the IOLMaster 700 (ZEISS) have improved keratometry accuracy compared to their predecessors. One study found that these systems were more accurate in measuring corneal curvature than topography (Abulafia A et al., J Cataract Refract Surg 2015; 41:936-944). However, topography still provides important information regarding the corneal surface, regularity of astigmatism and possible ectasia. Dr Chang regularly looks at corneal wavefront aberrometry with all premium IOL patients. “Diagnosing corneal abnormalities preoperatively will generally rule out diffractive multifocal IOLs, and allows me to counsel patients regarding issues that will likely impair their vision following surgery,” he said. We have also learned about the importance and impact of posterior corneal curvature (Koch DD et al., J Cataract Refract Surg 2012; 38:2080-2087; Koch DD et al., J Cataract Refract Surg 2013; 39:1803-1809), and there are several devices to measure it preoperatively. However, Dr Chang highlighted a study showing that the Barrett toric IOL formula was as good for predicting toric IOL power as for directly measuring the posterior corneal surface (Ferreira T et al., J Cataract Refract Surg 2017; 43:340-347). Digital overlay systems incorporated into the microscope, such as the Callisto (ZEISS) and Verion (Alcon), help us to align toric IOLs more accurately, Dr Chang said. “Intraoperative aberrometry enables fine-tuning of the toric IOL alignment – particularly when different corneal measurements suggest different axes.” He added: “One study shows that the majority of any postoperative toric IOL rotation occurs within the first hour after surgery” (Inoue Y et al., Ophthalmology 2017; 124(9):1424-1425). “These many advances in technology are giving us better toric IOL outcomes than ever before,” said Dr Chang. “But once we get adjustable lenses, many of these same technologies may become superfluous, because we will just be treating the stable post-op refraction after surgery.” The light-adjustable IOL from RxSight (formerly Calhoun Vision) was FDA approved one week following the conclusion of the AAO meeting. The utility of lenses that can be adjusted after surgery was recently demonstrated in a randomised prospective clinical trial comparing the RxLAL (RxSight) with a non-adjustable toric lens implanted in 371 astigmatic patients. Mean residual refractive error was two-fold less in the RxLAL group, resulting in 70% of patients achieving 20/20 uncorrected visual acuity compared with 40% in the non-adjustable toric IOL group. Dr Chang is a consultant for ZEISS, J&J Vision and RxSight.



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SMILE COMPLICATIONS Most SMILE complications are mild and diminish in frequency with experience. Roibeard Ó hÉineacháin reports


MILE has a rate of complications movement by the patient immediately similar to that of LASIK, and after docking the laser interface. The when complications occur they complication has been reported in 0.8-toare generally resolved with a good 4.4% of SMILE-treated eyes. visual outcome for the patient, “The incidence of suction loss decreases Catherine Albou-Ganem MD, with experience but it cannot be eliminated Paris, France, told the XXXV Congress of completely,” Dr Albou-Ganem stressed. the ESCRS in Lisbon, Portugal. Depending on when during the procedure “Most of SMILE’s complications are suction loss occurs, the surgeon can either related to experience and are included in abort the procedure or re-dock the eye the technique’s learning curve,” Dr Albouand continue. If suction loss occurs during Ganem reported. the creation of the lenticules, the possible She noted that an American Academy strategies include aborting the procedure, of Ophthalmology report in 2013 showed re-scheduling the procedure after the that the overall frequency of hazards reabsorption of the cavitation bubbles, and complications for SMILE was conversion to into thin-flap LASIK, 8.6%, which is comparable to or immediate re-docking and what is expected after LASIK. resumption of the procedure. Some complications that If suction loss occurs after occur in SMILE procedures the sculpting of the lenticules are the same as those that and during the creation of occur in LASIK, such as the incision, the best option decentration and epithelial is to restart the incision with a defects. She noted that epithelial decreased distance from the centre defects occur in around 40% of Catherine Albou-Ganem and an increased side-cut depth. patients. However, it is generally Black spots are reported in a mild problem that resolves in one or two 11-to-14% of cases. They result from the days with the use of artificial tears. It has no presence of water droplets, debris or air effect on visual acuity and is present only in between the laser and the coupling device the area around the incision. and the ocular surface. They leave an area Dr Albou-Ganem pointed out that dryness of untreated lenticule interface, making of the corneal surface is less frequent, less dissection more difficult. intense and it does not last as long after Opaque bubbles lead to the same SMILE as it does after LASIK. Diffuse consequence. They are more common in lamellar keratitis is also less frequent and eyes with a thicker cornea and a thinner there can be a hazy interface. There can also lenticule, but they do not affect the overall be epithelial in-growth, but more generally clinical outcome, she said. it is a case of epithelial “seeds” that are easily Lenticule ruptures often occur during rinsed away. Infection can also occur. the learning curve after difficult lenticule dissection. They can lead to remnant lenticule fragments between the stromal interfaces. SUCTION LOSS Incision ruptures during the enlargement An intraoperative complication that is of the small incision also occur more very specific to SMILE is suction loss. It frequently during the learning curve. generally results from excessive ocular

CALL FOR ENTRIES Entries to be sent to: henprize@eurotimes.org For further information visit: www.escrs.org EUROTIMES | MARCH 2018

Courtesy of Catherine Albou-Ganem MD


Intraoperative black spots are reported in 11-to-14% of cases

However, the problem can be overcome by very careful removal of the lenticule through the ruptured incision and adding a bandage contact lens.

RETREATMENT OPTIONS The primary options for eyes that need retreatment for refractive enhancement include the circle, the side-cut and PRK, as recommended by Zeiss. Other options, suggested independently, include LASIK and subcap lenticule extraction. The circle option converts the cap into a large diameter flap with the femtosecond laser, followed by lifting of the flaps and the performance of a refractive ablation on the exposed stroma. The circle option is indicated for corneas where lenticule creation leaves a thin anterior wall and thick posterior walls. The side-cut option is indicated for eyes with thin residual posterior stroma, but it can only correct small refractive errors with a small optical zone. PRK is indicated in eyes with thin residual posterior walls where the final pachymetry will be over 350µm. Catherine Albou-Ganem: cati.ganem@wanadoo.fr



PRIZE 2018 Young ophthalmologists are invited to write an essay on

“Do We Need a Randomised Controlled Clinical Trial in Cataract Surgery?” First prize is a €1,000 travel bursary to the 36th Congress of the ESCRS in Vienna, Austria.



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Improved outcomes with intraoperative aberrometry in difficult cases. Dermot McGrath reports


ntraoperative aberrometry is a promising tool to aid cataract surgeons in achieving better postoperative refractive outcomes, particularly in challenging cases of high myopia or toric IOL implantation, according to Valentijn Webers MD. “Based on the results of our study, we can conclude that intraoperative aberrometry is significantly more accurate compared to the commonly used preoperative calculator SRK/T for a general population,” he told delegates attending the XXXV Congress of the ESCRS in Lisbon. Dr Webers added that while intraoperative aberrometry was only slightly more accurate compared to the Hill-RBF and Barrett Universal II online calculators in a population of highly myopic patients, it was significantly more accurate compared to the Barrett Toric Calculator for toric IOL implantations. Dr Webers presented results from a single-centre study carried out at the University Eye Clinic Maastricht, the Netherlands, comparing the prediction error in postoperative spherical equivalent (SE) by intraoperative aberrometry (ORA, Alcon) and preoperative calculations using several different methods: SRK/T formula, online available Barrett Universal II and Hill RBF calculators and the online Barrett Toric Calculator. Patients were divided into two main groups: a non-toric IOL group of 151 eyes, 111 of which had a monofocal lens implanted, and a second group of 40 eyes that received a multifocal IOL. The mean prediction error, defined as the absolute difference between the achieved and the predicted SE, was significantly lower for the ORA compared to SRK/T. The percentage of patients with an SE less than or equal to 0.25D was 63% for the ORA and 48% for the SRK/T. The figures for eyes less than 0.50D SE was 89% for the ORA and 74% for SRK/T. For the high myopic eyes, defined as those with an axial length greater than 26mm, the mean prediction error was 0.20D for ORA, and 0.25D for HillRBF, 0.26D for Barrett Universal II and 0.35D for SRK/T. For the 40 toric IOL patients, the mean corneal astigmatism was 2.44D and the average IOL power was 18.62. Four types of toric lenses were used, the majority of which were Alcon SN6ATx models in 31 Valentijn Webers MD patients (77%). Comparing ORA with the Barrett Toric Calculator, the mean absolute prediction error was 0.24D for the ORA and 0.36D for Barrett. The prediction error was ≤0.25D and ≤0.50D in 40% and 78% of cases respectively with the Barrett Calculator, compared to 75% and 90% when performed using the ORA.

Intraoperative aberrometry is significantly more accurate compared to the commonly used preoperative calculator SRK/Te

LENSTAR 900 Improving outcomes Expanded Hill-RBF Expanded Hill-RBF Method based on Artificial Intelligence now uses 4x more information. This IOL calculation method provides an excellent accuracy from -5 to +30D. The inbuilt boundary model improves the safety by identifying unusual cases and warning the user.

T-Cone Toric Platform True Placido-Topography of the optional T-Cone complements the LENSTAR measurement palette. The powerful toric IOL planner, featuring the Barrett Toric Calculator, Hill-RBF Toric and Olsen Toric enables spot on calculation of toric IOL, considering posterior cornea.


Valentijn Webers: valentijn.webers@mumc.nl EUROTIMES | MARCH 2018




OPTIMISING OUTCOMES Data from devices that measure the posterior cornea improve power calculations. Cheryl Guttman Krader reports


he development of regression formulas that take into account posterior corneal astigmatism (PCA) has improved refractive outcomes with toric IOL implantation. But because the regression approaches use a population average for PCA and there is scatter in the population, better results should be achieved using patient-specific data, reported Thomas Kohnen MD, PhD, FEBO, at the XXXV Congress of the ESCRS in Lisbon, Portugal. Currently, there are several technologies that can directly measure PCA. Prof Kohnen discussed the use of Scheimpflug tomography (available from Oculus and Ziemer). “Precise refractive outcomes are critical for meeting patient expectations for good uncorrected vision with toric IOLs. Traditionally we used instruments that measure only anterior corneal power, and the role of the posterior cornea in total corneal refractive power (TCRP) was dismissed because of the small difference between the indices of refraction of the cornea and aqueous,” said Prof Kohnen, Professor and Chair, Department of Ophthalmology, Goethe University Frankfurt, Germany. “Due to the effects of the posterior corneal surface and corneal thickness, there might be large differences between SimK and TCRP. Neglecting the PCA may lead to a significant deviation in corneal astigmatism estimation in a proportion of eyes. I think it is good that we now have several devices for measuring PCA,” said Prof Kohnen. In a published study, Prof Kohnen and colleagues evaluated the repeatability of measurements obtained with a Scheimpflug tomographer. They reported that it generated the most repeatable anterior cornea astigmatism data compared with two different keratometers and two different Placido ring topographers. Total corneal refractive power measurements obtained with the Scheimpflug device also showed good repeatability. He also presented some case examples and reviewed three other studies using a Scheimpflug device that underscore how use of anterior cornea measurements alone can under or overestimate TCRP, depending on the type of anterior cornea astigmatism that is present. “Especially when the axis of the anterior surface is not with-the-rule, there might be a large discrepancy between the axis of EUROTIMES | MARCH 2018

Professor Thomas Kohnen speaking at the XXXV Congress of the ESCRS in Lisbon, Portugal

corneal astigmatism between the anterior and posterior surface,” Prof Kohnen said. Data from two of the studies using Scheimpflug tomography showed that the mean magnitude of posterior cornea astigmatism is about -0.3D.

MULTICOLOUR LED Douglas D Koch MD provided an overview of experience with a multicolour LED topographer (Cassini, i-optics). The topographer is reflection-based, ray-tracing technology that evaluates the posterior surface of the cornea using 2nd Purkinje imaging technology. Because it is based on reflection, not scanning, there are no movement artefacts. “To me, this technology uses the most accurate method for measuring corneal curvature to date, and it uses an interesting approach for measuring posterior corneal curvature,” said Dr Koch, Professor and Allen, Mosbacher, and Law Chair in Ophthalmology, Baylor College of Medicine, Houston, USA. “We are using it more in our practice and finding it to be very valuable. In the future I think the multicolour LED topographer will be a good fit for toric IOL calculations and for addressing other unsolved challenges in measuring corneal power.”

Dr Koch noted that while the device was somewhat cumbersome to use initially, it has become much easier subsequent to hardware and software improvements. He presented some examples showing how to apply the total corneal astigmatism measurement obtained using the multicolour LED topographer into practice and how using the data it provides rather than readings from optical biometry would lead to a more accurate refractive outcome. While he is planning a systematic study to compare outcomes of toric IOL implantation using the multicolour LED topographer measurements versus regression formulas, he cited a retrospective study conducted by Elizabeth Yeu MD showing evidence of its benefit. In consecutive series of eyes, Dr Yeu reported residual refractive astigmatism was <0.5D in 84% of 50 eyes when calculations were performed using the Baylor nomogram and in 95% of 74 eyes when IOL power was selected based on the multicolour LED topography data, Dr Koch said. Thomas Kohnen: kohnen@em.uni-frankfurt.de Douglas D Koch: dkoch@bcm.edu



CME RISK FACTORS Pseudophakic cystoid macular oedema is a common cause of reduced visual acuity gain after cataract surgery in patients with diabetes. A new study found unreported clinical characteristics that predispose diabetic patients to a high risk for this complication. The study evaluated 93 patients with type 1 or type 2 diabetes, comparing preoperative and postoperative spectral-domain optical coherence tomography imaging. The level of retinopathy was identified as a risk factor for central retinal thickness increase. This was also greater in patients with T1D than in patients with T2D, and the increase was greater in T2D patients who were insulin dependent than in T2D patients who were not using insulin. Not previously described, poor glycaemic control, which was determined by the high serum HbA1c level, was a predisposing risk factor. P Ylinen et al., JCRS, “Poor glycaemic control as a risk factor for pseudophakic cystoid macular oedema in patients with diabetes”, Volume 43, Issue 11, 1376–1382.


in Anterior


Surgery Monday April 16, 2018 1:00–2:30 pm

REDUCING INFECTIOUS ENDOPHTHALMITIS The beneficial effects of intracameral injection of antibiotics are supported by relatively strong evidence, whereas the beneficial effects of other prophylaxes against endophthalmitis have not been clearly established. A large-scale Japanese study evaluated the potential of the behind-the-lens technique to wash and clear the capsular bag for OVD removal for reducing the risk of infectious endophthalmitis. The prospective study looked at 9,720 eyes undergoing cataract surgery at 93 centres in Japan. Patients underwent phacoemulsification and implantation of a single-piece hydrophobic acrylic foldable intraocular lens and were followed for two months. All three cases of endophthalmitis that did occur had not received the behind-the-lens cleaning technique. The difference was statistically significant (P = .050, and the incidence of infectious endophthalmitis did not correlate with any other patient-related and surgery-related factors. T Oshika et al., JCRS, “Endophthalmitis after cataract surgery: Effect of behind-the-lens washout", Volume 43, Issue 11, 1399–1405.

EPITHELIAL REMODELLING WITH CORNEAL INLAYS The corneas of emmetropic eyes that undergo implantation of a corneal shape-changing inlay undergo central thinning that tapers approximately to the 2.0mm radial zone. A study conducted in Mexico looked at 34 hyperopic patients and 29 myopic patients who had implantation of a Raindrop Near Vision Inlay in the nondominant eye immediately after LASIK. The researchers concluded that the corneas of eyes undergoing corneal inlay implantation concurrently with myopic or hyperopic LASIK experience had similar amounts of epithelial remodelling to that seen in emmetropic eyes, with a minimal difference in profiles between the two procedures. RF Steinert et al., JCRS, “Corneal remodelling after implantation of a shape-changing inlay concurrent with myopic or hyperopic laser in situ keratomileusis”, Volume 43, Issue 11, 1443–1449.

THOMAS KOHNEN European editor of JCRS


Nick Mamalis, MD Sathish Srinivasan, MD

Presbyopia-Correcting IOLs Surgical Correction of Aphakia in a 60-Year-Old Treating Inflammation After Intraocular Surgery

During the ASCRS Annual Meeting Washington, DC, USA

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





22nd ESCRS Winter Meeting

MEETING FORGES LINKS The ESCRS Winter Meeting in Belgrade featured new educational programmes and exciting symposia

Béatrice Cochener, president of the European Society of Cataract and Refractive Surgeons, with Branislav Đurović, president of the Serbian Society of Cataract and Refractive Surgeons, at the 22nd ESCRS Winter Meeting in Belgrade, Serbia


or the first time in its history, the ESCRS convened its Winter Meeting in Belgrade, Serbia. More than 1,150 delegates attended the meeting, held in conjunction with the Serbian Society of Cataract and Refractive Surgeons, at the Sava Centar. “The Winter Meeting is very important, as in recent years it has been held in countries where ophthalmologists cannot easily access the main ESCRS Congresses,” said Béatrice Cochener, President, ESCRS. “This has allowed us to forge links with many of the emerging countries in Europe, working closely with their host national societies. Through these exchanges, ESCRS contributes to ophthalmic education all over Europe.” “I would also like to give special thanks to the President of the Serbian Society of Cataract and Refractive Surgeons (SSCRS), Professor Branislav Đurović, for his invitation to Belgrade and for his hospitality,” said Dr Cochener. “I must also thank Dr Sava Barisic, our young ophthalmologist representative from EUROTIMES | MARCH 2018

Serbia, for all his efforts and energy in helping us to organise and promote the Meeting. The ESCRS is very grateful for the support of all the members of the SSCRS and I hope that they enjoyed a very successful meeting.” There were very good attendances at Cornea Day (organised in conjunction with EuCornea), the Young Ophthalmologists Programme and the Cataract Surgery, Refractive Surgery and Cornea Basic Optics Didactic Courses. There were also Cornea, Cataract and Refractive Free Paper Sessions, Moderated Poster Sessions and Symposia. For the first time the European Society of Ophthalmic Nurses and Technicians held an ESONT Didactic Day. The Serbian Society of Cataract and Refractive Surgery also organised a “Near Live Surgery” session. “I would like to thank everyone involved for their contribution to the scientific programme,” said Dr Cochener. “With so much on offer, it will have been impossible to attend every session. However, if delegates log on to the Education Portal on the ESCRS website, they can access the sessions and didactic

courses on ESCRS On Demand and ESCRS iLearn,” said Dr Cochener. A prize of €1,000 was awarded to the best Cataract and Refractive ePoster presentations of the Meeting. The Cataract ePoster prize winner was Alexey Vasilyev, Russia, for his poster on “The analysis of the effectiveness of IOL pneumocompression method during phacoemulsification in prophylaxis of development of lens posterior capsule opacification”. The Refractive ePoster prize winner was Marina Dragovic, Serbia, for her poster on “LASEK for myopic anisometropic amblyopia in paediatric patients: long term results”. Another meeting highlight was the symposium on “Keeping Calm: Stress Management During Cataract Surgery”, organised by the Young Ophthalmologists Committee. As part of this symposium, delegates were given the opportunity to learn breathing techniques for stress management with Stig Severinsen. Mr Severinsen, MSc Biology & PhD Medicine, Freediving World Champion and multiple Guinness World Record Holder, delivered a talk on “Stress Control For Your Next Surgery”, and gave a practical demonstration on how breath control can assist in stress management during cataract surgery. “You can use breath control to become a better surgeon in general. You can be the best surgeon in the world, but if you don’t perform under high pressure, that doesn’t matter. In critical situations, you can get better outcomes with breathing exercises and breath control,” said Mr Severinsen. This year's Winter Meeting also marked Dr Cochener's first Winter Meeting as ESCRS president. “To be elected president of ESCRS is a great honour, but it is also a great responsibility,” she said. “I am following in the footsteps of the prestigious presidents who preceded me and it is my duty to ensure the continuation of the successful development of this outstanding Society.”





TOPOGRAPHY ADVANCES Emerging diagnostic imaging technologies promise better detection of pre-clinical corneal ectasia. Roibeard Ó hÉineacháin reports


he growing range of corneal imaging tools continues to evolve, revealing information that enhances the ability for the diagnosis of early forms of keratoconus, as well as for staging the disease and planning individualised treatment strategies for helping such patients, said Renato Ambrósio Jr MD, PhD, Rio de Janeiro, Brazil. First of all, this is important to consider the nomenclature for such instrumentation that goes from ultrasound central corneal thickness (CCT) and Placido disk-based topography up to Scheimpflug 3D tomography. While topography characterises the front surface, tomography depicts both front and back surfaces of the cornea, also providing thickness mapping. In addition, high-frequency ultrasound (HFUS) and optical coherence tomography (OCT) devices provide a layered tomographic outline, with the ability for epithelial mapping. Furthermore, corneal biomechanical parameters are also characterised by novel technologies, such as the ultra-highspeed Scheimpflug camera that monitors corneal deformation during air-puff non-contact tonometry, Prof Ambrósio told the 8th EuCornea Congress in Lisbon, Portugal. His current understanding is that the refractive surgeon should aim for characterising the susceptibility of the cornea for biomechanical failure and ectasia progression when screening candidates for laser vision correction procedures. This cannot be determined only by classic CCT and corneal topography, while such procedures do provide relevant information. In fact, it requires an enhanced characterisation of the cornea with conscious use of the diagnostic information. Nevertheless, the challenge is to efficiently interpret the enormous amount of data from a variety of instruments. A collaborative research was established between Instituto de Olhos Renato Ambrósio (Rio de Janeiro, Brazil) and Vinci Eye Clinic with Prof Paolo Vinciguerra MD and Riccardo Vinciguerra MD (Milano, Italy) and also Prof Cynthia Roberts PhD (Columbus, Ohio USA). The Corvis Biomechanical Index (CBI), available at the Vinciguerra Screening Report (VSR) of the Corvis ST (Oculus Optikgeräte GmbH, Wetzlar, Germany), was developed based on corneal thickness profile and deformation parameters, providing very high accuracy to separate normal (n=480) from clinical ectatic corneas (n=276) with an area under the curve (AUC) of 0.983 (cutoff value of 0.48, 95.7% specificity and 97.5% sensitivity). Interestingly, the BAD-D (Belin-Ambrósio deviation index), available on the Oculus Pentacam, had in the same series an area under the curve of 0.999 (cut-off value of 1.95, 98.9% specificity and 99.2% sensitivity). Nevertheless, while these data confirm the high accuracy of isolated corneal tomographic and biomechanical assessments for detecting clinical ectasia, there was evidence for the need to go beyond to detect abnormalities in asymptomatic cases with very mild ectatic corneas. This is the case of the eyes with normal topography from patients with clinical ectasia in the other eye. Ninety-six eyes with normal topography from very asymmetric ectasia cases (VAE-NT) were included in the work for the integration of Scheimpflug imaging from the Pentacam and Corvis ST (Oculus, Wetzlar, Germany). The Tomographic and Biomechanical Index (TBI), available in the ARV (Ambrósio, Roberts and Vinciguerra) display, was developed to integrate tomographic and biomechanical data using artificial intelligence, exceeding the accuracy to detect ectasia. The random forest method with leave-one-out cross-validation (RF/LOOCV) was the best model for the TBI, providing 100% sensitivity and specificity with EUROTIMES | MARCH 2018

Courtesy of Renato Ambrósio Jr MD, PhD


Biomechanic/Tomography Assessment (Ambrósio, Roberts and Vinciguerra [ARV] Display) from the right eye with clinical keratoconus. RV Display from OD with moderate clinical ectasia detected

a cut-off of 0.79 for distinguishing clinical ectasia (n=276) from normal corneas (n=480). The AUC of the TBI for the normal versus the VAE-NT cases (n=94) was 0.985, with a cut-off value of 0.29, providing 90.4% sensitivity and 96% specificity. Interestingly, studies from Iran, India, Portugal and Germany were done for external validation of the TBI with similar results as the original study. Corneal anatomical evaluation has further evolved into layered tomography, providing the ability to characterise structures, such as the epithelium, Bowman’s layer and Descemet’s membrane. This capability may help in early diagnosis of keratoconus, Prof Ambrósio said, citing original work developed by Professor Dan Z Reinstein MD, MA (Cantab), FRCOphth, using HF-US, and Professor David Huang MD, PhD, using OCT. In the future, the inclusion of molecular biology is expected. Nevertheless, the current evolution we have in corneal diagnostic devices represent a true revolution, which is in constant evolution, concluded Prof Ambrósio. Renato Ambrósio Jr: dr.renatoambrosio@gmail.com






C o r n





European Society of Cornea and Ocular Surface Disease Specialists

Blood derivatives show promise for ocular surface healing. Dermot McGrath reports


aematic derivatives have rich potential to treat a wide range of ocular surface diseases such as neurotrophic dry eye, post-LASIK or post-keratoplasty dry eye and graft versus host disease (GVHD), among other potential ocular applications, according to Jesús Merayo-Lloves MD. Addressing a clinical research symposium on new drugdelivery methods at the XXXV Congress of the ESCRS in Lisbon, Dr Merayo-Lloves explained that platelet-rich plasma (PRP) derivatives work by supplying fundamental factors to maintain the integrity of the ocular surface. “Early studies and our own clinical experience to date have shown the effectiveness of plasma rich in growth factors (PRGF) in the management of patients with severe or moderate dry eye disease. However, it will probably prove of most benefit in patients with neurotrophic dry eye, dry eye post-LASIK or post keratoplasty and graft versus host disease (GVHD),” he said. Despite the widespread use of platelet preparations in medical applications, there is no consensus on the most appropriate preparation method, and growth factors concentration vary with different systems, said Dr Merayo-Lloves.

GROWTH FACTORS More than 30 growth factors, which play an important role in tissue regeneration and wound healing, have already been identified in platelets, he said. Research by Anitua et al. led to these growth factors being combined with autologous proteins and biomaterials in a therapeutic formulation that they called plasma rich in growth factors (PRGF-Endoret). “The PRGF protocol is easy to use and we have successfully developed several different PRGF formulations: collyrium, fibrin clot and membrane. It can also be used as a scaffold for stem cell applications or as an amniotic membrane substitute,” he said. A key difference between PRGF and autologous serum is the ability of the former to suppress myofibroblasts, said Dr Merayo-Lloves. “In studies it was shown that the myofibroblasts disappear from corneal tissue or cell cultures when PRGF is present. This is important because myofibroblasts are known to play a major role in corneal haze and are also associated with problems of scarring in glaucoma and retinal surgery,” he said. Since the first trials in humans in 2009, PRGF has now been used to treat chemical burns, neurotrophic ulcers and dry eye after GVHD. For ease of use in the clinic, PRGF is now available in the form of an eye drop kit that is biologically stable for up to three months, said Dr Merayo-Lloves. “We tested the kit in 850 patients with moderate-to-severe dry eye associated with various pathologies that were not responding to traditional lubricants or anti-inflammatory treatments. The results were very promising in terms of the improvement of visual acuity and reduction in the severity of symptoms,” he concluded.

Abstract Submission Deadline 15 March 2018


Jesús Merayo-Lloves: merayo@fio.as EUROTIMES | MARCH 2018



EPITHELIAL MAPPING Epithelial thickness has high diagnostic importance in detecting corneal abnormalities. Roibeard Ó hÉineacháin reports


apping the corneal epithelium with layered tomographic imaging can be useful in determining whether refractive surgery candidates are at risk of postoperative ectasia, reports Dan Z Reinstein, MD, FRCSC, FRCOphth, FEBO, London, UK. There are now currently several tomography devices available that can distinguish between the corneal epithelium and the underlying stroma with considerable accuracy. These include optical coherence tomography (OCT) and very high-frequency (VHF) digital ultrasound, Dr Reinstein told the XXXV Congress of the ESCRS in Lisbon, Portugal. He noted that because ultrasound requires immersion of the eye and examination time takes a little longer, it is less popular than OCT. However, ultrasound has an inherent advantage over OCT in terms of accuracy. “Even though the wavelength is longer than light, VHF digital ultrasound has higher accuracy than OCT for measuring the epithelium, and the reason for this is that the acoustic impedance differences at the level of epithelium and stroma are much higher than they are for light.” In a study comparing the Artemis Insight 100 (ArcScan) VHF digital ultrasound device with the RTVue OCT (Optovue) device they found that there is close relation between the measurements of the two machines for measuring the central epithelium. However, the measurements diverged progressively as they extended more peripherally. He pointed out that although the difference was only a few microns, it was still enough to have clinical importance from a diagnostic perspective. In another study using VHF digital ultrasound in 110 eyes with a mean central thickness of 53.4µm, the epithelial thickness was found to be not uniform throughout, but on average was 5.7µm thicker inferiorly than superiorly, and 1.2µm thicker nasally than temporally. Dr Reinstein said this could be explained as a result of the eyelid’s tarsus exerting

Courtesy of Dan Z Reinstein, MD, FRCSC, FRCOphth, FEBO


Quad display including Artemis Insight 100 VHF digital ultrasound

greater frictional force on the superior and temporal region of the cornea than the inferior nasal region when the eye blinks, which occurs 10,000 times a day. The eye balances out the chafing of the epithelium by stimulating its outward growth, thereby maintaining the cornea’s curvature. Following laser refractive surgery, epithelial growth will partially compensate for the change in curvature by becoming thicker in the centre and thinner paracentrally following myopic ablations, and by thinning in the centre and thickening paracentrally following hyperopic ablations. The bulk of the compensatory epithelial changes occur within the first postoperative day and continue at a slower rate for three months, after which the corneal curvature remains stable.

SCREENING FOR SUBCLINICAL KERATOCONUS In eyes with keratoconus, the same principle applies, in that the epithelium gets thinner at the cone but thickens around the cone. The result is that epithelial mapping will show a donut pattern that is highly characteristic of the condition. Epithelial mapping can therefore be useful in

...VHF digital ultrasound has higher accuracy than OCT for measuring the epithelium... Dan Z Reinstein, MD, FRCSC, FRCOphth, FEBO EUROTIMES | MARCH 2018

screening laser refractive surgery patients for subclinical keratoconus. For example, in an eye with early keratoconus, epithelial mapping can detect whether a cone not detected by front surface topography is being masked by the epithelium. Conversely, in a topographically suspicious but actually normal cornea, epithelial mapping will show a normal epithelial pachymetry. Dr Reinstein noted that he and his associates have developed an automated algorithm to distinguish between eyes with keratoconus and those without the condition, based on epithelial and stromal pachymetric profiles. They studied a wide range of variables and found six variables that could detect keratoconus with 99% specificity and 95% sensitivity without additional data. In a study involving 136 forme fruste keratoconus suspects identified among 1,532 myopic LASIK candidates by tomography and topography, epithelial mapping with VHF digital ultrasound showed that only 22 (16%) were true keratoconus. The remaining 114 eyes underwent LASIK and none have subsequently developed ectasia. The contribution of epithelial remodelling after corneal refractive surgery to the cornea’s final refraction can also lead to undercorrection in eyes that have undergone myopic LASIK and overcorrection in posthyperopic eyes. The integration of epithelial thickness profiles into IOL power calculation formulae could further improve their accuracy, Dr Reinstein said. Dan Z Reinstein: dzr@londonvisionclinic.com


CORNEAL ANATOMY New approaches to difficult corneal pathologies follow anatomic discoveries. Soosan Jacob MD reports


ew understanding of the anatomy of the cornea has led to the development of new interventional strategies to challenging corneal pathologies, Harminder Dua MD, PhD, told the World Congress of Paediatric Ophthalmology and Strabismus in Hyderabad, India. Prof Dua, Chair and Professor of Ophthalmology, University of Nottingham, Queen’s Medical Centre, Nottingham, UK, discussed this topic during his keynote speech after receiving the Kanski Medal. Prof Dua reviewed the research leading to the discovery of the pre-Descemet’s layer (PDL), generally known as Dua’s layer. He described the three bubble types that are formed when air is injected into a corneo-scleral rim: Type 1, formed between the stroma and PDL; Type 2, between PDL and Descemet’s membrane (DM); and Type 3, a combination of Types 1 and 2. The demonstration of this layer in paediatric eyes as young as three weeks old confirms the distinctness of this layer, he said. He explained that the consistent path taken by air injected in the cornea, from the initial “cracks in a glass” pattern reminiscent of bacterial colonies travelling within the compact lamellae in infectious crystalline keratopathy, the subsequent circumferential migration along the limbus to the formation of the bubbles, gives information about the anatomy of the cornea. He quoted a paper from Liu et al. that showed that deep fungal filaments follow the coronal plane of this layer and spread along it before penetrating deeper. The PDL merges imperceptibly with the trabecular meshwork at the corneal periphery. Description of this layer has made deep anterior lamellar keratoplasty (DALK) safer and has led to the innovation of three new surgeries – DALK triple, Pre-Descemet’s endothelial keratoplasty and suture management of acute hydrops (Chérif HY et al.). The 15-20-micron-thick PDL can withstand intraocular pressure up to 700 mmHg. The Type 1 bubble DALK has a stronger wound than a penetrating keratoplasty and can also withstand the stress of performing a phaco and IOL implantation successfully under this membrane, he said. Descemet’s detachments can involve both the PDL and the DM, and Descemetoceles have been reported to consist of both the PDL and DM, so these should be looked for. Acute hydrops in keratoconus is most often due to a rupture of the DM and PDL and pre-Descemet’s sutures could be used to resolve acute hydrops. The role of the PDL in glaucoma, posterior corneal curvature and corneal biomechanics are current hot topics for research, he said. He concluded by informing the delegates that the American Association of Ocular Oncologists and Pathologists had resolved to designate the layer the ‘DuaFine layer’ in recognition of his work and the early images presented in the 1979 2nd edition of Ocular Histology: A Text and Atlas, co-authored by Drs Fine and Yanoff. Harminder Dua: harminder.dua@nottingham.ac.uk

31st International Congress of

GERMAN OPHTHALMIC SuRGEONS 14th – 16th June 2018 NürnbergConvention Center, NCC Ost Main Topics


➤➤ Hall of fame and honorary lectures

➤➤ Anesthesia Symposium

➤➤ Cataract Surgery

➤➤ Contact lenses symposium

➤➤ Glaucoma Surgery

➤➤ Affiliate Symposium

➤➤ Corneal Surgery

➤➤ Courses for junior doctors

➤➤ Vitreoretinal Surgery

➤➤ Meeting of the administrative director

➤➤ Orbita, eye lid, lacrimal duct surgery

➤➤ Masterclass courses

➤➤ Forum: ocular surgery in developing countries

➤➤ NEW: surgery courses

➤➤ Strabological symposium

➤➤ Symposium Patient-oriented health services research

➤➤ Video Live Surgery 3D ➤➤ DOC – ISRS/AAO-Symposium

➤➤ Seminar for the practice of the ophthalmologist ➤➤ Management seminar ➤➤ Consilium Therapeuticum ➤➤ Consilium Diagnosticum ➤➤ Training conference for ophthalmological assistants

Accompanying program


➤➤Come together after General Session ➤➤DOC – Summer Party


You are invited to visit a comprehensive industry exhibition with exhibits and information on medical equipment and pharmaceuticals. The exhibition will take place in Hall 7a during the congress.

31st International Congress of German Ophthalmic Surgeons, NürnbergConvention Center, 14th - 16th June 2018 $ Please send me a preliminary program $ Please send me the DOC-Express-Newsletter as well as more information by email. The consent can be contradicted at any time by e-mail, telephone or fax. E-mails should be sent to: datenschutz@mcn-nuernberg.de

MCN Medizinische Congressorganisation Nürnberg AG Neuwieder Str. 9 90411 Nürnberg, Germany Z +49 (0) 911/3931625 hi +49 (0) 911/3931620 Email: doc@mcnag.info

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Dr Dua discussed the discovery of the Dua layer in an Eye Contact interview: http://bit.ly/ET-DuaLayer EUROTIMES | MARCH 2018








Treatment Study

Need for individualised glaucoma treatment highlighted.


he results from the United Kingdom Glaucoma Treatment Study (UKGTS), which provide strong evidence for the visionpreserving benefit of intraocular-pressure-lowering topical medications, should help clinicians to make more informed choices about the day-to-day management of their glaucoma patients, according to David F GarwayHeath MD, FRCOphth. “The UKGTS results provide strong evidence for the vision-preserving effects of IOP lowering by latanoprost. A 20% IOP reduction was associated with a relative risk reduction of visual field progression by 50%. Some patients progress rapidly and close monitoring and treatment escalation may be needed, whereas other patients may not need immediate treatment because they are at low risk of visual disability during their lifetimes,” he told delegates at a Glaucoma Day session at the XXXV ESCRS Congress in Lisbon, Portugal. Dr Garway-Heath, International Glaucoma Association Professor of Ophthalmology at the UCL Institute of Ophthalmology, London, UK, said that UKGTS is the first randomised, triplemasked, placebo-controlled trial to assess the benefit of topical treatment for reduction of loss of vision in patients with open-angle glaucoma (OAG). “There was a lack of evidence of the protective effect of prostaglandins in the scientific literature. We were interested in rectifying that and looking at quality of life and visual field progression for our patients, not simply IOP alone, which is the way most glaucoma drugs are evaluated in clinical trials,” said Dr Garway-Heath. Another motivation for the UKGTS is the current duration of glaucoma clinical trials, said Dr Garway-Heath. “The typical observation periods for therapeutic trials with visual field deterioration as an outcome are four years or longer. Longer trials increase the cost of drug development and delay bringing benefit to patients. We wanted to see if we could design a trial that would help shorten EUROTIMES | MARCH 2018

Dermot McGrath reports

The UKGTS results provide strong evidence for the vision-preserving effects of IOP lowering by latanoprost David F Garway-Heath MD, FRCOphth

that timeline and bring treatments more quickly to patients,” he said. In order to achieve this, the study was designed to measure progression quickly, drawing on research by Professor David Crabb at City, University of London, that shows that identification of progression is improved by clustering tests at the beginning and end of a two-year followup period compared to the traditional three VF tests per year evenly spaced over the same period. The primary hypothesis of the UKGTS was that treatment with a topical prostaglandin analogue (latanoprost) reduces the incidence of VF deterioration events compared with placebo by 50% over a two-year observation period, said Dr Garway-Heath. He noted that the design was modelled closely on the Early Manifest Glaucoma Trial (EMGT) in order to facilitate future meta-analysis of the data. Baseline mean intraocular pressure was 19.6mmHg in 258 patients in the latanoprost group and 20.1mmHg in 258 controls. At 24 months, the mean reduction in IOP was 3.8mmHg in 231 patients in the latanoprost group and 0.9mmHg in 230 patients in the placebo group. “The pressure reduction of almost 20% for the latanoprost group is less than that usually seen in clinical trials. This is because pharmaceutical companies usually put in patients with very high IOPs in order to achieve large pressure reductions. By contrast, our patients were newly diagnosed without a pressure criterion,” he said. Visual field preservation was also significantly longer in the latanoprost group than in the placebo group, noted Dr Garway-Heath.

“The relative risk reduction was 50%, so it is a strong treatment effect on VF progression. To put it in context, it means that we need to treat eight patients with glaucoma in order to prevent one VF progression in a twoyear time period,” he said. In terms of translating the results to reallife practice, Dr Garway-Heath said that it is important to treat glaucoma patients on an individual level, monitoring them with quality of life, likely visual disability and life expectancy in mind. He pointed out that based on the UKGTS data, two-thirds of patients have no measurable progression without any treatment over a two-year period. “Even with longer follow-up in the EMGT trial, one-third of patients after seven years had no measurable progression. That is a lot of patients who are not going to get a lot worse even if the treating physician does nothing,” he said. Treatment intensity can be low in low-risk patients, but they need to be followed for progression. Other patients may progress rapidly despite treatment, in which case careful monitoring and greater treatment intensity are called for, he said. While the treatment target is typically a compromise between reducing the risk of symptomatic vision loss and the adverse consequences of therapy, patient preferences should also be taken into account, said Dr Garway-Heath. “At the end of the day, treatment is the patient’s choice – we need to advise patients of the risks of symptomatic vision loss, match the treatment intensity to the risk, and monitor for progression,” he concluded. David F Garway-Heath: david.garway-heath@moorfields.nhs.uk


PHACO-TRAB VS SICS-TRAB Phaco-trab beats MSICS in terms of both safety and IOP control. Roibeard Ó hÉineacháin reports


hacotrabeculectomy (phaco-trab) appears to offer better intraocular pressure control and visual rehabilitation with fewer complications, but with a slightly higher loss of endothelial cells, than small-incision cataract surgery combined with trabeculectomy (SICS-trab), according to a study by Ganesh Venkataraman MD, presented at the XXXV Congress of the ESCRS in Lisbon, Portugal. The non-randomised comparative study included 60 eyes of 60 glaucoma patients who underwent either phaco-trab or SICS-trab, said Dr Venkataraman, Aravind Eye Hospital, Coimbatore, Tamilnadu, India. The patients had a mean age of 66.4 years and both treatment groups included 18 eyes with primary open-angle glaucoma and 12 eyes with primary angle-closure glaucoma that had undergone peripheral iridotomy. All eyes had coexistent cataracts. The mean preoperative IOP was of 17.53mmHg in the phaco-trab group and 17.0mmHg in the SICS-trab group. Patients were excluded from the study if they had pseudoexfoliative glaucoma, small pupils and endothelial cell counts below 2,500/mm2. Also excluded were those with retinal disease or diseases of the optic nerve other than glaucoma, or who had undergone previous ocular surgery and those aged younger than 35 years. Dr Venkataraman noted that at six months’ follow-up, IOP was significantly better controlled in the phacotrabeculectomy group, which had a mean IOP of 13.68mmHg compared to 16.0mmHg in the SICS-trab group. In addition, the proportion maintaining their target IOP without medication was 89.3% in the phaco-trab group, compared to only 73.1% in the SICS-trab group. Furthermore, there was only one treatment failure in the phaco-trab group compared to six in the SICS-trab group. Twenty-three patients in both groups achieved logMAR visual acuity from 0 to 0.2 at six months postoperatively. However, more patients in the phaco-trab group achieved a visual acuity of 6/6, Dr Venkataraman noted. The mean endothelial cell loss was significantly lower in the SICS-trab group, with cell counts falling by only 10.56%, compared to in the 13.97% in the phaco-trab group (p=0.05). Dr Venkataraman noted that the rate of intraoperative complications was only 5.7% in the phaco-trab group compared to 26.7% in the SICS-trab group. The two complications that occurred in the phaco-trab group were choroidal detachment in one eye and a posterior capsular rent in one eye. By comparison, complications in the SICS-trab group included one case of choroidal detachment, one case of fibrinous membrane, two of posterior rent, one of vitreous in the ostium, one vitreous haemorrhage, one case of corneal filaments and one case of punctate keratitis. This study highlights the relevance of manual small-incision cataract surgery combined with trabeculectomy in poor socioeconomic regions of the world where national health services are limited or non-existent and medical insurance is beyond the reach of many.

European Union Web-Based Registry The aim of the project is to build a common assessment methodology and establish an EU web-based registry and network for academics, health professionals and authorities to assess and verify the safety quality and efficacy of corneal transplantation.


the ECCTR Registry


your Surgical Results

www.ecctr.org ECCTR is co-funded by Co-funded by the Health Programme of the European Union

Ganesh Venkataraman: ganeshvr75@gmail.com EUROTIMES | MARCH 2018





WSPOS World Society of Paediatric Ophthalmology & Strabismus

s u B s p E C i A l tY d A Y

Friday 21 September 2018, Vienna, Austria

Preceding the 36th Congress of the ESCRS, 22 – 26 September 2018

Outcomes show favourable profile for phakic posterior chamber lens. Cheryl Guttman Krader reports


hakic posterior chamber lens implantation (Visian ICL, STAAR Surgical) is a good option for treating children with unilateral high myopia and moderate amblyopia who failed conventional therapy with glasses or contact lenses. This is according to data from 20 years of follow-up study presented at the 2017 WSPOS Paediatric Subspecialty Day meeting in Lisbon, Portugal. In addition to having good safety, refractive, and functional outcomes that lead to quality-of-life improvement, the Visian ICL has advantages compared with the alternatives of laser vision correction and implantation of an anterior chamber phakic IOL. “PRK and LASIK can provide good refractive results, but these require patient cooperation, modify the cornea and can lead to haze. The anterior chamber phakic IOL has not been associated with significant complications during 36 months of follow-up, but it can cause endothelial cell loss and the long-term safety is unknown,” said Laurence C Lesueur MD, Centre d’Ophtalmologie, Toulouse, France. Implantation of the posterior chamber Visian ICL is performed through a small incision and maintains integrity of the cornea. It is a reversible technique that has shown good refractive predictability and stability, and it has not been associated with significant endothelial cell loss, lens opacification, or increased IOP, she noted. Dr Lesueur and Jean L Arne MD first implanted a Visian ICL in a child in 1997. An updated review of their experience Laurence C Lesueur, MD analysed data from 20 eyes of patients (mean age 8.8 years) implanted with versions V2, V3, V4b, and V4c of the lens. Mean refraction was -12.3D preoperatively and -0.4D at last follow-up (mean 9.4 years). Mean BCVA improved from 0.12 to 0.35. No eyes lost more than one line of BCVA, 66% had a BCVA gain of at least one line, and a single eye lost one line of BCVA after a traumatic retinal detachment. Presence of strabismus was reduced from 53% to 30%, as four children underwent surgery for strabismus with high angle deviation (>40D) after ICL surgery. The percentage of children with binocular vision improved from 12% to 43%. There were no late significant inflammatory reactions. One eye implanted with the V2 ICL developed moderate anterior capsule opacification. “Secondary opacification of the crystalline lens is the main risk with this phakic IOL, but cataract surgery with capsular bag implantation of a pseudophakic IOL could restore good functional vision,” Dr Lesueur said.

PRK and LASIK can provide good refractive results, but these procedures require patient cooperation...

Laurence C. Lesueur: lesueur.lc@gmail.com EUROTIMES | MARCH 2018


IOLS IN CHILDREN Pros and cons of a controversial option in paediatric cataract surgery. Soosan Jacob MD reports


hould multifocals be used in the paediatric population, and if so, how should they be used? This question formed the basis for a spirited debate during the World Congress of Paediatric Ophthalmology and Strabismus 2017 in Hyderabad, India. Proponents of the use of multifocal IOLs in children suggest the lenses should counter the loss of accommodation following cataract surgery. Cyres Mehta MD, International Eye Centre, Mumbai, spoke in favour of multifocals, arguing that it was important to give depth perception to the growing visual system considering that the visual apparatus developed rapidly up to the age of eight months. Quoting Rychwalski’s article in the Journal of Cataract and Refractive Surgery (2010), Dr Mehta stated that loss of accommodation had a greater effect on visual function and development in the paediatric age group, and since the visual world of little children was limited to their arm’s length, clear vision was required for near and distance to avoid amblyopia and disruption of binocular single vision. He also cited various studies that showed improvement in stereopsis and spectacle independence following multifocal IOLs. Multifocal implantation in children younger than two years is controversial, and he admitted that he was perhaps in the minority of cataract surgeons comfortable with implanting a multifocal IOL in an infant. In his experience, similar benefits as in an adult were achieved, the most important being “relative” spectacle independence. He also expanded upon the concept of piggybacking by placing in the bag, a hydrophobic multifocal IOL of estimated power at the age of 15 years, followed by a HEMA piggyback IOL in the sulcus for the residual refractive error. The piggyback IOL is then explanted when the power difference reaches 4 dioptres. Thin nature, non-reactivity and ease of explantability were reasons he preferred HEMA IOLs for piggybacking. He concluded that multifocality is not an option but a necessity and is best achieved by using multiple IOLs with phased removal.

PRECISE BIOMETRY Asimina Mataftsi MD, Aristotle University of Thessaloniki, Greece, on the other hand opposed the use of multifocals in children, stating that advantages these offer in adults need not necessarily translate into the paediatric age group. Multifocals need precise biometry, excellent centration, pupil size <2.5mm and astigmatism <0.5D. Inflammation after paediatric cataract surgery is high, especially in infants, and the previously mentioned conditions are generally not satisfied in this age group.

PIGGYBACKING: THE MOST FUNCTIONAL CONCEPT The Advantages 1. Easy to compute 2. Better stimulus for amblyopic prevention 3. Easy to calculate the appropriate time for removal 4. In case of gross inaccuracy, another permanent piggyback can be replaced later




+ 0.50



+ 1.00



+ 1.50






+ 2.50



+ 3.00



+ 3.50






Residual ametropia over 2D can have correction with additional temporary glasses

Questions that also still need to be resolved include whether the child will be able to select the image to focus on as well as adults with multifocal IOLs do, and whether photic phenomena will hinder developing vision. It is also important to know the effect of multifocality on motion and depth perception, and whether refractive or diffractive optics are better. Other crucial questions that need answering before large-scale adoption of multifocal IOLs in the paediatric age group, especially in unilateral cataracts, are how the multifocal will be able to compete with the contralateral normal eye. Low-contrast images secondary to multifocality affect vision more than a blurry image would do, and this can contribute to amblyopia development rather than protect against it. Posterior capsular opacification can be prolific in children, and its effect on vision through multifocal optics is important to know, as is the degree of posterior capsular opacification acceptable before significant disruption of vision occurs. Dr Mataftsi also cautioned that considering that there is a significant level of explantation of multifocal IOLs even among adults because of patient dissatisfaction, it is important to note that the infant or toddler is simply unable to complain about any problems. Even older children are less likely than adults to complain about poor quality of vision. Other yet unresolved issues regarding whether overcorrection is required to compensate for myopic shift will also need to be resolved. She contended that unless a child is physically incapable of wearing spectacles or contact lenses, multifocal IOLs are not an advantage. Ken Nischal MD, Chief of Paediatric Ophthalmology, University of Pittsburgh Eye Centre, commented during a panel discussion that historically, paediatric ophthalmologists have generally lagged behind adult cataract surgeons in the acceptance of new/changed practice patterns, and that the first ophthalmologists to implant IOLs in children were actually adult cataract surgeons. Therefore, before rejecting multifocal IOLs in children, pros and cons should be weighed with an open mind. Cyres Mehta: cyresmehta@yahoo.com Asimina Mataftsi: mataftsi@hotmail.com EUROTIMES | MARCH 2018





LOW POWER MODE Nidek has launched LPM, Low Power Mode for the MC-500 Vixi laser photocoagulator. “LPM is a new feature that allows better management of laser energy delivery to the retina with multiple scan patterns,” said a spokesman for Nidek. “LPM reduces the thermal energy delivered to the retina by reducing the standard (yellow) laser treatment by a specified ratio. This treatment paradigm addresses various conditions, including macular oedema,” he said. “As the indications of laser therapy evolve, more opportunities for the development of unique, innovative applications arise,” said Nidek President Motoki Ozawa. “The incorporation of the Low Power Mode provides optimal treatment outcomes with a wider range of applications, “ he said. www.nidek.com

DEPENDABLE PARTNER OCULUS and Leica Microsystems have announced that the new link to Leica’s Pro Guidance system and TrueVision’s TruePlan is now ready for purchase. “The Pentacam AXL enhances clinical applications while providing optical biometry for IOL power calculation along with the known smart software modules,” said a company spokeswoman. “The Pentacam IOL Calculator with its standard IOL formulas, as well as latest-generation formulas such as the Savini toric calculator and the Barrett formulas, makes the OCULUS Pentacam AXL a dependable partner for cataract surgeons,” said the spokeswoman. www.oculus.de


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NEXT GENERATION PLATFORM Bausch + Lomb, has received CE Mark from the European Commission for the Stellaris Elite Vision Enhancement System, the company’s ophthalmic surgical platform. “We’re pleased to bring the Stellaris Elite Vision Enhancement System, including the cuttingedge Vitesse technology, to the greater European market,” said Joseph C. Papa, chairman and CEO, Valeant. “Because this surgical platform offers the opportunity to continuously add innovative upgrades and enhancements, it enables surgeons to customise their systems and expand their capabilities as their needs evolve,” he said. www.bausch.com



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THE FEBOS-CR EXAM FEBOS-CR is not an exam you have to take. It's an exam you must want to take, says Sorcha Ni Dhubhghaill


n September of last year, I sat — and passed — the very first FEBOS-CR qualification exam. Truth be told, I initially had no intentions of sitting another exam. I remember vividly the sense of relief after passing the EBO exam. No more exams, I thought. Ever! But the late Peter Barry changed all of that. He told me a few years ago that they were planning another exam. A subspecialist exam with a far lower pass rate. Not an exam that everyone has to pass. But one that, by design, only few should pass. It all sounded a little daunting to be honest, but Mr Barry — I never got over calling him by his consultant title — showed such enthusiasm for the endeavour that I came to think of it as an exam in his memory. And now, I wanted it. To start, you have to be allowed to sit it in the first place. I submitted two surgical videos, a simple case and a complex case, and made it through. I was allowed to come to Lisbon for the exam itself.

SELF-CONFIDENCE Once I knew I was in, I hit the books. Or more precisely, I hit the ESCRS iLearn platform. It is a veritable treasure trove of expertise compiled by some of the Society’s most esteemed members. Its lessons are the perfect fodder for an allnight study binge, while its quizzes help cement your new-learnt knowledge, and build your self-confidence. The exam itself flew by in a stressful haze. The poker-faced examiners didn’t give any indication on whether I was doing well or not. So it was a nail-biting wait until the next day when the results were announced. I passed and stood on stage as one of the first graduates of the FEBOS-CR exam. I felt honoured, but it was also a deeply emotional moment for me to pass the exam so shortly after Mr Barry’s passing. FEBOS-CR is not an exam you have to take. It’s an exam you must want to take. It’s not easy, nor is it supposed to be, as passing it means the ESCRS will vouch for you to be an expert in your field. Those are powerful credentials that can open doors for you, and facilitate mobility within Europe. One day you too may want to distinguish yourself and join the ranks of the FEBOSCRs. I hope you will.

I remember vividly the sense of relief after passing the EBO exam. No more exams, I thought. Ever! Sorcha Ni Dhubhghaill is an anterior segment surgeon and guest lecturer at Antwerp University Hospital in Belgium • The EBO-ESCRS Examination Board do not prescribe recommended reading for the FEBOS-CR examination. However, there are a range of resources available from ESCRS, including the

Player (surgical and interview videos), ESCRS On Demand (members only, recordings of main sessions), ESCRS iLearn (members only, interactive eLearning platform), as well as JCRS case reports and landmark journal articles. Links to all of these resources are available from http://education.escrs.org


Carlos Lisa (Spain)

Juan Alvarez De Toledo (Spain)

Tobias Neuhann (Germany)

John Bolger (United Kingdom)

Sorcha Ni Dhubhghaill (Belgium)

Burkhard Dick (Germany)

Julio Ortega-Usobiaga (Spain)

Luis Fernandez-Vega Cueto-Felgueros (Spain)

Pantelis Papadopoulos (Greece)

Tiago Ferreira (Portugal)

Pavel Stodulka (Czech Republic)

Firat Helvacioglu (Turkey)

Andrew Tatham (United Kingdom)

Frederik Potgieter (South Africa)



CME Educational Symposium

Washington, D.C. 2018

Save the date Friday, April 13– Monday, April 16, 2018 Make the most of your time at the ASCRS•ASOA Annual Meeting and attend our EyeWorld multi-supported CME, independent education, and Corporate Events. They are a great opportunity to network with your colleagues while learning tips and techniques from the experts.

Among the topics to be covered in these sessions are:

• Updates on diagnosing and treating the ocular surface, including dry eye disease and meibomian gland disease • New developments in glaucoma medical and surgical treatment options • LACS: Tips and pearls for current users • Maximizing presbyopia-correcting outcomes • Successfully integrating toric IOLs and improving results and patient satisfaction • Mastering phaco dynamics, fluidics, power, and nuclear disassembly • Modern laser vision correction • A discussion on recent developments in anti-inflammatory therapeutic treatments

ASCRS-Authorized Education These non-CME, ASCRS-authorized educational programs will provide timely and important information on:

• Microinvasive Glaucoma Surgery

Corporate Education EyeWorld Corporate Events are directly developed by industry and hosted by EyeWorld. These non-CME meetings provide valuable information on new products, procedures, and applications of existing products. Included among the topics discussed in these sessions are:

• • • • • • •

Live surgery New developments in surgical instrumentation Growing the overall size of the premium IOL market Considerations in the selection of a premium IOL New developments in laser vision correction Advanced IOL technology Discussion of technological advances and breakthroughs in cataract surgery • Update on crosslinking • Advances in diagnostic and imaging equipment


Topics are subject to change.


LEADER AND INVENTOR Here we profile Professor Dorde Nešić, who was the founder of ophthalmology in Serbia. Andrzej Grzybowski reports


orde Nešić was born in 1873 in Šabac, where he graduated from the Secondary School in 1890. In the same year, he entered the Faculty of Medicine in Moscow. He became a teaching assistant to Professor Adrian Aleksandrovich Kryukov (1849-1908), simultaneously working at the University Institute of Physics and Mathematics. In 1896, he graduated from the University as a Doctor of Medicine at the age of 23. That same year, he established the Department of Ophthalmology at the Military Hospital in Belgrade. In 1901, he moved to the Department of Ophthalmology at the General State Hospital, in which in 1904 he was appointed Head of the Department of Ophthalmology. From 1904-05 he participated in the Russian-Japanese war as a volunteer, and from 1912-1918 he served as a reserve medical corps officer in the Balkan Wars and the First World War. From 1916 to 1918, he was Commander of the First Field Surgical Hospital of the Second Army in Dragomanci, at the Salonika Front. In 1918, he published a paper, in which he refuted the then assumption on contagiousness of night blindness (nyctalopia)

and proposed treatment for this disorder. Among his medical technology inventions, the most prominent were the giant electromagnets for extracting metallic foreign bodies from the eye and from the body as well as the syringe for injecting biogenic stimulators. He contributed also to the fight against trachoma, which was widespread at that time in different parts of Europe. In 1921 he was appointed the Head of the newly established Ophthalmology Clinic and Professor of Ophthalmology at the Faculty of Medicine in Belgrade. He was a Dean of the Medical faculty there in 1924-25, 1930-31 and 1931-32. During WWII he was suspended, but continued his work at the Clinic without the approval of the occupier. In 1945, he was reappointed as the Professor at the Faculty and the Head of the Ophthalmology Clinic. He retired at the age of 82 and died in Belgrade in 1959. l

This article was written and researched by Andrzej Grzybowski MD, PhD, MBA, Professor of Ophthalmology, Chair of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland, Head of the Institute for Research in Ophthalmology, Poznan, Poland

See into the future of eye surgery and patient care. Belong to something inspiring. Join us.

www.escrs.org EUROTIMES | MARCH 2018



EXPLORING VIENNA The Museum of Modern Art Ludwig Foundation (MUMOK) is home to pieces by Andy Warhol and Yoko Ono




TRAVELLING THROUGH THE AGES Published in 2010, The Hare with Amber Eyes quickly became a bestseller, reprinted repeatedly in its first six weeks and translated into 22 languages. The book traces the journey of a collection of tiny carved Japanese figures – netsuke – and the history of five generations of the staggeringly wealthy Jewish family, the Ephrussi, to whom they belonged. The narrative shifts from Paris to Vienna to England to Tokyo and back to London, but the descriptions of Vienna and the fate of the Ephrussi family at the time of the 1938 Anschluss alone make the book well worth reading – or rereading – if Vienna is in your travel plans. The vast 19th-Century ‘palace’ that was their Viennese home still stands on Schottengasse opposite the University. The modern wing, replacing one destroyed in the war, was OPEC headquarters. The Hare with Amber Eyes, by Edmund de Waal, is available in hardback, paperback, Kindle and audio versions

A LITERARY ACHIEVEMENT The Radetzky March is a three-generational novel that narrates the rise and fall of the Trotta family, set against the history of Austria from the Battle of Solferino in 1859 to the fall of the Austrian-Hungarian Empire in 1918. Considered one of the top literary achievements of the German language, the novel by Joseph Roth was first published in English in 1933 and in 1995 republished in a new English translation by Michael Hofmann. The Radetzky March is published in hardback and in a Kindle version

FROM PAGE TO SCREEN The ‘treatment’ on which the classic motion picture The Third Man was based (with significant variations) is also a haunting novella. A moody masterpiece, the story plays out in the rubble of the “smashed, dreary city of Vienna” just after WWII; Graham Greene’s words bring the vanquished city and the narrator’s pursuit of the war profiteer Harry Lime to life as vividly as the film. Two versions: a print edition in which The Third Man’ comes coupled with The Fallen Idol, and an enhanced Kindle version of The Third Man integrating film clips, notes from the script and other bonus material into the text



Vienna has more than 100 museums to explore. Which are ‘unmissable’? Maryalicia Post reports One of Vienna’s most visited tourist attractions is the ensemble of buildings and performance spaces that make up the Museum Quarter. The 335-metrelong facade of the 18th-Century Imperial Stables screens the area off from the street, secluding a neighbourhood of the arts in the middle of a capital city. The central area of the Baroque building, the former winter riding arena, has been restored and transformed into two halls for the exhibition of contemporary art. Beyond that, in a park-like area with outdoor seating and coffee shops, two museums anchor the complex left and right. At one end, there’s the white cube by Viennese architects Ortner and Ortner that houses the Leopold Collection, with its definitive works by Egon Shiele and Klimt. At the other, there’s the imposing black basalt structure known as Mumok (The Museum of Modern Art Ludwig Foundation Vienna), by the same architects. The largest museum for modern and contemporary art in Central Europe, its highlights include Pop Art pieces by Andy Warhol and Yoko Ono. The Museum Quarter is about 15 minutes away from the Messe Centre by underground. Details of opening hours and current exhibitions are on the websites: http://www.kunsthallewien.at; http://www. leopoldmuseum.org; http://www.mumok.at Three museums – the Sisi Museum, the Imperial Apartments and the Silver Collection – can be visited with one ticket in the Hapsburg Palace in Vienna’s inner city. The Hapsburg, built in the 13th Century, was the winter home of the Hapsburg dynasty rulers; today it is the administrative centre of Vienna and the official home and workplace of the President of Austria. With 18 groups of buildings and 2,600 rooms, space is not a

problem. The apartments of the Empress Elisabeth, affectionately nicknamed Sisi, contain many of the objects belonging to this poignant figure, from the time of her arrival in court in 1854 as the 16-yearold bride of Emperor Franz Josef I to her assassination, aged 60. For hours and ticket prices: https://www.hofburg-wien.at The Jewish Museum in Vienna occupies two buildings; the main museum is in the Palais Eskeles on Dorotheergasse and another, telling the story of Jewish life in Vienna in the Middle Ages, on Judenplatz. In 2018, from May 30 until October 7, the Jewish Museum on Dorotheergasse presents a special exhibition, ‘The Place to Be’, an exploration of Vienna salons between 1780 and 1930. Most of these ‘networking events’ were hosted by Jewish women whose gatherings were a highlight of the social, economic and political scene of the day. Details: http://www.jmw.at

The Jewish Museum in Vienna


The 4th ESASO Anterior Segment Academy will take place in Milan, Italy



MARCH 2018

14th ISOPT Clinical: The International Symposium on Ocular Pharmacology & Therapeutics 1–3 March Tel Aviv, Israel https://www.isoptclinical.com/

32nd International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery 1–4 March Athens, Greece www.hsioirs.org/index.php/en/ NEW

Snowmass Retina & Eye 2018 12–16 March Colorado, USA https://www.snowmasscme.com

Frankfurt Retina Meeting 2018


NEW 69th Annual Conference of Delhi Ophthalmological Society

15th Congress of the South-East European Ophthalmological Society

6–8 April New Delhi, India http://doscon.org/

31 May – 2 June Szeged, Hungary http://www.seeos.eu

2018 ASCRS•ASOA Annual Meeting


13–17 April Washington DC, USA http://annualmeeting.ascrs.org/

World Congress on Clinical, Pediatric and Neuro Ophthalmology

4th ESASO Anterior Segment Academy

4–5 June Osaka, Japan https://neuro.ophthalmologyconferences.com

26–28 April Milan, Italy https://esasoasa2018.org/


NEW French Society of Ophthalmology (SFO) 5–8 May 2018 Paris, France http://www.sfo.asso.fr/congres/ congres-international-sfo-2018

NEW SAFIR Congress 5–6 May 2018 Paris, France https://www.safir.org/inscription/

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

The SFO and SAFIR Congresses will take place in Paris, France




JUNE 31st International Congress of German Ophthalmic Surgeons 14–16 June Nuremberg, Germany http://www.doc-nuernberg.de/ index-e.php

3rd World Eye Bank Symposium 15 June Barcelona, Spain http://www.gaeba.org/events/ 3rd-world-eye-bank-symposium-gaeba/

WOC 2018 16–19 June Barcelona, Spain www.icoph.org

NEW Aegean Cornea XIV 29 June – 1 July Mykonos, Greece http://www.aegeancornea.gr/

The 2018 EURETINA, EuCornea and ESCRS Congresses will take place in Vienna

SEPTEMBER 2018 WSPOS Subspecialty Day


21 September Vienna, Austria www.wspos.org

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

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


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

Watch the latest video content from ESCRS and EuroTimes, FREE on the ESCRS Player l

Eye Contact Interviews


Video of the Month


Video Journal of Cataract & Refractive Surgery


Young Ophthalmologists Videos: “My Early Surgeries”


Online Museum

player.escrs.org EUROTIMES | MARCH 2018


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

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

VIENNA 2018 36 Congress of the ESCRS TH

22â&#x20AC;&#x201C;26 September Reed Messe, Vienna, Austria


Abstract Submission Deadline 15 March 2018


Laser Cataract Surgery

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e and piec h S e s u FECTION Single N I M O R TS F PROTEC . g needle SS* in O v L o L m L E o C N THELIAL O D N E S LES * J Cataract Refract Surg. 2016 May;42(5):725-30. doi: 10.1016/j.jcrs.2016.02.039. Tanev I, Tanev V, Kanellopoulos AJ. Nanosecond laser-assisted cataract surgery: Endothelial cell study.

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