EuroTimes Vol. 23 - Issue 3

SPECIAL FOCUS

CORNEA

CATARACT & REFRACTIVE

OPTIMAL PLACEMENT FOR PHAKIC IOLS

RETINA

VITREORETINAL IMAGING: THE FUTURE IS NOW

GLAUCOMA

SUSTAINED IOP REDUCTION FROM CANALOPLASTY April 2018 | Vol 23 Issue 4

DA L K PK

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VIENNA 2018 36 Congress of the ESCRS TH

22–26 September Reed Messe, Vienna, Austria

Registration & Hotel Bookings www.escrs.org

P.18

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

CONTENTS

Designer Monica De Iscar Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Gearóid Tuohy Priscilla Lynch Soosan Jacob

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS CORNEA 4

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

DALK vs PK – improvements in technique are delivering on the promise of improved graft survival

6 Diagnosing infectious 7

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17 JCRS highlights

RETINA 18 The future is now

for intraoperative vitreoretinal imaging

Femtosecond lasers offer stronger wounds and faster healing in penetrating keratoplasty

22 Predictors for diabetic

Arachnid house pets are driving an apparent rise in ophthalmia nodosa incidence

23 Ophthalmologica update

CATARACT AND REFRACTIVE 10 Everything you ever wanted to know about phacoemulsification in small eyes – Part 2

12 Conscious breathing can help battle stress in the operating room

13 SMILE appears to be

a step forward from LASIK in terms of effects and results about his work with phaco pioneer Eric Arnott

15 Patrick Condon recalls how phaco came from New York to Europe

P.37

optimal placement for phakic IOLs

21 We report from the

14 Richard Packard talks As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2017 and 31 December 2017 is 45,316.

16 Experts discuss the

keratitis after refractive surgery is essential

When are steroids an appropriate treatment for keratitis?

www.eurotimes.org

8th EURETINA Winter Meeting in Budapest retinopathy help identify who is most at need of treatment

GLAUCOMA

INDUSTRY 30 CEOs give their view on the state of the market

24 Medium-term canaloplasty results show sustained IOP reduction

25 A new miniature

filtration device appears to provide better IOP control as a solo procedure

PAEDIATRIC

REGULARS 33 Books 35 Hospital diary 36 Industry news 37 ESCRS news 38 Travel 39 Calendar

27 Selecting the right

IOL power for children presents significant challenges

28 Myopia interventions are effective but limited in the face of a rising epidemic

Clarification

In the February 2018 Vol 23 Issue 2 of EuroTimes, in the article New intraocular lenses, we referred to an InfiniteVision Optics’ (IVO) lens as Perquisite - this was incorrect.

The lens is called Precisight.

Supplement April 2018

Ocular Surface Disease: Accurately Diagnose & Effectively Treat Your Surgical Patients

Included with this issue...

ESCRS/EuCornea Education Forum supplement

Supported by an unrestricted educational grant from

EUROTIMES | APRIL 2018

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EDITORIAL A WORD FROM JESPER HJORTDAL MD, PHD

REVOLUTION IN CARE

Major developments have helped improve the standard of treatment for corneal diseases

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he last 15 years have revolutionised the medical and Tips and pitfalls in corneal graft surgery was the topic of the surgical treatment of corneal and ocular surface diseases. third session, and after the keynote lecture on long-term results The development of new lamellar techniques for treatment of DALK or PK for keratoconus, the case presentations covered of endothelial diseases (DSAEK and DMEK) and diseases almost all types of keratoplasty, including a new DMEK loading involving the corneal stroma (DALK) has meant a major technique, timing of DMEK, coping with retained Descemet’s improvement in the healthcare of patients with corneal membrane after PK and corneal melting after Boston KPro diseases: Patients have faster visual recovery, a more stable and implantation and using a lamellar autologous graft in acute stronger eye and less risk for immunological rejection episodes. transplantations when donor tissue is unavailable.

Similarly, the use of serum eye-drops, amniotic membranes, In the last session, focus was on infectious keratitis. In the keynote new drug developments and improvement in medical lecture clinical points on discriminating contact lenses have significantly reduced the disease between sterile and infectious interface Overall, the Cornea Day burden in patients with ocular surface diseases. inflammation were presented, and the was very well attended During the same time period, “new” corneal diseases following presentations included difficult have become more common in Europe (fungal and cases with keratitis caused by atypical and the meeting in acanthamoeba keratitis) and new iatrogenic diseases mycobacteria, leptospirosis, acanthamoeba Belgrade perfectly have been discovered (ectasia after LASIK, and graftand fusarium. organised versus-host disease after bone-marrow transplantation).

Overall, the Cornea Day was very well These major changes in corneal healthcare require attended and the meeting in Belgrade ophthalmologists in general and corneal specialists perfectly organised. in particular to continuously keep updated on new diagnostic In September, the Board and Programme Committee of methods and new treatment modalities. The Cornea Day at the EuCornea look forward to welcoming residents and colleagues ESCRS Winter meeting organised by ESCRS in collaboration with to the beautiful city of Vienna where the 9th EuCornea Congress EuCornea and the EuCornea annual meeting in the autumn are will take place 21-22 September 2018. The programme will two good opportunities for this. include seven symposia and six courses. The topics include The annual Cornea Day was held this year on Friday 9 symposia updates in fungal keratitis, ocular surface inflammation, February during the ESCRS Winter Meeting in Belgrade. José management of keratoconus and current trends in keratoplasty, Güell from EuCornea and Rudy Nuijts from ESCRS had jointly while the headlines for the courses comprise handling of difficult organised the four programme sessions, each composed of a cases in lamellar surgery, gluing, management of surface tumours, keynote lecture followed by several case presentations. keratoprostheses and indications for therapeutic contact lenses.

The session on ocular surface disease included a keynote lecture To keep you updated with the newest advances in management on Meibomian gland dysfunction and interesting case reports on of ocular surface and corneal diseases, we look forward to seeing various topics such as the effectiveness of compressive sutures in you in Vienna in September! management of acute hydrops and the use of corneal lenticules from ReLEx SMILE surgery for the treatment of corneal ulcers.

The second session on management of corneal complications after refractive surgery was opened with a keynote lecture on how to deal with induced astigmatism, followed by a wide variety of case presentations on coping with corneal femtosecond laser complications, corneal ectasia and epithelial ingrowth after phakic Jesper Hjortdal IOL implantation.

President-elect, EuCornea

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

INTERNATIONAL EDITORIAL BOARD Noel Alpins (Australia), Bekir Aslan (Turkey), Roberto Bellucci (Italy), Hiroko Bissen-Miyajima (Japan), John Chang (China), Béatrice Cochener (France), Alaa El Danasoury (Saudi Arabia), Oliver Findl (Austria), I Howard Fine (USA), Jack Holladay (USA) , Soosan Jacob (India), Vikentia Katsanevaki (Greece), Anastasios Konstas (Greece), Dennis Lam (Hong Kong), Boris Malyugin (Russia), Marguerite McDonald (USA), Cyres Mehta (India), Thomas Neuhann (Germany), Rudy Nuijts (The Netherlands), Gisbert Richard (Germany), Leigh Spielberg (The Netherlands), Sathish Srinivasan (UK), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Emrullah Tasindi (Turkey), Marie-José Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy), Roberto Zaldivar (Argentina), Oliver Zeitz (Germany)

EUROTIMES | APRIL 2018

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European Society of Cornea and Ocular Surface Disease Specialists

Registration & Hotel Bookings www.eucornea.org

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SPECIAL FOCUS: CORNEA

DA LK PK Improvements in technique are delivering on promise of improved graft survival Roibeard Ó hÉineacháin reports

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doption of the Descemet’s-baring big-bubble technique appears to improve the short-term survival of deep anterior lamellar keratoplasty (DALK) grafts, raising hopes of lifelong graft longevity even in young keratoconus patients, said Bruce Allan FRCS, Moorfields Hospital, London, UK. “The key message here is that if you have good technique you will have good results,” EUROTIMES | APRIL 2018

Dr Allan told the 22nd ESCRS Winter Meeting in Belgrade, Serbia.

DALK and penetrating keratoplasty (PK) appear to perform equally well in terms of visual outcomes, he noted.

However, DALK has several theoretical advantages over PK. Since it leaves the host endothelium intact, DALK reduces the risk of immune rejection and endothelial cell loss and should therefore extend graft longevity potentially for the life of the patient.

Registry studies show that PK grafts have a good survival rate during the first 10 years of around 90%, but by 20 years the survival rate drops to around 50% and by 23 years to 17%. Moreover, second and third penetrating grafts have a 10-year survival rate of only around 50% and 33% respectively. Therefore, keratoconus patients who undergo penetrating keratoplasty are at a greater risk of corneal blindness in their later years, since they generally undergo their first graft when they are in their 20s.

SPECIAL FOCUS: CORNEA

The donor cornea is supported on an artificial anterior chamber filled with air to facilitate applantation and laser cutting shown here using the J&J iFS femtolaser. Drying excess fluid before application facilitates accurate visualisation of the application meniscus

The air injection cannula is introduced into the deep stroma in the 6mm central ‘mushroom stalk’ zone of the host cornea prior to air injection and big bubble formation

Because the pre-Descemet’s layer inserts into the stroma at 6-8mm diameter, bubble formation often covers the entire 6mm-diameter central zone

The overlying stroma can be removed relatively easily along the track of the 6mm posterior side cut to expose the preDescemet’s layer in the central host cornea

After removal of the donor Descemet’s membrane, the donor cornea is washed in balanced salt solution and placed ready for fixation with 10/0 nylon interrupted sutures

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The reasons for graft failure following PK procedures include not only immune rejection but also an accelerated endothelial cell loss. In contrast, although there is some endothelial cell loss during the first six months following DALK procedures, thereafter the rate drops to normal physiological levels, as occurs with phacoemulsification. On that basis, one could extrapolate that a successful DALK graft could last the lifetime of a young patient, compared to the 17-year median survival of PK grafts, Dr Allan said.

However, what the registry studies have actually shown is that DALK has historically had a poorer graft survival in the short term, with 12% of DALK grafts failing in the first three years in the Australian registry and similar results in the UK (OTAG) database. The principal causes for failure of DALK grafts include perforation, persistent double anterior chambers and fibrosis in the stromal interface. Immune stromal rejection can also occur, and although it is usually easy to treat, it can cause neovascularisation and graft failure.

POOR SHORT-TERM RESULTS ARE HISTORY Nonetheless, Dr Allan pointed out that the historic nature of the registries should be taken into account when considering these findings. The data covers the early years of DALK surgery, when surgeons primarily used deep stromal dissection and when the precision of surgery and the understanding of the cornea’s lamellar anatomy were less advanced than today.

Since that time, the DALK technique has evolved considerably, particularly with the advent of Descemet’s membrane-baring techniques like the big-bubble technique, introduced by Mohammed Anwar MD in the early years of the current century. As data accumulates, DALK with the newer techniques appears to be on an equal footing with PK in terms of early graft survival.

For example, in a single-surgeon series of 158 patients undergoing the big-bubble DALK technique, the failure rate at four years was only 2%, and in a multi-surgeon study at Moorfields involving 350 cases the rate was 3% at three years.

“Now that we understand the techniques better we are getting better early results, and I think that is the key to understanding why the registry data which is quite historic is showing relatively poor results for DALK,” he explained.

Dr Allan noted that the air-reflection manual dissection approach, introduced by Dr Gerrit Melles in the late 1990s, is still very useful in some S FRC cases, particularly when there n Alla ce is a scar in the posterior stroma.

Bru It involves using an air bubble in the anterior chamber to create a mirror image of the dissector blade. The apparent width of a dark band between the leading edge of the blade and its bright reflection is twice the residual stromal thickness. The technique has also been used to help locate the cannula tip deep in the corneal stroma for the big-bubble technique.

MINI-BUBBLE TECHNIQUE Regarding the big-bubble technique itself, he notes that he and his associates have developed a variant they call the “mini-bubble technique”. Inspired in part by Harminder Dua’s description of the pre-Descemet’s layer anatomy, it involves using the femtosecond laser to create a mushroom graft with a 6.0mm Descemet’s membrane baring optical centre and a 9.0mm outer diameter.

Courtesy of Bruce Allan FRCS

ACCELERATED ENDOTHELIAL CELL LOSS

Topical steroid drops are tailed over slowly in the first four months post surgery. Rejection reactions, as seen with mild superficial stromal haze here, generally respond easily to further topical steroid treatment

He noted that perforations during the big-bubble technique generally occur in the periphery as the bubble extends outward to 8.0mm. The pre-Descemet's layer inserts into the stroma with about 6-to-8mm diameter.

The narrow optical zone of the mini-bubble dissection respects the anatomy of the pre-Descemet's layer, and the 9.0mm graft provides good optical quality and should help prevent late ectasia resulting from continued thinning of the host-side corneal periphery, which commonly occurs decades after conventional 7.5-8mm diameter PK. He added that the technique also has the advantage of being easy to perform and that procedure could still be feasible in corneal surgical centres that don’t have femtosecond lasers, since the laser part of the procedure could be carried out at a centre that does have the laser.

“You've heard of pre-cut donors, I think in the future we may be seeing pre-cut patients,” Dr Allan concluded.

Bruce Allan: bruce.allan@ucl.ac.uk EUROTIMES | APRIL 2018

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SPECIAL FOCUS: CORNEA

INFECTIOUS KERATITIS Differential diagnosis of keratitis following refractive surgery is essential for ensuring early and appropriate treatment. Roibeard Ó hÉineacháin reports

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lthough infectious keratitis is very rare following LASIK, differential diagnosis between infectious and non-infectious inflammation should be made as soon as possible, because the earlier the treatment the better the outcome, said Vikentia Katsanevaki MD, PhD, at the 22nd ESCRS Winter Meeting in Belgrade, Serbia.

The true incidence of infectious keratitis following refractive surgery is unknown and estimates have varied widely from zero to 1.5% of treated eyes. A survey of ASCRS members conducted in 2001 suggested an incidence of about one infection per 3,000 procedures, while the 2008 ASCRS survey suggested an incidence of one infection in every 1,102 procedures.

Of the 19 cases reported in the 2008 survey, eight (42%) were LASIK performed with a microkeratome, two were LASIK with femtosecond laser flap creation (10.5%), and eight cases had surface ablation procedures (42%). The time of presentation ranged from one week to more than one month postoperatively.

In most cases described in the literature it is not possible to determine the origin of the infection. However, there are predisposing factors, including breaks in the epithelial barrier and excessive surgical manipulation. In surface procedures delayed postoperative re-epithelialisation of the cornea may play a role, although it may also be the infection that causes the poor re-epithelialisation in such cases.

Sterile lamellar keratitis following LASIK in its usual diffuse lamellar keratitis (DLK) manifestation occurs much more commonly than infectious keratitis, with reported incidences of 2%-4%. Its characteristics include central circular opacity and stromal thinning. Its cause is not understood, but it seems to occur in clusters of patients treated on the same day, Dr Katsanevaki noted.

DIFFERENTIAL DIAGNOSIS There are a few signs and symptoms on first examination that can help differentiate between infectious and sterile lamellar keratitis. In terms of symptoms, infectious keratitis will be marked by pain and decreased vision, whereas non-infectious keratitis is more typically characterised by soreness rather EUROTIMES | APRIL 2018

Dr Vikentia Katsanevaki speaking at the 22nd ESCRS Winter Meeting in Belgrade, Serbia

than pain, grittiness in the eye and decreased vision. In addition, there is ciliary injection in eyes with infectious keratitis whereas this is not seen in noninfectious keratitis.

Furthermore, in eyes with infectious keratitis the opacity is focal or multifocal but rarely diffuse and extends into to the flap. In eyes with non-infectious keratitis the opacity is diffuse, rarely focal and it is confined to the interface. Furthermore, in infectious keratitis there is an anterior chamber reaction and hypopyon, whereas in non-infectious keratitis the eye is quiet.

The course of treatment in the two conditions is also very different. In sterile keratitis, the first line of action is to increase steroids. For eyes with grade I DLK, she recommended hourly dexamethasone and for grade II or grade III washing out the interface, and hourly dexamethasone.

Infectious keratitis cases require a more rigorous workup and treatment.

Lifting the flap and obtaining samples for staining and cell culture to identify the pathogens responsible is always recommended and can be particularly helpful in cases where first-line treatments are ineffective, she advised.

In cases where the onset of keratitis

occurs within the first two postoperative weeks staphylococcal and streptococcal species are the most commonly isolated pathogens. Therefore, treatment should start with three loading doses at fiveminute intervals with a topical fourthgeneration fluoroquinolone, such as gatifloxacin 0.5% or moxifloxacin 0.5%, followed by three doses every 30 minutes.

That should be alternated with a 50mg/ mL dose every 30 minutes with a rapidly bactericidal antimicrobial agent with increased activity against gram-positive organisms, such as vancomycin, Dr Katsanevaki said.

Late onset infectious keratitis can occur from two weeks to three months following surgery and is usually caused by opportunist organisms such as fungi, nocardia and atypical mycobacteria, she noted. When it occurs, she recommended the same fourth-generation fluoroquinolone regimen alternated with amikacin 50mg/mL every 30 minutes.

Additional measures can include the use of oral doxycycline, 100mg twice daily, to inhibit collagenase production, and discontinuation of corticosteroids.

Vikentia Katsanevaki: vikentia2015@gmail.com

SPECIAL FOCUS: CORNEA

PRECISE CUTS WITH FS LASER

OPHTEC | Cataract Surgery

Stronger wounds and faster healing improve refractive outcomes.

Howard Larkin reports

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s with many ophthalmic procedures, restoring vision is no longer enough for penetrating keratoplasty. “Patients want to know how quickly they will get back to their life, what is the rate of their visual recovery, are they going to be limited to wearing rigid gas permeable lenses…

Refractive goals really are our current challenges,” Marjan Farid MD told the American Academy of Ophthalmology 2017 Annual Meeting in New Orleans, USA. Femtosecond lasers help, said Dr Farid, of the University of California – Irvine, USA. Lasers enable precise cuts at specified depths that cannot be done manually. The resulting interlocking incisions have been shown to be stronger, and promote faster wound healing and earlier suture removal.

They may also improve refractive outcome, though more study is needed to confirm this, she added.

The medical and biomechanical characteristics of femtosecond PK incisions vary with profile. For example, a “top hat” profile provides a broad expanse of donor endothelium, but is not self-sealing due to aqueous leaking in dislodging the posterior flap. A “mushroom” profile features a broader anterior surface and preserves more host endothelium, making it attractive for keratoconus patients, but does not inherently align the anterior surface or hermetically seal.

Inspired by self-sealing cataract incisions and developed by the late Roger Steinert MD, the “zig-zag” profile provides a smooth transition between host and donor tissue, while its interlocking pattern creates a precise apposition over 360 degrees. Its structure also guides suture placement, making it easier to use, Dr Farid said.

Early lab tests show zig-zag PK grafts have higher burst strength than conventional incisions (Steinert et al., Am J Ophthal 2007; Maier et al. Cornea 2016; Malta et al. Curr Eye Res 2009; Bahar et al. Cornea 2008), Dr Farid noted.

“Several studies have clinically shown patients who have had femtosecond laser cuts can have sutures removed at an earlier timepoint,” she added (Chamberlain et al. Ophthal 2011; Bahar et al. BJO 2009; Birnbaum et al. Graefes Arch Clin Exp Ophthal 2013; Shivanna et al. Indian J Ophthal 2013).

Easier and lower-tension suturing enabled by zig-zag incisions also reduce torsional tension and vertical misalignment, Dr Farid said. Ongoing retrospective studies at UC Irvine suggest this reduces astigmatism and HOAs. The resulting more-regular astigmatism is easier to correct with LASIK or toric IOLs, leading to even better refractive outcomes.

However, other studies are less conclusive regarding refractive benefits, Dr Farid noted. Standardised, prospective head-to-head studies comparing incision patterns and similar graft size are needed to quantify any differences. Nonetheless, she believes femtosecond laser incisions are superior. “If you had to have PKP, what incision would you prefer? Femto is the future.”

Marjan Farid: mfarid@uci.edu

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SPECIAL FOCUS: CORNEA

PET SPIDERS AND THE EYE Arachnid house pets drive apparent rise in ophthalmia nodosa incidence. Howard Larkin reports

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he previously healthy 17-year-old male presented after two weeks of intense foreign body sensation, photophobia and periocular rash that had spontaneously resolved. Though his visual acuity was 20/20, IOP normal and skin on the lids appeared normal, his conjunctiva was diffusely injected, and he had nummular stromal opacities scattered about the cornea, associated with 2+ cell and flare of the anterior chamber.

At the slit lamp, discrete corneal lesions were observed.

Some were superficial, others very deep, and each lesion was associated with a small, linear refractile structure. One of these structures perforated the posterior cornea and was associated with keratic precipitate on the endothelium, Mark J Mannis MD told the American Academy of Ophthalmology 2017 Annual Meeting in New Orleans, USA. Having seen similar cases, Dr Mannis suspected ophthalmia nodosa. First described by Saemich in 1904, it is caused by setae – fine, sharp spines or hairs – launched by some caterpillars and spiders to discourage potential predators. The spines measure from 0.06mm to 1.5mm, are coated with irritating proteins and have microscopic barbs that prevent them from backing out once they are embedded in tissues. In the eye, rubbing and movement of the globe propel the spines deeper, potentially into the anterior chamber, iris, lens, vitreous or even the retina.

So Dr Mannis asked some pointed questions – and the patient revealed he had a pet tarantula. “Interestingly, his name was Blade,” Dr Mannis said.

GROWING THREAT Tarantulas are an increasingly common household pet, said Dr Mannis, of the University of California – Davis Eye Center, Sacramento, California, USA. Many varieties, particular non-venomous species as large as 30cm in diameter from Mexico and Brazil, defend themselves by rubbing their legs across their dorsal abdomen, spraying clouds of barbed hairs into the air. As a result, ophthalmia nodosa is increasingly seen.

Ophthalmic manifestations include conjunctivitis, localised or diffuse keratitis, iridocyclitis and even chorioretinitis and endophthalmitis. Natural history generally progresses from initial reaction to a quiescent interval, followed by resolution or advancing to iritis and keratoconjunctivitis, with periodic recurrences, Dr Mannis said (Watson PG, Sevel D. BJO 1966; 50:209-217).

Treatment consists of observation and topical corticosteroids, Dr Mannis said. Outcomes are variable, ranging from spontaneous resolution leaving behind small corneal scars, to chronic iritis, granuloma formation or even phthisis bulbi.

“My advice to the clinician is, take a careful history and know what your patient is exposed to. My advice to the patient is – get a dog,” Dr Mannis concluded.

Mark J Mannis: mjmannis@ucdavis.edu

EUROTIMES | APRIL 2018

SPECIAL FOCUS: CORNEA

STEROIDS FOR KERATITIS? Early use might help in worst bacterial cases; avoid for nonbacterial ulcers. Howard Larkin reports

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oncern that corticosteroids may slow healing or worsen infections has made their use in treating corneal bacterial ulcers controversial for decades. But with up to one-quarter of bacterial keratitis patients ending up with <20/200 best corrected visual acuity, controlling scarring is also critical. Recent research suggests corticosteroids may be useful for treating the worst bacterial corneal ulcers and are most effective when used early, Thomas M Lietman MD told the American Academy of Ophthalmology 2017 Annual Meeting in New Orleans, USA. In the Steroids for Corneal Ulcers Trial (SCUT) conducted

by Dr Lietman and his team at the University of California – San Francisco, USA, Dartmouth-Hitchcock Medical Center in New Hampshire, USA, and Aravind Eye Hospitals in India, 500 patients with culture-confirmed bacterial keratitis were treated with moxifloxacin for 48 hours, and then received either 1.0% prednisolone phosphate or a placebo on a tapering dose.

Overall, mean visual acuity at three months was nearly equal in the treatment and placebo arms, with the treatment group less than one letter better, Dr Lietman reported. The only significant differences in adverse events were minor, with more steroid patients experiencing late re-epithelialisation (P=0.04), and, contrary to expectations, more placebo patients experiencing IOP spikes (P=0.04) (Arch Ophthalmol. 2012 Feb;130(2):143-50).

STEROIDS ADVANTAGEOUS IN SOME CASES By organism, patients with pseudomonas infections in the steroid group had about one-half line better visual acuity with steroids, though the difference was not significant, while those with nocardia infections had about one line worse than placebo at three months. Removing nocardia cases from the mix, the steroid group overall had significantly better visual acuity at one year than the placebo group, Dr Lietman said.

Patients with the most severe ulcers, whether measured by visual acuity of <20/400, ulcer depth or central location, did 1.7 lines better with steroids (P=0.03). Patients who began treatment at 48 hours after antibiotics were initiated also did better by 1.1 lines (P=0.01) than a subgroup that started 72 hours or more after antibiotics.

“So that case that we’d all be scared of, that central pseudomonas ulcer, may be exactly the case where you want to use steroids, and you might want to add them early,” Dr Lietman said.

Dr Lietman cautioned that all SCUT cases were proven bacterial in culture, and had no evidence of fungal, acanthamoeba or herpes involvement.

“If you use steroids and it’s not bacterial you can get in trouble. But if bacteria grow on culture I think you can feel comfortable using steroids; or if you don’t want to you can defend that, too.”

Thomas Lietman: tml@itsa.ucsf.edu EUROTIMES | APRIL 2018

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CATARACT & REFRACTIVE

PHACOEMULSIFICATION IN SMALL EYES Everything you ever wanted to know about phacoemulsification in small eyes â&#x20AC;&#x201C; Part 2: Hyperopic eyes Soosan Jacob MD reports n the last issue, small eyes secondary to microphthalmos and relative anterior microphthalmos (RAM) were discussed, as well as surgical techniques for small eyes. In this issue we deal with hyperopic eyes, as well as IOLs for small eyes. The axial length is small and the anterior chamber depth is normal in axial hyperopia. It differs from RAM, where the axial length is normal and the anterior chamber depth is small. Phacoemulsification can generally be carried out using normal techniques but with extra care.

Surgery can be done for cataractous hyperopic eyes or alternatively as clear lens extraction for correction of refractive error.

Hyperopic patients have always had to use spectacles to see clearly for both distance and near. Therefore, they are generally very happy with the results.

CLEAR LENS EXTRACTION This is a good choice in older hyperopic patients who have already started to lose accommodation. In this age group, it has numerous advantages over keratorefractive procedures â&#x20AC;&#x201C; it is not associated with problems of regression and higher powers can be corrected with good predictability and fewer aberrations. Surgery is generally easy as the nucleus is soft and can easily be hydroprolapsed out of the capsular bag and aspirated. The risks of an intraocular procedure should be kept in mind, however, and surgery should proceed with all due precautions taken.

Loss of accommodation is a major drawback, and one of the reasons why it is less popular in younger age groups. If opted for, the patient should be counselled appropriately preoperatively. In case of high hyperopia, customised IOLs may need to be ordered or piggybacking of IOLs may be used.

IOL POWER CALCULATION Most eyes have an axial length between 22 and 24.5mm, and third-generation formulas EUROTIMES | APRIL 2018

Relative dimensions of A: Normal eye; B: Microphthalmic eye with small anterior segment and short axial length

such as the SRK-T, Holladay 1 and Hoffer Q estimate IOL power satisfactorily in these eyes. This is because the effective lens position (ELP) is predictable in eyes that fall within this range. However, this is not the case in shorter and longer eyes, which require special formulas. IOL power calculation in these eyes can be associated with a greater degree of error.

Small errors in axial length measurements can get magnified while calculating IOL power in small eyes. Accurate measurements may be difficult with ultrasound biometric machines as these are calibrated for normal eyes with fixed anatomical proportions. In microphthalmic eyes, the normal-sized lens takes up a larger volume in the small eye.

Theoretical formulas may be more accurate; however, most still err towards some residual hyperopia.

Measurement of axial length and prediction of ELP is very important and repeated measurements should be taken carefully. Immersion and optical biometry can be used. A relatively anteriorly placed effective lens position can lead to errors in calculation and the Holladay 2, Haigis and Hoffer Q formulas are better relied upon.

It is advisable to calculate using different formulas and lean towards the Hoffer Q in deciding final IOL power. Intraoperative aberrometry (ORA Inc, Wavetec Vision) can also be useful.

CHOICE OF IOL For lower degrees of hyperopia, standard choices may be made, but higher degrees require special IOLs. These can be either in the form of customised IOLs of high power or piggybacking of two IOLs. Piggyback lenses with the higher-powered one in the bag and the lower-powered one in the sulcus are reported to give lesser spherical aberration than a single IOL with very high power. Placing two IOLs in the bag should be avoided, as this can lead to interlenticular fibrosis, decrease in vision and late hyperopic shift. It should be remembered, however, that many of these small eyes may not have enough space or may not tolerate two IOLs with resultant crowding, uveitis-glaucomahyphaema syndrome etc. Also, interlenticular membranes may still develop even with one IOL in the bag and another in the sulcus, and even if made of different materials.

If piggybacking is opted for, many surgeons prefer implanting the maximumpowered IOL that is available in the bag.

The piggyback IOL can be done in a second stage after assessing postoperative refractive result. The power may be calculated by using the Gills nomogram: {(1.5 x Spherical equivalent) +1}. Acrylic IOLs have higher a refractive index and are thinner than both PMMA and silicone, and are therefore preferred to be placed in the bag.

CATARACT & REFRACTIVE preoperatively by vitreous dehydration, and intraoperatively by doing a limited dry vitrectomy. Loosening the lid speculum also helps decrease positive pressure.

FEMTOSECOND LASER-ASSISTED CATARACT SURGERY (FLACS)

C: Relative Anterior Microphthalmos (RAM) with small anterior segment and normal axial length; D: Axial Hyperopia: normal anterior segment and short axial length

The piggyback IOL that is placed in the sulcus should be thin and non-reactive.

Silicone IOL is a good option for this.

Hyperopic eyes may have a large-angle kappa, and multifocal IOLs should be avoided in such eyes.

SHALLOW AC A shallow anterior chamber can occur secondary to hypermetropia, primary angle-closure glaucoma, anterior rotation of the ciliary body, lax zonules allowing anterior movement of the lens such as pseudoexfoliation etc. It can also occur as part of microphthalmos and relative

anterior microphthalmos, which were discussed in the last issue. In cases of narrow-angle glaucoma, the large lens, small pupil and shallow AC all contribute to difficult phacoemulsification. However, cataract extraction with IOL implantation generally treats the condition by decreasing overcrowding of the anterior segment and letting the iris fall backwards. This opens the angle and treats the glaucoma as well.

Instilling viscoelastic will instantaneously deepen the AC in diffuse zonulopathy, leading to a shallow AC, whereas it may result in increased IOP and possibly iris prolapse in other cases. Positive pressure leading to a shallow AC can be tackled

ESCRS

Practice Management

& Development

FLACS can be very useful in shallow anterior chambers where there is less space to manoeuvre. Longer tunnels should be programmed and positioned carefully to prevent iris prolapse. A femtosecondcreated rhexis decreases the chances of a runaway and is a major advantage.

Pre-treatment of a dense nucleus with femtosecond can break the nucleus into smaller fragments, thus making removal easier and thereby decreasing possible endothelial damage.

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

Scan this QR code to view the live surgery

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22–26 September 2018 Vienna, Austria

ESCRS Practice Management and Development Marketing Case Study Competition Submission Deadline Monday 30 July 2018

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EUROTIMES | APRIL 2018

11

CATARACT & REFRACTIVE

12

Image courtesy of Casper Tybjerg

Delegates at the 22nd ESCRS Winter Meeting in Belgrade, Serbia, practise the sky stretch as instructed by Stig Severinsen

STOP – BREATHE – THINK Conscious breathing can help anyone battling stress in the operating room, according to Stig Severinsen. Aidan Hanratty reports

T

he key to relaxation is in the exhalation. This was the main point made by freediving champion, Guinness World Record holder and expert in ‘Breatheology’, Stig Severinsen. He was speaking at a symposium “Keep Calm: Stress Management During Cataract Surgery” organised by the Young Ophthalmologists Committee as part of the 22nd ESCRS Winter Meeting in Belgrade, Serbia.

Severinsen has a background in biology (specifically marine biology and neurophysiology) and medicine – his PhD was on inner ear hair cell regeneration on mammals and humans – and has gone from freediving and breath-holding to offering courses and lectures on efficient breathing and mental training. This is for anyone from Olympians and CEOs to Navy SEALs and sufferers of posttraumatic stress disorder.

As he writes in his book Breatheology: The Art of Conscious Breathing: “The ability to relax ‘on command’ and overcome or completely avoid stress and the accompanied improved mental control and confidence are gifts that help in all parts of life.” This is particularly relevant for cataract surgeons who may be placed under stress in their early surgeries.

Severinsen’s younger brother Martin is a cataract surgeon and a member of the Young Ophthalmologists Committee.

Introducing his brother in Belgrade, he gave an example of a stressful situation that may arise in a cataract operation. While his trainee was performing a capsulorhexis, the patient started coughing. The trainee managed to keep a steady hand and Dr EUROTIMES | APRIL 2018

Severinsen helped him finish the procedure.

What would the elder Severinsen recommend in such a situation? “If you feel something's going wrong, just stop what you're doing. Sit Up. Breathe for a moment and just hold your breath for about two seconds, maybe five seconds.

“When we stop and when we hold our breath, even for a few seconds, the brain opens in a different way. When you have experience and you control your mind then you come up with a solution.”

Speaking to EuroTimes after the event, he recommended the following: “Stop – Breathe – Think.”

Another tip he suggests is what he calls 1:2 breathing. This consists of exhaling for twice as long as you inhale. “You decide how long your inhale is, and then exhale through the mouth, but double the time.

Feel what's going on in your body.”

Methods like this help to activate the vagus nerve or 10th cranial nerve, which spreads out all over the body, connecting the brain to your heart, lungs, glands and more. “With the vagus nerve activation, there is more empathy, there is more collaboration, and you become more reflective and more open minded.”

In what may have been a first for an ESCRS Meeting, Severinsen invited the audience to stand up and partake in exercises to strengthen and improve breathing and breath holds. One was the sky stretch, which involves stretching one arm as high up above your head as possibly while breathing in, holding and then exhaling. Another involved breathing in, pulling your shoulders back, bending your knees and then reaching forward like a cat.

Vasilios F Diakonis MD, PhD, was part of the Young Ophthalmologists Committee that invited Severinsen to speak. For this Meeting he and the team wanted to host an unusual or “out-of-the-box” symposium, one that would still be relevant to young surgeons. “We make mistakes in surgery, we need to learn to correct our mistakes, we need to learn to prepare ourselves in order to decrease the mistakes we make etc., but at the same time besides skill and knowledge there is a physical component that most of us deal with, especially early in our carriers, which is stress during surgery.”

Having met Severinsen at the ESCRS Congress in Barcelona in 2015, he was a natural choice. “I believe that everyone in the audience enjoyed the talk as they performed exercises under Stig’s instructions, not a common phenomenon from a group of scientists during a scientific meeting.”

Severinsen spoke highly of the people he met in Belgrade, noting the high level of engagement and enthusiasm demonstrated by everyone during the breathing and relaxation exercises. His takeaway message was that doctors seemed to be willing to use breathing, meditation, mindfulness, imagery and relaxation as complementary ‘tools’ to improve both surgical results and a better and deeper connection with themselves, their team and even their patients.

“The mind is very difficult to control.

That's why we have stress. Stress leads to panic. Panic will always lead to bad decision making,” Severinsen said. “When the breath is calm, the mind too will become still.”

CATARACT & REFRACTIVE

OCULUS Pentacam®

Please note: The availability of the products and features may differ in your country.

Specifications and design are subject to change. Please contact your local distributor for details.

EVOLUTIONS IN SURGERY Corneas happier with SMILE than with excimer laser procedures.

Roibeard Ó hÉineacháin reports

S

mall-incision lenticule extraction (SMILE) appears to be a step forward from LASIK in the evolution of corneal refractive surgery. This is because it has greater respect for the cornea’s biomechanical and neuronal integrity, is less traumatic to the lamellar tissue and induces a less vision-compromising healing response, asserts Leonardo Mastropasqua MD, University of G d’Annunzio, Chieti-Pescara, Italy.

Although excimer laser corneal refractive procedures have advanced since their introduction, many drawbacks remain.

In the case of PRK, regression and haze are still an issue. For LASIK, flap creation alone causes biomechanical changes in the cornea that can lead to ectasia and it also severs the nerves of the ocular surface, leading to dry eye and other flap-related complications, Dr Mastropasqua told the XXXV ESCRS Congress in Lisbon, Portugal.

“Small-incision refractive lenticule extraction has the advantage over PRK of being intrastromal and therefore less likely to induce haze. And unlike LASIK, it is flapless and the entire procedure can be performed with the same laser,” Dr Mastropasqua said.

In addition, research has shown that collagen destruction and cell damage is minimal in femtosecond laser-created lenticules in the areas adjacent to the laser cut. Studies also suggest that SMILE induces less inflammation and extracellular matrix deposition than excimer laser procedures, especially at high refractive corrections, Dr Mastropasqua said.

NEW! Belin ABCD Progression Display

Keratoconus Progression Now Included !

BETTER BIOMECHANICAL STABILITY SMILE also has much less impact on biomechanical integrity than LASIK, he noted. The resistance to deformation following LASIK is dependent on the thickness of the residual stromal bed, but after SMILE the residual stromal bed starts from Bowman’s membrane. Therefore, the deformation aptitude index is only slightly modified after SMILE for high myopic correction when tested with a Scheimpflug-based non-contact tonometer.

He added that in vivo findings suggest that there is significantly less nerve loss after SMILE than after flapbased techniques and that SMILE is associated with quicker nerve regeneration. This may account for reduced dry eye symptoms reported in SMILE-treated corneas.

BEYOND SMILE Looking ahead, Dr Mastropasqua noted that the less traumatising impact of the femtosecond laser also allows the possibility of implanting of lenticules from other corneas for refractive correction and the treatment of keratoconus.

In a trial involving 10 eyes of 10 severe keratoconus patients that he and his associates conducted, preliminary results showed that lenticule implantation induced a significant flattening of anterior corneal central areas and an increase of corneal thickness that correlated consistently with the implanted lenticules with thickness and diameter.

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Leonardo Mastropasqua: mastropa@unich.it EUROTIMES | APRIL 2018

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CATARACT & REFRACTIVE

EARLY DAYS OF PHACO Richard Packard talks about the early days of phacoemulsification in Europe. Aidan Hanratty reports

T

o mark 50 years since the birth of phacoemulsification, EuroTimes spoke to Richard Packard, who got in at the ground floor of phaco in the 1970s. Starting at Charing Cross Hospital in London, he observed a course in phaco and lens implantation, and he describes this as his “road to Damascus” moment.

“Before that I had been planning to do ocular oncology, I’d done my MD thesis on choroidal melanoma, and that went out the window straight away.” By the following month he had performed his first phaco surgery.

Machinery in those days was both crude and expensive. Dr Packard said that back then, a phaco handpiece had something attached to it that was called the grey lead. This was sterilised in a disinfectant called Cydex, not in an autoclave. “It was left there for 15 minutes and you had to remember to stick the rubber bung in the end, because if the Cydex got inside the grey lead then that was basically the end of that particular handpiece. And they were £3,000 pounds apiece.” That was on top of the roughly £25,000 each machine cost, which is a much higher relative cost than machines in use today.

The early machines had no linearity of power delivery – this meant that as you passed into foot pedal position 3 the full power came on. The machines did not tune the handpieces for you either. “The nurse stood there listening to the device until

First folded IOL in a rabbit eye

Test for phaco learners

EUROTIMES | APRIL 2018

you got to the right pitch, and you’d say ‘Oh! that’s it!’” The arrival of linearphaco power with the Coopervision 9001 machine was, in Dr Packard’s words, “a revelation”.

While he missed the very beginning of phaco itself, Dr Packard was right there for the advent of foldable lenses.

Charles Kelman teaching an early course He worked with Mr Eric Arnott, the European phaco pioneer, undertaking a study on implanting these lenses in rabbits. “We wrote that up and sent it off to the American Intraocular Implant Society journal, who rejected it, because they said that even though the professor of pathology at the Institute of First phaco Ophthalmology was doing the pathology it wasn’t adequate. It was accepted by not getting as good as we could in terms of the British Journal of Ophthalmology predicting the outcome.” unchanged and immediately published.”

Further, he believes that advances in He had been advised against working microelectronics will eventually lead to the with Mr Arnott, his bosses at Moorfields production of a lens that will be able to High Holborn saying he would “ruin his mimic accommodation. While cataracts career” in doing so. “Being young and may eventually be prevented, in some way foolish I decided to carry on, and we were or another, presbyopia will not go away, proved right!” and so people will need still need some sort Along with foldable lenses, Dr Packard of accommodative lens. No matter how feels that the enthusiasm of younger doctors advanced the technology gets, however, he was vital for the success of phaco. “The doesn’t believe that robotics will replace the senior registrar grade could see what was surgeon in the operating room. happening elsewhere and they were pushing “Patients are patients, and you can’t their bosses to do this.” These doctors necessarily predict the way that their tissues would take their newly acquired skills and are going to behave. The other issue is that then train their superiors in the procedure, if there is a problem during surgery, even if leading to broader uptake. you’re a robot, your ability to adapt to the Asked about what he saw in the future situation that you find yourself in is going for cataract surgery, Dr Packard believes to be quite difficult.” The job of the surgeon capsulotomy is key. “Having an accurately is safe, for now, he believes. In other words: placed capsulotomy combined with a “A very long time after I retire.” lens that makes use of the capsulotomy will get us much closer to predicting the This article is based on a EuroTimes Eye effective lens position. Because with all Contact interview. See player.escrs.org/ the wonderful formulae that we have and eurotimes-eye-contact/fifty-years-of-phacoWarren Hill’s big data and so on, we’re still richard-packard

Courtesy of Richard Packard MD

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CATARACT & REFRACTIVE

PHACO PIONEERS Patrick Condon discusses early meetings with pioneers Charles Kelman and Eric Arnott and his own experiences with the phaco. Aidan Hanratty reports

L

Courtesy of Richard Packard MD

ast year marked 50 years since the dawn of phacoemulsification, the operation that changed the face of cataract surgery.

Speaking to Paul Rosen FRCS, FRCOphth, at the XXXV ESCRS Congress in Lisbon, Mr Patrick Condon from Waterford, Ireland, detailed his early meetings with Dr Charles Kelman, who developed phaco in 1967.

“He flew out from Manhattan in his own helicopter, from his private practice in the top of the Empire State Building. I met him at the operating room, having gone out to his hospital by train from my hotel, and saw him do this wonderful surgery.”

Dr Condon recalls that once the surgical list was complete, Dr Kelman went to each patient one by one asking how they were feeling and making sure they had their appointments within him the following day.

“It was really a new way of looking after patients immediately postoperatively.”

Dr Kelman then brought Dr Condon back to Manhattan in his helicopter, but on the way overflying several golf clubs to check which course would be playable the following day.

The Waterford surgeon was also Mr Eric Arnott’s first surgical assistant, when he worked at the Royal Eye Hospital group in London. Eric Arnott was an Anglo-Irish ophthalmic surgeon who spearheaded the introduction of phaco in Europe. The first live surgery phaco was carried out by Eric in the New Charing Cross Hospital, London.

Following a succession of attending courses internationally, in 1984 Condon brought phaco to Ireland, where he ran his own

had a foldable silicon lens that could be put courses as a consultant in University through a small incision that phaco really Hospital Waterford, bringing over eminent took off, and it was after that, that things guests such as Kelman and Arnott, as well as started to happen.”

Dermot Pierse, Peter Choyce and Bill Looking to the future, Dr Maloney and many other wellCondon wondered what, if known surgeons involving anything, might overtake live surgery. phaco. He himself had At first, many surgeons his cataracts removed in Europe were with femtosecond extremely sceptical laser-assisted surgery. of phaco, having Despite it being his heard horrific stories personal choice, he involving damage doesn’t see it taking to the endothelium over completely at and dislocation of this moment in time. nuclear fragments “Looking at the into the vitreous: so ESCRS studies, and much so, that a motion being very friendly with put forward at one of the late Peter Barry, who the UK Implant Society was involved in looking meetings by Dr Condon at it statistically through recommending “phaco be EUREQUO, the mechanics of taught to junior doctors as part Eric Arnott it – [femto] is far too complicated, of their training”, generated heated especially when phaco is so good, and the discussion but was finally passed by just one operation itself has become so cheap to do. vote. “We didn’t have social media at that The technique is relatively easy now, so I stage, but if we did, I think it could have think it’s going to be very difficult for femto upset the uptake of phaco significantly!” to take over.”

Needless to say, the changeover from As an early adopter of such other special extra-capsular to phaco was not easy, in that: surgical methods as Automated Lamellar “The pump systems were not sophisticated Keratoplasty (ALK) and subsequently enough, one of the big problems being LASIK, which was started by him in anterior chamber collapse – if you hit a Dublin in conjunction with Professor very hard piece of nucleus, the build-up of Michael O’Keeffe in 1993, Dr Condon was the suction in the tubing was so great that always keen to learn new technology. At when it released itself you had a sudden the ESCRS conference in Lisbon recently, collapse.” Inspired by the late Dr Michael he mentioned a discussion he overheard Blumenthal, Dr Condon made use of an regarding “nano-phaco” which is a different anterior chamber maintainer to avoid form of energy in which there is no heat this side-effect. This involved the use of release and no ultrasound involved, and a double infusion, one for the irrigationwhich may be a possible replacement for aspiration line phaco in the future. and one for the “I say ‘Let us know about this, let’s anterior chamber hear some more!’ That’s why we come maintainer.

“I to these meetings, because it generates still continued to people with brilliant ideas and excitement use Blumenthal’s about new products.” anterior chamber His great hope for the future is that even after ophthalmologists continue to work hand viscoelastics in hand with pharma companies, as they became the norm.” have done to date, so that these companies Another major can develop more sophisticated gadgets and step towards machines to make life easier for the patient the widespread at the end of the day. acceptance of the procedure was This article is based on an EuroTimes Eye the development Contact interview. See http://player.escrs. of foldable org/eurotimes-eye-contact/50-years-ofintraocular lenses. phaco-paddy-condon “It wasn’t until we

Eric Arnott operating during phaco course

EUROTIMES | APRIL 2018

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CATARACT & REFRACTIVE

PHAKIC IOLS

A

Where is best place for a phakic IOL? Anterior or posterior chamber? Roibeard Ó hÉineacháin reports

nterior chamber and iris-fixated phakic IOLs have been shown to produce good visual outcomes in ametropic patients. The question of which is safer for the eye was debated at the XXXV Congress of the ESCRS in Lisbon, Portugal.

Rudy MMA Nuijts MD, University Eye Clinic, Maastricht, said that he favours the iris-fixated anterior chamber lenses, the Verisyse/Veriflex (Ophtec), also coined Artisan/Artiflex (AMO) lenses.

He noted that eyes with the lens generally have a rate of endothelial cell loss well within safety limits, and unlike the posterior sulcus-positioned ICL, pose minimal risk of inducing a cataract and have no sizing issues.

In his own cohort of 379 myopic Artisan cases with up to 10 years’ follow-up, there also was annualised endothelial cell loss of only 1.4% (figure 1). That is roughly twoand-a-half times the normal physiological loss of 0.6% per year.

In terms of long-term refractive predictability, 46.2% were within half a dioptre of the attempted correction after five years, and that decreased to 23.1% after 10 years. Similarly, 68.4% were within one dioptre after five years, and that decreased to 47.9% within one dioptre after 10 years.

That translates into a loss of one line in uncorrected distance visual acuity after five years and two lines after 10 years.

The myopic change in refraction probably results from nuclear sclerosis in patients’ crystalline lens.

The endothelial cell loss was a little bit higher in a cohort of 293 eyes implanted with the Artiflex lens, reaching 10.5% after five years, amounting to an annualised loss of 1.94%.

On the other hand, in this younger group of patients, postoperative refraction changed by a mean of only 0.14D at five years. In addition, two-thirds were within 0.5D of attempted refraction at five years and 88.7% were within 1.0D. That translates to a loss of only half a line of UDVA. He noted that out of 1,196 phakic IOL implantations at his centre there were 120 explantations, a rate of roughly 10% (figure 2). Of these, 57% were due to cataract and 28% were due to endothelial cell loss.

He noted that among patients who received the Artisan for myopia, 63% of explantations were due to cataract formation and 28% were due to endothelial cell loss.

However, among those who received the lens for hyperopia, explantations were due to endothelial cell loss in 67% and due to cataract in 22%.

EUROTIMES | APRIL 2018

ICL PROBLEMS Concerning the Visian ICL (Staar), Dr Nuijts noted that the lens has gone through many changes over the years, with an increase in the vault of the lens to prevent anterior subcapsular cataract formation and, most recently with a hole in the centre of the optic and in the haptics to prevent pupillary block and eliminate the need for laser iridotomy.

He noted that in published series of patients implanted with the V4 ICL the incidence of cataract has ranged from 0 to 18.9%. That in turn raises the risk of retinal detachment, particularly among myopic patients.

The ICL also has sizing problems. An oversized ICL can result in pupillary block due to closed iridectomies, and pigment dispersion, Dr Nuijts pointed out.

The traditional way to estimate sulcus size is to measure whiteto-white diameter. However, many studies have shown that there is no correlation between the two parameters. Ultrasound echography may provide a better measure of sulcus diameter, he said.

He also pointed out that the rates of endothelial cell loss with the ICL range from 0.1 to 27.4%. In the FDA studies the rate has been about 1.5 to 2.3% per year.

IN FAVOUR OF THE ICL Taking the opposing view, Roberto Zaldívar MD, Argentina, cited the increasing popularity of the lens as proof of its superiority. He noted that between 2006 and 2015 the use of ICL grew by 17% per year, a trend that still continues. In fact, the ICL now accounts for nine of every 10 phakic IOLs implanted.

“The reason behind the popularity of the lens is that although we have had problems with the lens we have always tried to solve

Long-term endothelial cell loss

Courtesy of Rudy MMA Nuijts MD

16

Incidence of phakic IOL explantations

them through improvements in the design,” Dr Zaldívar said.

He noted that the improvements in vaulting and the holes in the in the optic and haptics appear to have reduced the incidence of cataract and pupillary block.

He cited a study by José Alfonso MD, Spain, which showed that in 1,531 eyes implanted with the V4a ICL from 2002 to 2008, the incidence of cataract was 1.35%.

However, there were no instances of cataract in 1,108 eyes implanted with the V4b from 2008 to 2011, and 1,957 eyes implanted with the V4C ICL from 2011 to 2017.

He added that in his own series of 186 eyes implanted with the V4c ICL, intraocular pressure has remained stable and endothelial cell counts have remained virtually unchanged throughout three years of follow-up.

Rudy MMA Nuijts: rudy.nuijts@mumc.nl Roberto Zaldívar: zaldivar@zaldivar.com

CATARACT & REFRACTIVE

JCRS SYMPOSIUM JCRS HIGHLIGHTS VOL: 43 ISSUE: 12 MONTH: DECEMBER 2017

COMPARING LASIK APPROACHES FOR MYOPIC ASTIGMATISM A retrospective study of 128 patients compared vector planning with manifest refraction planning for the treatment of myopic astigmatism. At a six-month follow-up, researchers observed no significant differences between the two groups in terms of difference between corrected distance visual acuity and uncorrected distance visual acuity (UDVA) and postoperative UDVA. Significant differences were observed between the two groups in terms of achieved spherical equivalent, corneal toricity and ocular residual astigmatism. Vector planning helps in retaining the natural corneal shape after refractive surgery without inducing manifest refractive astigmatism. MC Arbelaez et al., JCRS, “Clinical outcomes of laser in situ keratomileusis with an aberration-neutral profile centred on the corneal vertex comparing vector planning with manifest refraction planning for the treatment of myopic astigmatism”, Volume 43, Issue 12, 1504–1514.

Controversies

in Anterior

Segment

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

FEMTOSECOND INCISIONS FOR CATARACT SURGERY Researchers reviewed surgical videos to compare the expected versus actual position and dimension of corneal incisions during femtosecond laser-assisted cataract surgery. The primary incision internal and external exits were within 142μm ± 70 and 151 ± 75μm of the planned position. The dimensions and position did not correlate with biometric variables. However, the superior secondary incision external exit was displaced centrally (321 ± 84μm) and the internal exit was displaced peripherally (84 ± 102μm). The inferior secondary incision external exit was displaced centrally (278 ± 142μm) and the internal exit was displaced peripherally. Eye tilt and eccentric docking influenced the position of the secondary incisions. C Baal et al., JCRS, “Factors affecting corneal incision position during femtosecond laser–assisted cataract surgery”, Volume 43, Issue 12, 1541–1548.

Moderators:

Nick Mamalis, MD Sathish Srinivasan, MD

BEST WAY TO MEASURE LENS DENSITY? A prospective case series of 110 eyes (51 with cataract and 59 controls) assessed a new objective cataract grading method based on lens densitometry on swept-source optical coherence tomography (SS-OCT) scans provided by the IOLMaster 700. This proved to be a reliable technique to grade cataract severity. In eyes with an average lens density greater than 82.9 pixel units, surgery might be discussed if a patient has visual impairment.

The average lens density strongly correlated with previously validated objective methods such as objective scatter index and nuclear staging measurements. An automated measurement of the average lens density on SS-OCT scans provided by the IOL measuring device would allow for assessing cataract severity to help surgeons to make surgical decisions in controversial cases.

C Panthier et al., JCRS, “New objective lens density quantification method using sweptsource optical coherence tomography technology: Comparison with existing methods”, Volume 43, Issue 12, 1575–1581.

THOMAS KOHNEN European editor of JCRS

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

EUROTIMES | APRIL 2018

17

18

RETINA

Visualising

THE FUTURE From micro-incision vitrectomy surgery to digitally assisted vitreoretinal surgery. Intraoperative vitreoretinal imaging: the future is now. Sean Henahan reports

D

igital imaging technologies now entering the clinic represent a revolutionary step forward that will allow vitreoretinal surgeons an unprecedented degree of threedimensional resolution and depth of focus. EuroTimes gets a close-up look at intraoperative digital imaging techniques now in use and those in the pipeline.

The development of digitally assisted vitreoretinal surgery (DAVS) follows up on tremendous innovations in micro-incision vitrectomy surgery (MIVS) developed by pioneering surgeon Claus Eckardt. Those developments led to faster and more efficient surgery and better outcomes compared to what came before.

Digital visualisation systems involve special high-resolution 3D video cameras attached to the traditional operating microscope. The camera feeds images to a large, high-resolution 4K OLED flat-panel EUROTIMES | APRIL 2018

display. The surgeon and team members wear 3D glasses or head-mounted displays while watching the display.

TrueVision 3D Surgical was a pioneer in intraoperative ophthalmic digital imaging.

It found its first applications in anterior segment surgery some 10 years ago. The intervening years have seen a steady improvement in resolution and depth of focus. This culminated in an agreement with Alcon, leading to the NGENUITY 3D Visualization System (Alcon).

“The ability to do vitreoretinal surgery with TrueVision at the kind of resolution we need has been fairly recent. I’ve been using it exclusively for three years now.

“I like it for many reasons. It is a tremendous teaching tool, and the entire staff is in tune with you. I also like that everything is bigger, the resolution is better, the depth of focus is better, you are always in focus as you operate,” Pravin Dugel MD, Retinal Consultants of Arizona, Phoenix, US, told EuroTimes.

Digital visualisation allows the surgeon to do some things not possible before.

For example, it is possible to reduce the amount of illumination significantly during surgery, sparing the retina any unneeded light exposure. Digital manipulation can also help in cases of vitreous haemorrhage and other situations where colour filtering can improve visualisation.

Proponents of 3D visualisation systems also cite the importance of ergonomics.

The surgeon is relieved of the constant stress on neck, back and shoulders that accompany the use of conventional operating microscope over a lifetime.

“This is very important. This is a major cause of morbidity for our profession. If you are able to do your surgery while not being in pain, you will likely do a better job, and likely have a longer career,” commented Dr Dugel.

Another 3D imaging system, developed

by Sony, also allows the surgeon to capture, record, and display 3D video during ophthalmic microsurgery. The system includes a HD 3D camera system, a 3D/2D video recorder and 4K highresolution monitors.

RETINA

19

Courtesy of Perry Athanason/Retinal Consultants of Arizona

Pravin Dugel using the TrueVision 3D operating system. Heads-up surgery (far left); 3D projection on a television (below)

The world of intraoperative retina surgical imaging is evolving rapidly. A new system, BeyeOnics, borrows from the heads-up displays used by fighter pilots.

This brings a level of augmented reality, as the surgeon wears a head-mounted helmet that provides an operating image, as well as overlays of OCT and other information.

This new approach offers several advantages, according to Anat Loewenstein MD, Professor of Ophthalmology, Sackler Faculty of Medicine, Tel Aviv University, Israel. Firstly, it is more comfortable, since the surgeon’s head does not need to be attached to the microscope. Secondly, there is potential to see real-life input from OCT, fluorescein angiography etc., which would be of great benefit to the surgeon. Finally, having better resolution and the ability to control multiple parameters during surgery has many possible benefits for the surgeon, she told EuroTimes.

“We have performed several surgeries to evaluate image quality, comfort of use and basic functionality. After the surgeries’ success, this year we are now performing complicated surgeries like ERM peeling and retinal detachment.”

Indeed, Dr Loewenstein believes this approach represents a significant step forward from current technology.

“First, the displayed image adjusts to the positioning of the surgeon’s eye, providing high-quality central and peripheral images.

This eliminates the traditional microscopic pinhole view or the necessity to be fixed to a 3D monitor. The displayed image goes with the surgeon gaze direction, so no matter where I look at and no matter what is the orientation of the OR, I see a clear image. Due to the nature of the head display, the image that is displayed is true 3D the same as in a microscope, unlike 3D monitors,” she explained.

Due to the nature of the head display, the image that is displayed is true 3D the same as in a microscope, unlike 3D monitors Anat Loewenstein MD

The BeyeOnics system also has the capability to present an unlimited number of virtual screens. This makes it possible to see at the same time a large virtual display of the magnified image and next to it important data like patient retina imaging from OCT and other sources.

“Maybe the most important, the system provides the ability to overlay external data like OCT in real-time in the surgical field and incorporates digital icons that provide reference to position and orientation on the magnified image.

The technology tracking and real-time mapping will allow surgical tools to be visualised through blood and tissue, providing accuracy where the surgeon has no direct vision.”

“I have no doubt that the use of digital visualisation will become ubiquitous, in our field. We will look back and say this was a decisive time. We’re not going to be using analogue microscopes in the future.

Systems now in development will couple the imaging information with informatics, which will open up a new range of possibilities. This is just the beginning,” stressed Dr Dugel.

Pravin Dugel: pdugel@gmail.com Anat Loewenstein: anatl@tlvmc.gov.il EUROTIMES | APRIL 2018

18TH EURETINA

CONGRESS

VIENNA 20-23 SEPTEMBER

2018 Registration & Hotel Bookings www.euretina.org

RETINA

EURETINA IN BUDAPEST Winter Meeting focused on clinical studies and education.

90° Directional Laser Probes

Dermot McGrath reports

R

etinal specialists from around the globe converged on the banks of the Danube for the 8th EURETINA Winter Meeting, the first time that the meeting has taken place in Budapest.

Jan van Meurs, Chairperson of the EURETINA Winter Meeting, welcomed delegates to this historic European country for what he hoped would prove a lively and stimulating meeting.

“While traditionally the EURETINA Winter Meeting has focused on research-related topics, this time we are excited to put the spotlight more on clinical studies and education.

We have an excellent programme with a host of international experts to share their insights with us.

“I would like to extend our sincere thanks to the Hungarian ophthalmological community who have helped us at incredibly short notice in organizing this meeting,” he said.

Andrea Facskó, President of the Hungarian Society of Ophthalmology, said that she was honoured on behalf of her organisation to welcome more than 500 delegates to Budapest.

“This educational conference will provide a wonderful forum for you to refresh your knowledge base and explore innovations in diagnostic and therapeutic fields of the retina. The meeting will also offer plenty of networking opportunities and the opportunity to interact with leading scientists and researchers.

“Above all, the EURETINA Winter Meeting gives us the chance to discuss key points of scientific and professional policies and strategies, helping us to define how we should encourage responsible practice in our special medical field,” she said.

There were three Poster Prize Winners chosen from nearly 50 Posters. María Paz Santos Ramos from Spain was awarded third place for her presentation on “Early diagnosis of type I choroidal neovascularization in patients with exudative age-related macular degeneration by optical coherence tomography angiography”.

In second place was Aniko Balogh from Hungary, with a presentation on “Retinal vascular density in patients with exudative AMD after anti-VEGF therapy: An optical coherence tomography angiography study”.

In first place was Monika Ecsedy, also from Hungary, who focused on “Mineralokortikoid antagonist therapy biomarkers in patients with chronic central serous chorioretinopathy”.

A free paper session covered a range of topics from retinal artery occlusion and AMD to treatment options and Jan van Meurs MD postoperative care.

...the EURETINA Winter Meeting gives us the chance to discuss key points of scientific and professional policies and strategies...

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22

RETINA

DME PROGRESSION Predictors identified for progression in diabetic retinopathy help guide who needs treatment most. Dermot McGrath reports

T

he identification of diabetic retinopathy (DR) phenotypes characterised by different dominant retinal alterations and different rates of progression to clinically significant macular oedema (CSME) paves the way for more personalised management of diabetic retinopathy, according to José Cunha-Vaz MD, PhD. “If the patients with the greatest risk of progression and with the greatest potential to benefit from treatment can be identified, fewer patients will need to be followed closely to prevent vision loss from proliferative DR and diabetic macular oedema,” he told delegates attending the 17th EURETINA Congress in Barcelona.

Prof Cunha-Vaz, Emeritus Professor of Ophthalmology of the University of Coimbra, Portugal, said that DR is currently classified according to the ETDRS scale.

“This is the best and most recognised scale for classification of DR, and whatever new developments we have in this field we still have to refer to this gold standard. However, it does have some limitations – macular oedema can occur at any level and it is not included in the scale, so something more precise is needed to help us manage our DR patients,” he said.

Risk algorithms based on diabetic disease are helpful, but they don’t address the full picture, said Prof Cunha-Vaz, as there are different risks for vision loss in different patients with similar metabolic control and duration of disease.

“We have all seen diabetic patients with excellent metabolic control

who follow their physicians' instructions carefully and they may still develop CSME and potentially proliferative DR, whereas other patients who are less careful never go on to develop any macular vision-threatening problem. We definitely need more natural history studies to try to identify some of the possible causes,” he said.

Much of Prof Cunha-Vaz’s research in recent years has focused on trying to answer the question of why different patients with the same metabolic control and disease duration progress differently. Using non-invasive colour fundus photography and optical coherence tomography over repeated examinations yields a lot of valuable information, such as micro-aneurysm (MA) turnover, blood-retinal barrier (BRB) alteration and neuronal and glial damage, he said.

An initial prospective two-year study of 410 DR eyes confirmed clinical observations that micro-aneurysm turnover and central retinal thickness measurements were different in patients with comparable ETDRS levels, disease durations and metabolic controls.

Three different DR phenotypes with different risks for CSME were thereby identified: type A, ‘slow progression’, with absence or low levels of leakage and MA turnover; type B, ‘leaky’, with increased retinal thickness on OCT; and type C, ‘ischaemic’, with increased MA turnover and active remodelling of the retinal circulation.

POOLED ANALYSIS These results were further refined in a recent pooled analysis of four independent longitudinal DR studies involving a total of 882 patients with non-proliferative diabetic retinopathy (NPDR).

“It is important to bear in mind that this pooled analysis was based on four different studies involving mild NPDR eyes but having the same inclusion criteria, using the same methodology, and having the image analysis performed by the same reading centre,” said Prof Cunha-Vaz. Of the 882 eyes/patients that completed the studies, 103 developed CSME – 14 from phenotype A (14 of 466: 3.0%), 48 from phenotype B (48 of 164: 18.6%) and 41 from phenotype C (41 of 252: 16.3%). The patients from phenotypes B and C showed much higher risks for macular oedema development compared with phenotype A characterised by low MA turnover and no signs of increased RT, said Prof Cunha-Vaz. “This is of great relevance as phenotype A, representing approximately 50% of the mild NPDR patient population, shows a negative predictive value of 97% for the development of macular oedema,” he said.

This observation has important implications for the management of DR, added Prof Cunha-Vaz, as it suggests that a large proportion of eyes presenting initial stages of retinal vascular disease will progress very slowly, and those eyes are not likely to develop macular oedema for a period of at least two years. He said that this subtype of NPDR should, therefore, be excluded from clinical trials evaluating new therapies for DR because of its slow rate of progression.

...whatever new developments we have in this field we still have to refer to this gold standard José Cunha-Vaz MD, PhD EUROTIMES | APRIL 2018

José Cunha-Vaz: cunhavaz@aibili.pt

RETINA

OPHTHALMOLOGICA VOL: 293 ISSUE: 3

NEW GUIDELINES FOR INTRAVITREAL INJECTIONS This month’s issue of Ophthalmologica includes the updated EURETINA guidelines for intravitreal injections. Based on a review of the recent literature on the subject the article highlights important aspects of pre- and post-injection management and provides evidence-based suggestions for a standardised and structured approach. It includes suggestions regarding IOP spikes and patients with other ocular diseases or previous ocular surgery. It also includes discussions of the controversies regarding anaesthesia and antisepsis. A Grzybowski et al, “2018 Update on Intravitreal Injections: Euretina Expert Consensus Recommendations”, Ophthalmologica 2018, Volume 293, Issue 3.

BELTS AS GOOD AS SUTURES FOR SCLERAL BUCKLE PROCEDURE Installing scleral buckles using a belt loops sutureless technique appears to be as safe and effective as using a conventional scleral buckle suturing technique for repair of retinal detachment, with similar anatomic and functional outcomes, according to a new study. The retrospective consecutive case series study showed that successful anatomic attachment and appropriate buckle height were achieved among all 18 eyes treated with PPV and sutureless belt loops and all 17 eyes treated with combined pars plana vitrectomy (PPV) and scleral buckling. There was one case of re-detachment in each group during the follow-up. No cases of buckle infection, extrusion or intrusion were noted during the follow-up period. G Landa et al, “Sutureless Belt Loops versus Sutured Buckle Technique in Combination with Vitrectomy for Retinal Detachment Repair: A Comparative Analysis”, Ophthalmologica 2018, Volume 293, Issue 3.

31st International Congress of

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

Courses

➤➤ 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

Program:

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

www.doc-nuernberg.de

DEXAMETHASONE IMPLANT EFFECTIVE IN DME REFRACTORY TO ANTI-VEGF Repeated intravitreal DEX injections can bring about significant improvements in visual acuity and reductions in central retinal thickness in diabetic macular oedema (DME) patients refractory to anti-vascular endothelial growth factor (anti-VEGF) therapy, according to a new study. The two-centre retrospective case series included 40 eyes of 31 refractory DME patients treated with the DEX implant for at least two consecutive cycles. Best corrected visual acuity improved by a mean of 7.0 letters from baseline to month two (p < 0.001), and by a mean of 5.1 letters between the first and second cycles. In addition, mean central retinal thickness was reduced by 194µm two months after the first implantation and by -134 ± 150µm two months after the second implantation. K Hatz et al “Repeated Dexamethasone Intravitreal Implant for the Treatment of Diabetic Macular Oedema Unresponsive to Anti-VEGF Therapy: Outcome and Predictive SD-OCT Features”, Ophthalmologica 2018, Volume 293, Issue 3.

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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Street/No.

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Z

hi

Email-address

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

EUROTIMES | APRIL 2018

23

GLAUCOMA

CANALOPLASTY UPDATE Medium-term canaloplasty results show sustained IOP reduction.

A

Roibeard Ó hÉineacháin reports

b externo canaloplasty is safe and effective in lowering intraocular pressure in eyes with refractory open-angle glaucoma, with more than a third of patients who undergo the procedure likely to remain dropfree four years after surgery, said Paolo Santorum MD, San Maurizio Regional Hospital, Bolzano, Italy.

“Ab externo canaloplasty has an efficacy similar to that of trabeculectomy but with a better safety profile,” Dr Santorum told the XXXV Congress of the ESCRS in Lisbon, Portugal.

COMPARATIVE STUDY He presented a retrospective case series study that compared 58 eyes that underwent canaloplasty with 89 eyes that underwent trabeculectomy with mitomycin-C for primary open-angle glaucoma, Figure 1: Slit-lamp photograph of an eye with refractory pseudoexfoliation glaucoma, four years after canaloplasty. pigmentary glacuoma or pseudoexfoliation glaucoma No bleb is present, and the scleral flap is barely visible. Intraocular pressure is 11mmHg on no medication during the years 2011 to 2017.

Dr Santorum and his associates defined complete success as not needing a major reoperation or medication to control the intraocular pressure (IOP), and qualified success as not needing a major reoperation to control the IOP. Laser suture lysis, bleb-needling and suture of bleb-leakage procedures were not considered reoperations.

He noted that Kaplan-Meier survival analysis showed that, four years after surgery, canaloplasty-treated eyes had a 39% probability of complete success, and a 96% probability of qualified success. In comparison, trabeculectomy-treated eyes had a 15% probability of complete success and an 81% probability of qualified success, although the differences between the groups were not significant.

Figure 2: Gonioscopy photograph at the 12 o’clock position of the same eye of Figure 1. Two On the other hand, only six additional interventions were 10-0 Prolene sutures and their knots are evident in the Schlemm’s canal performed in the canaloplasty group, whereas 44 were necessary in the trabeculectomy group.

Dr Santorum emphasised that, although ab externo canaloplasty is not a minimally invasive surgery, it has several advantages over trabeculectomy. They include a lower risk of hypotony, a shorter POSTOPERATIVE INTERVENTIONS hospital stay and a more easily managed postoperative course.

The postoperative interventions in the canaloplasty group were In addition, canaloplasty leaves the patient with a more normal two sutures of inadvertently formed leaking bleb, two reoperations looking and physiologically natural eye. (Figure 1 and 2) for high IOP, one hyphaema wash-out and one-cutting of the However, unlike trabeculectomy, canaloplasty cannot bring canal suture because of a flat anterior chamber.

IOP any lower than the episcleral venous pressure. Therefore, Postoperative interventions in the trabeculectomy group included canaloplasty is not recommended in eyes with a very low target 16 laser suture lyses, six reoperations for hypotony, five bleb needlings, IOP, Dr Santorum said. four reoperations for high IOP, three sutures of leaking bleb, three viscoelastic refills and three conjunctival cyst removals.

Paolo Santorum: psantorum@gmail.com

ask the experts EUROTIMES | APRIL 2018

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

Courtesy of Paolo Santorum MD

24

GLAUCOMA

FILTRATION IMPLANT Miniature filtration device more effective as a solo procedure.

Roibeard Ó hÉineacháin reports

T

The XEN Gel (AqueSys) appears to provide better intraocular pressure (IOP) control when it is implanted as a solo procedure than it does when combined with cataract surgery, according to a study presented at the XXXV Congress of the ESCRS by Jan Van der Hoek MD, FRCOphth.

“Our early ‘real world’ clinical outcomes show good reductions in IOP and use of medication, albeit with lower success rates than shown in published data. Although XEN placement is a convenient operation to combine with cataract surgery, our data suggest that combining phaco with XEN is slightly less effective for IOP lowering than XEN alone,” said Dr Van der Hoek, Scarborough General Hospital, Scarborough, UK. He noted that the XEN Gel implant is a subconjunctival filtration device. However, unlike trabeculectomy and other filtration surgeries it requires no dissection of the sclera or conjunctiva. It is composed of a soft pliable collagen-derived gelatine material. It is inserted using a 27-gauge needle and visualising the meshwork with a gonio mirror.

The retrospective study included outcome data from 58 XEN gel insertions collected from April 2016 to March 2017 at day one and at months one, three, six and 12 using a specially adapted computer database. The patients’ mean age was 74.3 years (range 43-92), 38 patients underwent both phacoemulsification and XEN implantation and 18 underwent solo-XEN. All had mild-to-moderate open-angle glaucoma with a mean preoperative IOP of 24.6mmHg. At six months’ follow-up, the overall mean IOP was reduced to 14.7mmHg. Mean IOP was reduced from 23.6mmHg to 16.9mmHg in the phaco-XEN group and from 25.2mmHg to 15.3mmHg in the solo-XEN group.

IOP REDUCTION The treatment’s overall rate of success, that is an IOP lower than 22.0mmHg and a 20% IOP reduction without topical pressure-lowering treatment, was 55%, and the overall rate of complete or qualified success, defined as IOP reduced to the same levels but with topical medication, was 83%.

However, in the phaco-XEN group only 40% achieved complete success and only 65% achieved complete or qualified success, whereas in the solo-XEN group, 62% achieved complete success and 76% achieved complete or qualified success. It should be noted that in the phacoxen group a high number of patients had IOP of 22 or less preoperatively on medication and many of these maintained their pre-op IOP levels without medication postoperatively. If these are also included in the qualified success group the phaco-Xen group achieved 86% complete or qualified success at six months.

He noted that the procedure appeared to be safe, there was no visual loss and there were no flat anterior chambers.

Two patients had a prolonged hypotony in two eyes, which resolved at one month. One patient required bleb repair at day one and 17 required revision and needling.

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 l

l

l

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

Jan van der Hoek: jvdh@doctors.net.uk EUROTIMES | APRIL 2018

25

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PAEDIATRIC OPHTHALMOLOGY

IOL POWER SELECTION Balancing the changing needs of the patient over time.

Soosan Jacob MD reports

S

electing the right IOL power for children undergoing cataract surgery poses significant challenges. Careful planning is required to produce good long-term results, according to Rupal Trivedi MD, Medical University of South Carolina, USA, who spoke at the World Congress of Paediatric Ophthalmology and Strabismus 2017 in Hyderabad, India.

She shared results from the Delphi consensus study of a target refraction of about 6-10 dioptres for infants younger than 6 months of age, 4-6D at 6-12 months of age, steadily decreasing down to about 0-1D at more than 8 years of age.

She also explained that these target refractions need to be customised based on amblyopia, anticipated compliance to residual refraction, state of the fellow eye, family history and other factors. Eyes with postoperative glaucoma during infancy grow fast, resulting in myopic shift. However, it is not possible to predict preoperatively which eye will develop postoperative glaucoma.

An immediate post-surgical emmetropic target refraction, while making the battle against amblyopia easier, does result in a significant myopic adult refraction. Conversely, an immediate post-surgical high hypermetropic refraction does bring the adult refraction closer to zero, but makes the more pressing need of amblyopia management difficult. A customised approach of moderate hypermetropia avoids very high refractive error during adulthood, yet helps to fight against amblyopia, so is therefore important.

While answering questions from the audience about optimal timing of surgery, she mentioned that available literature suggests that in unilateral congenital, dense cataract should be operated at six weeks of life, as by this age, the eye is more mature and the risk of general anaesthesia is also reduced. In bilateral congenital dense cataract, the window for surgery is up to two months. However, the gap between the two eye surgeries preferably should be shorter than seven days.

She explained that difficulties are to be expected with axial length measurement, with a magnified impact of measurement error in short eyes. Considering the significant differences commonly seen between contact and immersion methods, immersion biometry is preferred. Challenges with keratometry included lack of fixation, supine position of measurement, a quicker tear break-up time and use of eyelid speculum. She recommended that automated keratometer readings should be taken as soon as possible after induction of anaesthesia, immediately after intraocular pressure, and should be measured without an eyelid speculum in place.

Dr Trivedi also shared Professor Warren Hillâ&#x20AC;&#x2122;s correction table for IOL power adjustment in cases of unplanned sulcus implantation.

She concluded by stating that the aims of paediatric cataract surgery should include having a manageable course of refraction between the period of IOL implantation and adulthood, having good vision as an adult and having the least refractive error in adulthood.

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 â&#x20AC;&#x201C; 26 September 2018

Registration & Hotel Bookings www.wspos.org

Rupal Trivedi: trivedi@musc.edu EUROTIMES | APRIL 2018

27

28

PAEDIATRIC OPHTHALMOLOGY

HALTING MYOPIC

PROGRESSION

Myopia treatments are effective but limited as an epidemic looms. Dermot McGrath reports

A

range of interventions including atropine, orthokeratology and soft contact lenses with myopia control features can all significantly reduce myopia progression when compared with spectacle lenses or placebo, according to Andrzej Grzybowski MD, PhD. “All of these treatments have been shown to be effective for the management of myopia progression, although we need a lot more studies to address many of the unanswered questions relating to myopia prevention and progression,” he told delegates attending the 17th EURETINA Congress in Barcelona.

Some of those questions include the additive effect of combining atropine with other emerging myopia therapies such as peripheral defocus contact lenses and environmental interventions such as increased outdoor time, said Dr Grzybowski, Professor of Ophthalmology at University of Warmia and Mazury, Olsztyn, Poland. He also noted the need to shed light on questions related to clinical treatment algorithms.

“We need to know more about which children would best benefit from treatment in terms of age, level of myopia, rate of progression and family risk factors, when atropine should be started and stopped and for how long it should be used,” he said.

In a broad overview of current methods to treat myopia, Dr Grzybowski said that the need for effective strategies to tackle myopia has never been greater.

EUROTIMES | APRIL 2018

He cited a 2016 study by Holden et al. that predicted a massive increase in the prevalence of myopia and high myopia over the next 30 years. That study warned of the implications for global health systems in managing and preventing myopia-related ocular complications and vision loss among almost 1 billion people with high myopia.

A meta-analysis by Huang et al. in 2016 compared the efficacy of 16 interventions for myopia control in children and concluded that the most effective current interventions were pharmacologic, notably muscarinic antagonists such as atropine and pirenzepine.

Certain specially designed contact lenses, including orthokeratology and peripheral defocus modifying contact lenses, had moderate effects, whereas specially designed spectacle lenses showed minimal effect.

In terms of pharmacological treatments, atropine has been in use for many years and has proven its effectiveness, said Dr Grzybowski. The side-effects associated with the use of 1% atropine in early studies, such as photophobia, decreased visual acuity, abnormalities of accommodation and problems with near vision, seem to have been greatly reduced with the use of lower concentration of 0.01%.

A recent five-year trial of a daily dose of 0.01% atropine found it to be an effective first-line treatment for children aged 6-to12 years with myopic progression of 0.5D in the preceding year, with few side-effects.

“Because atropine appeared more effective in the second year than the first,

treatment initially should be continued for at least two years,” he said.

While practically all studies of atropine have involved Asian populations, one Dutch study

by Polling et al. in 77 children found atropine 0.5% an effective and sustainable treatment for progressive high myopia. However, there was a high rate of side-effects, said Dr Grzybowski, with photophobia in 72%, reading problems in 38%, and headaches in 22%.

Turning to pirenzepine, this drug provides myopia control with less light sensitivity and fewer near-vision problems than 1% atropine, said Dr Grzybowski.

“However, its long-term use has not been proven to be effective and it is not commercially available at the moment,” he added.

In a Danish study of 800 children over eight years of follow-up, the compound 7-Methylxanthine (7-mx) was shown to reduce myopia progression and excess eye elongation by around 50% in children aged 9-to-13 years, with no major side-effects.

Looking at environmental factors, Dr Grzybowski cited the growing evidence of the role of time spent outdoors as a protective factor against the onset of myopia.

“A lot of studies have now shown that increased time outdoors prevents the onset of myopia and reduces the effects of large amounts of near-work and parental myopia.

However, the effects of time outdoors on progression are more controversial and needs further study,” he said.

Andrzej Grzybowski: ae.grzybowski@gmail.com

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INDUSTRY

A VIEW FROM THE TOP CEOs say where their companies are headed in illuminating discussion. Aidan Hanratty reports

W

e often hear from experts in the field of ophthalmology about how technological advances are helping their practice. We rarely hear from the people pushing these innovations, however.

The Ophthalmology Futures European Forum 2017 in Lisbon brought together some of the leaders in ophthalmology for a talk entitled “A view from the top: Corporate CEOs interviewed”. Chairing this discussion was James Mazzo, Global President for Carl Zeiss Meditec’s Strategic Business Unit Ophthalmic Devices. On the

panel were Alcon CEO Michael Ball, Tom Frinzi, Worldwide President of Surgical at Johnson & Johnson Vision and Dr Ludwin Monz, President and CEO of Carl Zeiss Meditec.

To start with, Mazzo pressed Frinzi on Johnson & Johnson Vision’s acquisition of TearScience, a US-based company that specialises in the treatment of dry eye disease.

The move made perfect sense, said Frinzi. “A healthy ocular surface is critical

A healthy ocular surface is critical... to prolonged contact lens use... as well as to surgery...

Tom Frinzi EUROTIMES | APRIL 2018

Tom Frinzi

James Mazzo

not only to prolonged contact lens use, which also plays to our portfolio, as well as to surgery, be it corneal-based or lens-based surgery.”

While Johnson & Johnson Vision moved into dry eye, Alcon took a step into the area of Minimally-Invasive Glaucoma Surgery (MIGS) with the development of the CyPass Micro-Stent, which is implanted in the eye to reduce intraocular pressure. “When you look at glaucoma drops, and even seeing my parents fight with each other about putting drops in each other’s eyes – not a pretty sight whatsoever – to get a surgical technique, a surgical product that can relieve them of that burden, I think is tremendous,” said Ball.

INDUSTRY “Given compliance is the biggest enemy of drops and given its importance in this setting, I think getting MIGS out there is fantastic.” While there is an additional cost for the procedure, he believes it pays for itself when offset against the price of living Ludwin Monz with glaucoma. “I think it’s Ludwin Monz incumbent on us to look at the economics associated with sure our equipment technologies that and make sure that the talk to one another, and payers across healthcare communicate with one understand what a great another wirelessly, but it’s plus this could be.” an opportunity for growth While ZEISS had for us, to get smarter and not made any surgical learn how to apply it across acquisitions, Monz spoke our portfolio.” about Veracity, a cloudBall agreed that digital was based platform for planning key, while acknowledging the and administration in cataract difficulty for “dinosaurs” like surgery ZEISS had recently Michael Ball himself: “It’s not natural to go acquired. He believed this after the digital era if you will, we represented a step forwards in have to force ourselves and get the people in how digital systems are changing the face the door who are way, way, way, way younger of surgery and ophthalmology. From using than us to get this thing moving along.” electronic records to increase efficiency and Monz did express concern however. As improve processes, he feels the next step is European authorities introduce stricter learning from the clinical data itself. regulations, he sees a knock-on effect not Frinzi spoke about his own company’s just in ophthalmology but across medical progress in the digital arena. “Obviously, industries. “I’ve heard that medtech we’re doing the near-term things, making

A close-up of the CyPass stent on a fingertip

Courtesy of Alcon

I’ve heard that medtech companies... were basically saying ‘we will not maintain our full portfolio, because it’s just too expensive to get the reapprovals’ companies – not just ophthalmology but neighbouring industries – were basically saying ‘we will not maintain our full portfolio, because it’s just too expensive to get the reapprovals’.”

Approvals are key for Alcon: “I think we will go where the approvals are and where the opportunities are. I see Asia developing as everybody does, as a very good market in terms of getting more coverage. But I still see great opportunities in Europe and in North America,” stressed Ball. “I point to AT-IOLs as something I think that baby-boomers want. They don’t want what their parents had, they want the newest technology, and they want to live a full active life until they’re 85, 95, 100 years old.”

For Frinzi and Johnson & Johnson Vision, changing regulations may or may not change their approach. “Historically we’ve brought a lot of things OUS (outside the United States) because it was a clearer path to the market. The fact that Europe is moving a little closer to what the US has in terms of regulatory pathways may level the playing field.”

The chair also pressed Ball on some of the mistakes he’d made in business, and what he might change throughout his career at companies like Allergan and Hospira. “As I look at it, if you don’t make mistakes, you aren’t taking enough risks.

You have to make mistakes, especially if you’re betting on innovation. It’s always great to have the sure thing, but you can’t move the science forward then. If you’re not getting smoked on a couple of deals, then you’re not doing a good job.”

Words to remember for aspiring CEOs.

INDIA VISIT OUR WEBSITE FOR INDIAN DOCTORS

www.eurotimesindia.org

EUROTIMES | APRIL 2018

31

BOOK REVIEWS

Readers 5% can get a 1 rice ep th ff o t n discou from ks o o of these b m o .c ss re ep Wis t code n u co is using the d Education RS on the ESC ucation.

Portal at ed escrs.org

PUBLICATION CELLULAR THERAPIES FOR RETINAL DISEASE: A STRATEGIC APPROACH EDITORS STEVEN D SCHWARTZ, AARON NAGIEL AND ROBERT LANZA PUBLISHED BY SPRINGER

CELLULAR THERAPIES

BOOK

REVIEWS

EMERGING OCULAR INFECTIONS PUBLICATION EMERGING INFECTIOUS UVEITIS EDITORS SOON-PHAIK CHEE AND MONCEF KHAIRALLAH PUBLISHED BY SPRINGER

Defined as “an infectious agent whose incidence is increasing following its introduction into a new host population”, an emerging pathogen can cause a great deal of confusion. As uveitis is already, for many, a confusing branch of ophthalmology, a textbook devoted to Emerging Infectious Uveitis (Springer) is certainly welcome.

Edited by Soon-Phaik Chee and Moncef Khairallah, this 200-page book covers not only the emerging diseases, but also those that are re-emerging, old adversaries such as syphilis and tuberculosis.

What kind of emerging ocular infections are covered? These are divided into sections based on the pathogens: bacterial (for example Mediterranean spotted fever and leptospirosis, among others), viral (Zika, chikungunya, Rift Valley fever), parasitic (intraocular nematodes such as onchocerciasis) and fungal (including aspergillus).

It’s an unusual bunch of pathogens, and will hopefully remain so. But a book like this is very handy in cases of uveitis in which the signs and symptoms don’t suggest the diseases we see in daily practice. Slit lamp, fundus, fluorescein angiography and OCT images supplement the text.

This book is intended for general ophthalmologists working in large cities or in developing nations who might be confronted by these emerging pathogens, and for uveitis specialists who never want to miss a diagnosis.

CHALLENGING TOPICS

PUBLICATION CORNEAL DISEASES IN CHILDREN: CHALLENGES & CONTROVERSIES EDITORS KATHRYN COLBY PUBLISHED BY SPRINGER

EUROTIMES | MONTH YEAR

Children with corneal problems can present challenges of their own. Simply examining a young patient in pain can be nearly impossible, much less making a diagnosis and initiating treatment.

Corneal Diseases in Children: Challenges & Controversies starts by elucidating the approach to the child with a corneal condition. Pearls are offered: “Swaddling an infant and placing a lid speculum may induce crying, but typically allows for an adequate examination.”

The following chapters prime the reader by covering the basic infections and allergies. The chapter on ocular surface disorders starts mildly, with tear film dysfunction, but then progresses to nightmares like Stevens-Johnson Syndrome in children. Topics such as congenital anomalies, paediatric keratoconus and corneal surgery follow.

This 150-page book relies primarily on text, rather than images, to inform its readers. This seems to work well, as many of the conditions described look similar to those in adults, despite often having different management strategies.

Corneal Diseases in Children is intended for paediatric ophthalmologists, corneal specialists who also see children and courageous general ophthalmologists who are willing to take on the challenge of treating children rather than immediately referring.

Transplantation keeps getting smaller. Organs and tissues are old news, and we’ve now moved on to cells, such as islet cells in type 1 diabetes. Cellular Therapies for Retinal Disease: A Strategic Approach “familiarizes the reader with the current landscape of cell-based therapies for the treatment of retinal disease”.

Part I covers cell replacement therapy, which primarily refers to stem cell-derived RPE cells, whether from human embryonic or autologous in origin. Scaffolds and surgical approaches each receive their own chapter.

Cell-based neuroprotection is the topic of Part II, in which subretinal delivery of cells via the suprachoroidal space is the most fascinating, at least from a surgical point of view. But first disease models had to be created, which is the topic of Part III. “Disease in a Dish” modelling is explained.

This 140-page book is intended as an introduction to an exciting new field.

PUBLICATION OCULAR TUBERCULOSIS EDITORS ATUL KUMAR, ROHAN CHAWLA AND NAMRATA SHARMA PUBLISHED BY SPRINGER

OCULAR TUBERCULOSIS Ocular Tuberculosis is a concise review of all aspects of the disease, from its epidemiology, pathogenesis and pathology to its ocular manifestations, and everything (diagnostics, therapeutics) in between.

Particularly interesting are the chapters devoted to diagnostics. Chapter 3 covers the ocular imaging studies (fundus photography, OCT, ultrasound); Chapter 4 focuses on the laboratory and radiological investigations; and Chapter 5 discusses the tuberculin skin test and interferon-γ release assays.

Each of the many manifestations of ocular tuberculosis receives its own chapter in this 130-page book. This includes conjunctival and corneal infection, scleritis, uveitis in its various presentations, multifocal serpiginoid choroiditis, retinitis and retinal vasculitis, optic neuropathy and (peri)orbital tuberculosis.

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

EUROTIMES | APRIL 2018

33

ESCRS NEWS

ESCRS

NEWS

ESCRS PETER BARRY FELLOWSHIP 2018 The closing date for applications for the Peter Barry Fellowship is 1 May 2018. The 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 one year.

Applicants must be European trainee ophthalmologists, 40 years of age or under on the closing date for applications, and have been an ESCRS member for three 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: A detailed up-to-date CV A letter of intent of one-to-two 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 Applications and queries should be sent to Danielle Maher at Danielle.Maher@escrs.org

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

Advanced Instructional Courses

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Eye Contact Interviews

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Video of the Month

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Video Journal of Cataract & Refractive Surgery Young Ophthalmologists Videos: “My Early Surgeries” Online Museum

ESCRS RELEASES NEW CATEGORY ON PLAYER: ADVANCED INSTRUCTIONAL COURSES ESCRS has created a brandnew category on the Media Player (player.escrs.org).

Selected advanced Instructional Courses from recent congresses will be published online, adding approximately 50 hours of brand-new, high-quality content.

These are recommended for all ESCRS members as essential viewing. Courses on a wide range of topics such as ‘Management of Paediatric Cataract’, ‘SMILE’ and ‘Correcting Presbyopia using Corneal Inlay Technologies’ are already available online.

player.escrs.org EUROTIMES | APRIL 2018

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INDUSTRY NEWS

True innovation comes from good research.

INDUSTRY

NEWS

EASY IMAGE CAPTURE

Clinical Research Awards 2018/2019 Call for Proposals ESCRS has made available funding of €750,000 over three years for clinical research projects in the field of cataract and refractive surgery.

The competition is open to all clinicians and researchers (with at least 3 years ESCRS membership) holding a full time clinical/research post at a EU-based clinical or academic centre.

Deadline for expressions of interest:

31 May 2018

www.clinicalresearch.escrs.org

EUROTIMES | APRIL 2018

Topcon Medical Systems has announced that its DRI OCT Triton Series has received 510(k) clearances from the FDA. “We are very pleased to announce the recent FDA Clearance of the DRI OCT Triton and DRI OCT Triton Plus. With a truecolour fundus camera and widefield OCT scanning capability, the Triton Series provides the first Swept Source OCT with multi-modal imaging capabilities. The revolutionary features of the DRI OCT Triton Series provides exceptional visualisation of the entire tomogram, allowing for a better understanding of many ocular pathologies and enhancing the standard of patient care,” said John Fujita, President of Topcon Medical Systems. http://www.topconmedical.com

NEW CHIEF OPERATIONS OFFICER

INTRAVITREAL INJECTION GUIDE

Domenic von Planta is the new Chief Operations Officer (COO) and Deputy Managing Director of SCHWIND eye-tech-solutions GmbH. In his new role at SCHWIND, Mr von Planta assumes responsibility for the areas of Purchasing, Production, Logistics and Service. He succeeds Kurt Geiss, who has reached the regular retirement age after more than 30 years’ service with the company.

“I am delighted to have Domenic von Planta on board as the new COO. Together with the SCHWIND team, we will be reaching the next level of corporate development”, said Rolf Schwind, CEO and Managing Director of SCHWIND eye-techsolutions. http://www. eye-tech-solutions.com

Malosa Medical has announced the release of its Intravitreal Injection Guide, which helps facilitate injections and reduce discomfort.

Designed by UK-based ophthalmologist Salman Waqar MBBS, FRCOphth, the Guide removes the need for both the drape and speculum as well as standardising the procedure, said a company spokesman.

Mr Waqar designed the device in collaboration with the Torbay and South Devon NHS Foundation and Plymouth Hospitals NHS Trusts under the South West Peninsula NHS Innovation Pathway. He said: “This innovation... is a new and unique design for delivering comfortable, safe and efficient eye injections.” https://www. malosa.com

HOSPITAL DIARY

THE PERFECT WAVE Surfing and cataract surgery have more in common than you might think, says Leigh Spielberg MD

Illustration by Eoin Coveney

f you’ve never gone wait for the “perfect cataract” to wave surfing on Costa select as your first case in the Rica’s Pacific coast, I OR while referring the difficult highly recommend you eyes to your colleagues. Pass. do so. Even if, like me, No need to get sucked into a you don’t know how to big wave that’s too dangerous surf. But it doesn’t matter. All to handle. Complications, like you need is a surfboard. And wipe-outs, are always stalking also airplane tickets to San the unprepared.

José, a 4-wheel-drive vehicle Both surfing and ophthalmology and some off-road driving have a steep learning curve, confidence. Because to reach requiring a lot of practice and get this ocean paradise, you’ll have much more fun once you get better to traverse steep, rocky, dirt at them. And, as I discovered, you roads and cross jungle streams. can get yourself into trouble if But once you arrive, surfboard you’re not ready. in hand, you’re ready to go.

I’ve since done some research Good luck! and realised that surfing is a The setting was perfect on serious pursuit in which only the this particular evening. It was most dedicated excel. Despite Christmas Eve, 2017. As the sun its apparent “laid-back” lifestyle set over the ocean, it lit up the and mellow image, professional sky in a riot of orange and pink, surfers are devoted, driven against which the other surfers athletes, true perfectionists. were silhouetted. Spectators on “I’m definitely not lackadaisical. the beach were illuminated like Otherwise I wouldn’t be here,” actors on a stage, their shadows said pro surfer Dane Reynolds in growing longer by the minute. an interview after winning a big Picturesque. surfing tournament. “I put a lot of However, I wasn’t there to pressure on myself to do it well.” enjoy the scenery. Although That wasn’t the answer the I had never surfed, I was reporter was expecting, but it determined to catch a wave and sounds exactly how most of us ride it in its entirety. But I did would describe ourselves as eye ...I found myself at the right place at a lot of waiting, which allowed doctors and surgeons. Study, the right time. Or so I thought. I cruised me to do some thinking. As preparation and diligence are down the front of the wave and suddenly I lay on my board, bobbing what leads to success. That is over the waves, which seemed how we do it.

I found myself underwater to keep breaking elsewhere, I know I’ll never become a good my mind started to do what surfer, but I’ll stay enthusiastic. I it often does during new experiences: it started comparing was back out on the water on New Year’s Eve, having messed the current activity to ophthalmology. It wasn’t easy. Wave around in smaller waves every day since Christmas eve. The surfing and ophthalmology do not, at first sight, have much water was empty. The only sign of life was the pelicans, who were in common. Surfing, I assumed, demands scant preparation, dive-bombing into the water, hunting for sushi. They eyed me simple equipment and no education. Just the opposite of suspiciously, as though I might steal their dinner. But I was there ophthalmology, right? to catch waves, not fish.

And then a wave came, and I found myself at the right place This time, luck was on my side. As a big swell surged beneath at the right time. Or so I thought. I cruised down the front of the me, I manoeuvred my 10-foot (3.3m) board downhill and stood wave and suddenly I found myself underwater, upside down and up! It was a bumpy ride, but I remained standing as the wave tumbling violently. Time seemed to slow down. My surfboard was crashed above and behind me. Its momentum brought me all the gone, and I hoped it wouldn’t crash into my skull. I also hoped I way back to shore. I stepped off the board, picked it up and walked wouldn’t crash myself onto the hard ocean floor. Damn! out of the water, smiling.

I surfaced with my body intact. Lucky. But then a second wave The sun set behind me as I strapped the board to the roof of my crashed overhead and I was back inside the sea, rolling as if in a car. I had had a good time, but I looked forward to getting back washing machine. in the OR, where I have everything more under control than I do And then it hit me. No, not my surfboard. Insight! in the water.

As I finally resurfaced, I realised that learning to surf is like being an early-career ophthalmologist. More specifically, an Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent early-career cataract surgeon. Very early. Like, first-monthUniversity Hospital in Belgium of-work early. Full of confidence, you wait until it’s your time leigh.spielberg@gmail.com to act, to operate. But you often have to wait a while. You EUROTIMES | APRIL 2018

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Demel

EXPLORING VIENNA

VIENNA

3

TO KNOW...

PROPRIETORS THROW WATER ON POTENTIAL SMOKING BAN A total ban on smoking in Austrian restaurants was due to come into effect in May 2018; however, the incoming government quashed that ruling, focusing instead on raising the legal age for smoking from 16 to 18. Unless the anti-smoking efforts of the Viennese Medical Chamber succeed in having the issue raised in parliament again, the 2009 regulations – widely flouted – are in place. These require larger establishments to set aside a ‘separate room for smokers’. A quarter of Austrians are regular smokers, causing some proprietors to fear loss of clientele if anti-smoking laws were put in place. For those for whom a totally nonsmoking restaurant is a non-negotiable issue, the German-language website http://da.stinkts. net has recommendations

LEARN TO SPEAK GERMAN WITH A VIENNESE WHIRL The Viennese speak German with a few variations of their own; a hundred years ago it was even possible to determine from which specific district of Vienna a speaker came based on his or her pronunciation and vocabulary.

Dialects like Schönbrunner Deutsch, named after the court of the Hapsburg Empire where it developed (it is said to sound like German spoken with a French accent), were still in use in some circles. Today, the overall tendency in Vienna, particularly among young people, is towards standard German. Nevertheless, two typical greetings you may hear in Vienna are ‘Servus’, which among friends does for both hello and goodbye, and ‘Gruss gott’, which is locally preferred to the German ‘Guten tag’.

BEFORE YOU LEAVE A TIP, ALWAYS REMEMBER TO ASK FOR YOUR CHANGE How much and who to tip in Vienna? Here are some guidelines: gratuities for hotel staff are covered by a 10% surcharge on the hotel bill, but give a few euro to porter and chambermaid. Tip the concierge for any special service. In restaurants, round up the bill to the nearest even number (e.g 16 becomes 20) and include it in the amount you pay; if you require change, specify or it will be considered the tip.

(Don’t leave the tip on the table.) In bars, the bill should be rounded up by 5 or 10%. In taxis, round up the fare by 10%.

EUROTIMES | APRIL 2018

FROM TRENDY TO TRAD

Delegates to the 36th Congress of the ESCRS have a host of shopping options. Maryalicia Post reports.

‘A diamond for everyone’ was the aim of Daniel Swarovski, who devised the process for manufacturing brilliant artificial crystals. He founded the Swarovski company in Wattens, Austria, 122 years ago. Today there are two Swarovski shops on Vienna’s famous Kärntner Strasse.

The dazzling flagship store is at Number 24. With three floors of displays and ‘installations’, you can immerse yourself in a world of sparkle. A champagne bar is at hand if you find yourself flagging. www.kristallwelten-swarovski.com If bling’s not your thing, two doors away from Swarovski is Lobmeyr, an iconic Viennese shop for classic crystal and china. A Lobmeyr paperweight engraved with an initial or message is a traditional Viennese gift. The company is run by the sixth generation of the Lobmeyr family, whose ancestors were Purveyors to the Imperial Court. Karntner Strasse 26. www.lobmeyr.at.

Also on Kärntner Strasse is Paul Vienna, a popular men’s clothing shop at Number 14 .

The staff at Paul’s will help you put together a look you’ll love from the shop’s collection of carefully selected brands. www.paul-vienna.at One of the most celebrated men’s outfitters in the world, Knize, is on Graben at Number 13, The distinctive shopfront as well as the interior were designed in 1910

by Adolf Loos, and are the epitome of oldworld elegance – as is their merchandise.

A bottle of their own perfume ‘Knize Ten’ makes a special souvenir, as would one of their handcrafted neckties. www.knize.at.

With a few days in Vienna, you’ve time to indulge yourself in a made-to-measure shirt or two from Gino Venturini. A shirt will cost about €200 made up in your choice of fabric, fitted and finished to absolute perfection. Gino Venturini, Spiegelgasse 9. www.venturini.at.

All shops mentioned above are closed Sunday and public holidays but open from at least 10.00 until 18.00 weekdays and until 17.00 on Saturdays. See websites for details.

If you’re more of a desperation shopper than a destination shopper, here are three suggestions for combining quick souvenir shopping with your Vienna sightseeing: on your way from a look at the Hapsburg Palace have coffee in nearby Demel, Kohlmarkt 14; their elegantly packaged treats make very welcome gifts. Open every day 08.00 to 19.00. If you’re visiting the Modern Art Museum browse the Mumok gift shop (also open daily), which is especially useful for sourcing surprises for the young ones on your list, and finally, call in to any supermarket for nicely presented chocolates at much lower prices than in speciality shops. If you’re looking for an upmarket supermarket make it Julius Meinl, Graben 19, where you could also lunch in style. www.meinlamgraben.at

Knize

CALENDAR

SFO and SAFIR Congresses will take place in Paris, France

↙

LAST CALL

APRIL 2018

69th Annual Conference of Delhi Ophthalmological Society 6–8 April New Delhi, India http://doscon.org/

2018 ASCRS•ASOA Annual Meeting 13–17 April Washington DC, USA http://annualmeeting.ascrs.org/

4th ESASO Anterior Segment Academy 26–28 April Milan, Italy https://esasoasa2018.org/

MAY

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

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

NEW RCOphth Congress 2018

21–24 May Liverpool, UK https://www.rcophth.ac.uk/events-andcourses/annual-congress-2018/ The 4th ESASO Anterior Segment Academy will take place in Milan, Italy

15th Congress of the South-East European Ophthalmological Society 31 May – 2 June Szeged, Hungary http://www.seeos.eu

JUNE

NEW EyeAdvance 2018

1–3 June Mumbai, India http://eyeadvance.com/

World Congress on Clinical, Pediatric and Neuro Ophthalmology 4–5 June Osaka, Japan https://neuro.ophthalmology conferences.com

NEW XLIX Congress of Polish Ophthalmologists

7–9 June Katowice, Poland https://pto.com.pl/zjazd2018

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

EUROTIMES | APRIL 2018

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CALENDAR

JUNE

33rd Annual Meeting of the JSCRS will take place in Tokyo, Japan

Aegean Cornea XIV

29 June – 1 July Mykonos, Greece http://www.aegeancornea.gr/

NEW 33rd Annual Meeting of the JSCRS 29 June–1 July Tokyo, Japan http://www.jscrs.net/jscrs2018/ eng/index.html

JULY

NEW 1st OCT-Angiography Summer Academy (OSA) 2–3 July Créteil, France http://www.creteilophtalmo.fr/osa

NEW 31st APACRS Annual Meeting 19–21 July Chiangmai, Thailand http://www.apacrs2018.org/

SEPTEMBER

SEPTEMBER

18th EURETINA Congress

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

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

NEW Baltic Eye Surgeons Talk Show Vol. 6

24–26 August Rigas Jurmala, Latvia http://balticeye2018.com/

OCTOBER

9th EuCornea Congress

Ophthalmic Imaging: from Theory to Current Practice

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

SEPTEMBER

NEW ALACCSA-R LASOA

12 October Paris, France http://www.vuexplorer.com/en/congres

2018 WSPOS Subspecialty Day

6–8 September Santiago, Chile https://www.alaccsasantiago2018.com/

↙

AUGUST

36th Congress of the ESCRS

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

21 September Vienna, Austria www.wspos.org

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