EuroTimes Vol. 23 - Issue 5

SPECIAL FOCUS CATARACT & REFRACTIVE LASER CORNEA

HOW TO ADDRESS FAILED PENETRATING KERATOPLASTY

RETINA

BIOMARKERS LEAD THE WAY IN DIABETIC RETINOPATHY May 2018 | Vol 23 Issue 5

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Content Editor Aidan Hanratty Senior Designer Lara Fitzgibbon Designer Monica De Iscar Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org

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

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ISSN 1393-8983

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.

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS CATARACT & REFRACTIVE LASER 4 Dr Soosan Jacob weighs

up the pros and cons of femtosecond laser-assisted cataract surgery

6 Low-energy femtosecond laser-assisted IOL fragmentation is less traumatic than manual methods

FEATURES CATARACT & REFRACTIVE 8 Astigmatic refractive

surprise can happen at any time – before, during or after the procedure

9 An innovative IOL has been redesigned to help in its aim of eliminating negative dysphotopsia

10 Calculating IOL power

based on the cornea’s steep and flat meridians can improve accuracy

14 JCRS highlights

CORNEA

www.eurotimes.org

RETINA 19 Biomarkers may lead

to more personalised therapies for diabetic retinopathy

20 Different treatments are

effective for neovascular age-related macular degeneration

GLAUCOMA 22 Optical coherence tomography angiography can reliably detect early glaucoma

P. 32

23 Patients with

idiopathic intracranial hypertension require a comprehensive workup

25 Learning about

minimally invasive strabismus surgery

PAEDIATRIC OPHTHALMOLOGY

27 Keratoplasty in children

24 What is the best approach

REGULARS

can have varying results

for accommodative esotropia: surgical or non-surgical?

P. 5

29 ESCRS News 31 Industry News 32 Travel 33 Random thoughts 34 Practice management 35 Calendar

15 Efforts are being made to reduce the need for repeat procedures following unsuccessful penetrating keratoplasty

16 Combined or sequential surgery? Which makes most sense for Fuchs’ endothelial dystrophy patients?

Included with this issue...

ESCRS Education Forum supplement EUROTIMES | MAY 2018

2

EDITORIAL A WORD FROM BORIS MALYUGIN MD, PhD

THE FUTURE OF FLACS

Looking at the past and present to determine the future of femtosecond laser-assisted cataract surgery

T

he history of cataract surgery for centuries was lasers have proven useful when an IOL has to be removed from spinning around two main issues – increased safety the eye for some reason. In these cases, either a pseudophakic or and improved efficiency. The first things that come to a phakic lens is cut prior to explantation in order to reduce the mind when we are talking about lasers in any field of surgical trauma. The whole spectrum of FLACS applications in medicine, including surgical procedures, are exactly complicated cataract cases is currently expanding, presenting those two already mentioned – namely new horizons for that technology. safety and efficiency. They are achieved by high However, in most cases it In 2008 the new page of cataract precision of laser energy applications combined is a bit early to make the surgery was started with the with minimal collateral tissue damage along final judgments. with the possibility to choose the wavelengths From the technical standpoint, introduction of the femtosecond selectively interacting with the target tissue, I do strongly believe that lasers now known as FLACS whether it is cornea, lens material, ciliary body, FLACS has still a lot of room (femtosecond laser-assisted vitreous, retina or any other. One of the most for improvement. These devices significant features of many laser procedures is should one day become truly cataract surgery). Ten years later the ability to treat ocular tissues without actually portable and compact; the we can turn back and reflect on opening the eye globe. necessity to move the patient Starting with retinal detachment and followed from one step to another should where are we now and where are by glaucoma and secondary cataract treatments, be excluded. I am not talking we heading with that technology? lasers become the integral part of ophthalmology’s today about the financial side of standard armamentarium. In 2008 the new page the FLACS story, but there is of cataract surgery was started with the introduction of the definitely room for improvement there as well. femtosecond lasers now known as FLACS (femtosecond laserIn summary, 10 years past the first steps taken we are still assisted cataract surgery). Ten years later we can turn back and climbing and have not yet reached the summit. The good news is reflect on where are we now and where are we heading with that that we can already see the top, at least some parts of it, and that technology? During these years hundreds of thousands of patients gives us hope of conquering that hill one day. were treated with FLACS. The data collected up to date showed that overall results are more or less similar to those achieved with the standard cataract procedures. That is more or less true for uncomplicated cataract surgery. However, when we are talking about complicated cataracts, things look very different.

FLACS has shown to be beneficial in patients with low endothelial cell counts, unstable zonules, displaced and subluxed lenses. Precise capsulotomy achieved with laser energy applications is considered to be good for paediatric cases, as well as the eyes when posterior capsulorhexis is indicated for any reason. Intraocular lenses specifically designed for FLACS Boris Malyugin, Professor of Ophthalmology and Deputy are based on the fact that this technology may provide the Director General at the S. Fyodorov Eye Microsurgery Federal precision of positioning and sizing the capsulorhexis that cannot State Institution in Moscow, Russia be achieved with manual techniques. Moreover, femtosecond

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

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

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4

SPECIAL FOCUS: CATARACT & REFRACTIVE LASER

UPDATE ON FLACS

The jury is still out on femtosecond laser-assisted cataract surgery. Soosan Jacob MD looks at the pros and cons of the procedure

T

he introduction of the femtosecond laser into the field of refractive surgery brought about a huge transformation.

Femtosecond-dissected flaps in LASIK and lenticules in SMILE have almost completely replaced manual microkeratomes. However, despite femtosecond laser-assisted cataract surgery (FLACS) having received FDA approval in 2010, the jury is still out regarding its utility, advantages and disadvantages.

The femtosecond laser is a nearinfrared laser of 1053nm wavelength and EUROTIMES | MAY 2018

femtosecond pulse duration (10-15 sec) that uses photodisruption. The laser creates plasma that expands to generate a shock wave. This creates a gas bubble that expands before it collapses, thus creating a cleavage plane.

Being of ultra-short pulse, there is minimal collateral damage. The femtosecond laser gives very high precision and predictability together with complex programming abilities.

It can also be linked to real-time spectral domain anterior segment optical coherence tomography (ASOCT) or Scheimpflug imaging to accurately create pre-programmed cuts at different levels within the transparent ocular tissues.

PROCEDURE Applanating curved contact lens or nonapplanating liquid optical immersion docking systems are used for docking.

Centration is ascertained and the real-time images are evaluated for quality and tilt.

Position of the chosen set of cuts is verified to be within the desired as well as safe zone. The cuts start with the capsulorhexis followed by lens fragmentation and softening, clear corneal incisions (CCI) and astigmatic keratotomy (AK) or corneal toric axis markings. Cuts larger than 6mm should be avoided, and a default clearance of 1,000

SPECIAL FOCUS: CATARACT & REFRACTIVE LASER microns from the posterior capsule and 250 microns from the pupillary margin should be maintained to avoid complications.

ADVANTAGES OF FLACS The aim of FLACS is to provide safety and ease of surgery while increasing precision and refractive outcomes. Many of the key steps of the cataract surgery such as capsulorhexis, nuclear fragmentation and softening, CCI and AK incisions are performed in a closed-chamber, no-touch machine-driven technique with high precision with regards to sizing, shape, centration, pattern, architecture etc, thus giving more predictable results and with less dependence on surgeon experience.

Better IOL centration, an accurate 0.5mm overlap of the rhexis edges all around the IOL optic, less tilt and more predictable effective lens position can all enhance premium IOL results. Nuclear fragmentation and softening can decrease intraocular manipulation, effective phaco time and cumulative dissipated energy, thus potentially decreasing endothelial and other complications such as vitreous loss and cystoid macular oedema.

Precise three-dimensional wounds can give better wound closure, greater predictability to the amount of induced astigmatism and lesser risk of endophthalmitis. Accurate depth, arc length and optic zone can improve accuracy of corneal and limbal-relaxing incisions.

Relaxing incisions also have the added advantage of providing the option to be opened in the postoperative period after assessing induced astigmatism. Iris or limbus registration in newer machines improves accuracy further.

USE OF FLACS IN DIFFICULT SCENARIOS FLACS is helpful to safely create a rhexis in shallow anterior chambers, white cataracts and subluxated cataracts. Both anterior and posterior capsulorhexes can be done in paediatric cataracts. It can also make nucleus removal safer in patients with endothelial dystrophy and hard cataracts. It also makes routine cataract surgery easier for the less experienced surgeon, while increasing precision in the more experienced surgeon.

COMPLICATIONS Significant corneal scarring that interferes with passage of the laser precludes FLACS. A prominent arcus may interfere with recognition of the limbus and cause anteriorly placed incisions that can cause oar locking of instruments and poor visibility. The rhexis in FLACS may not be as strong as a manual rhexis, though different studies have concluded differently regarding this. Scanning electron microscopy shows micro-irregularities in the edges of laser capsulotomies. These can result in radial run-outs of the rhexis.

Postage stamp rhexis tags can be avoided by setting the pulses to overlap.

A: Rhexis, two plane cuts and clear corneal incisions are seen; B: The free floating rhexis is grasped with forceps and removed; C: Nucleus is bisected through femtosecond dissected planes; D: Cortex seen cut in line with rhexis, which makes aspiration more difficult

Decentered and partial capsulotomies may still occur because of tilt, corneal folds, poor docking etc. A free-floating capsulotomy should therefore always be verified before removing the central cut capsule to avoid an uncut segment extending outwards. A pupillary size of at least 6mm is desirable for performing rhexis and if less than 5mm can cause iris injury, release of prostaglandins and miosis. Pretreatment with topical NSAIDs is helpful.

A default setting of about 250 microns should be set from the pupil margin to avoid accidental intraoperative iris trauma and miosis. Rhexis in hypermature cataracts may be incomplete because of release of milky fluid interfering with the laser as well as collapse of the capsular bag. In paediatric cataracts, the achieved diameter may be larger than the programmed diameter because of the elastic nature of the capsule.

Intra-lenticular gas released from nuclear fragmentation can cause a capsular block syndrome resulting in nucleus drop.

To prevent this, trapped gas should be released manually by rocking the nucleus prior to hydrodissection. Cortex aspiration can be more difficult as the sub-capsular cortex is also cut in line with the rhexis, resulting in absence of wisps of cortex that are routinely caught by the I/A probe in the case of a manual rhexis.

Flat anterior chamber after corneal arcuate keratotomies as well as accidental grid pattern delivery to the cornea and iris have been reported. In traumatic cataracts, overt or occult open globe injury should be ruled out before docking and any anterior capsular tears that may intersect with the FLACS rhexis should be checked for. In addition, intra-lenticular gas may cause

a nucleus drop through a pre-existing posterior capsular tear.

A meta-analysis by Popovic et al. of 14,567 eyes reported no statistically significant difference between manual phacoemulsification and FLACS in overall complications or uncorrected and corrected distance visual acuities though there was statistically significant difference for several secondary surgical outcomes.

To conclude, FLACS does have advantages in terms of precision, predictability and usage in difficult situations such as shallow anterior chambers and hard nuclei. However, disadvantages include greater time taken for surgery, potentially weaker rhexis, laser-induced miosis, capsular blow-out etc. Further advancements are needed to give it distinct and definite advantages over manual phaco in routine cataract surgery.

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 these QR codes to view live surgeries

EUROTIMES | MAY 2018

5

SPECIAL FOCUS: CATARACT & REFRACTIVE LASER

LASER IOL

FRAGMENTATION

Low-energy femtosecond laser-assisted IOL fragmentation is less traumatic than manual methods. Roibeard Ó hÉineacháin reports

L

ow-energy femtosecondlaser transection of IOLs prior to explantation appears to provide a clean dissection of the lens allowing safe and easy removal for exchange, said Natalia Anisimova MD, S. Fyodorov Eye Microsurgery State Institution, Moscow, Russia.

“The clinical application of femtosecond laser-assisted IOL fragmentation is feasible in cases of hydrophobic IOL explantation,” Dr Anisimova told the 22nd ESCRS Winter Meeting in Belgrade, Serbia.

She noted that the need for IOL explantation is rare but seems to be increasing. Decentration, dislocation and incorrect lens power are the most common indications. Modern surgical techniques for IOL explantation include criss-cross lensotomy, removal of the optic only, bisection and trisection.

However, these approaches carry a high risk of surgical trauma.

HIGH ENERGY Dr Anisimova noted that there is also research that has shown that transection of an IOL for explantation can be achieved with a femtosecond laser set at an energy of 8.0µJ with a spot size of 3.0µm and a line separation size of 6µm. However, the high energy used with a small spot and separation size may produce excessive cavitation gas bubbles and the release of toxins.

The clinical application of femtosecond laser-assisted IOL fragmentation is feasible in cases of hydrophobic IOL explantation Natalia Anisimova MD EUROTIMES | MAY 2018

The photo of the IOL after femtosecond laser-assisted IOL hemi-transection and consecutive explantation surgery

To determine the optimum laser energy and laser spot positioning parameters, Dr Anisimova and her associates transected three hydrophobic acrylic IOLs with a femtosecond laser using laser energies of 1.0µJ to 10µJ and laser spot and layer separation size of 7.0µm for femtosecond laser IOL transection.

They found that with a laser energy of 1.0µJ they achieved a fragmentation score of “one”, meaning that though transection lines were apparent, the fragments could not be separated manually. However, Scanning electron microscopy overview of the transected IOL (original at energies from 2.0µJ to 10µJ magnification ×400 x450) with the Quanta 200 microscope (FEI). The they achieved a score of three, scabrous-like surface can be seen, probably reflecting the application pattern meaning clear transection lines of femtosecond laser pulses and little force required for fragment dissection. to fragment and remove the lens without In addition, light microscopy showed difficulty and endothelial cell counts did not that significant changes occurred on change from one month postoperatively the surface of the IOLs proximal to the to six months postoperatively. In addition, transection lines when they used energies uncorrected visual acuity improved from of 8µJ to 10µJ, but not when they used 20/2000 preoperatively to 20/20 at one month energies of 6.0µJ. postoperatively, Dr Anisimova said.

In the first patient in whom they have tried the femtosecond laser-assisted technique Natalia Anisimova: using the 6.0µJ laser settings they were able mdnsanisimova@gmail.com

Courtesy of Natalia Anisimova MD

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CATARACT & REFRACTIVE

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REFRACTIVE SURPRISES Each step of toric IOL procedures poses a potential source of error.

Roibeard Ó hÉineacháin reports

D

etermining the cause of astigmatic refractive surprise in patients with toric IOLs involves a step-by-step review of the case, from preoperative biometry and on to the early postoperative weeks, said Alja Crnej MD, Slovenia, at the 22nd ESCRS Winter Meeting in Belgrade Serbia “You need to be thinking of the time prior to the operation, during the operation and of course after the operation. All three different times, things can go wrong,” said Dr Crnej, who presented the paper on behalf of Nino Hirnschall MD, PhD, Hanusch Hospital in Vienna, Austria.

Dr Crnej noted that the process of elimination should start with the most basic questions about the lens and the patient. A quick check should be made to ensure there were no mix-ups in the paperwork leading up to the operation that might have resulted in the patient receiving the wrong lens.

If the patient received the assigned lens in the correct eye, the next step of the investigation is to redo the keratometry.

She noted that, in a study Dr Hirnschall and his associates conducted involving 1,500 patients who had undergone IOL implantation, the main source of error was measurement of the cornea. Other factors, such as the axial eye length measurement and the measurement of the cornea, are a much smaller source of error.

Irregular astigmatism can also reduce the efficacy of toric IOLs, Dr Crnej said.

Patients with a high level of irregular astigmatism probably have a lot of higher-order aberrations and are unlikely to gain much visual improvement through such lenses.

Another thing to consider is whether the correct formula was used.

The same data entered into different formulas for toric IOL calculation will often Alja Crnej MD yield different results.

“Probably the best thing to do before we decide which toric IOL to implant is to do calculations with more formulas. We can compare them and then decide,” Dr Crnej said Surgically induced astigmatism can also be a factor in disappointing toric IOL results. Although modern cataract surgery induces on average only around 0.6D of astigmatism, there can be outliers with significant amounts of induced astigmatism, she pointed out.

And finally, there is the question of alignment errors, which can result from improper orientation of the patients’ head during examination, mistakes during surgery and spontaneous IOL rotation postoperatively, she added.

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EUROTIMES | MAY 2018

CATARACT & REFRACTIVE

9

ANTI-DYSPHOTOPIC IOL n innovative intraocular lens (IOL) intended to eliminate negative dysphotopsia has been redesigned to address early complications, Samuel Masket MD told the American Academy of Ophthalmology Annual Meeting in New Orleans, USA. The Morcher 90S anti-dysphotopic lens (Stuttgart, Germany) incorporates a groove around the optic that accepts the circular anterior capsulotomy so that the anterior lens surface overlaps the capsulotomy edge, apparently eliminating negative dysphotopsia, a shadow on the visual field that as many as 15% of patients may see after cataract surgery.

The idea came from treating negative dysphotopsia by implanting a conventional IOL with haptics in the capsule and the optic reverse captured outside the anterior capsulotomy, or placing the lens in the sulcus, said Dr Masket, who patented the design. The one-piece, foldable, hydrophilic acrylic lens is intended to provide the anti-dysphotopic advantages of the optic overlapping the capsulotomy, while preventing the capsule opacification and fibrosis often seen with reverse optic capture, and decentration and iris chafing seen with sulcus placement.

Capturing the optic in the capsulotomy provides a number of additional benefits, among them a stable axis for toric IOLs. “With 100 anti-dysphotopic lenses of all versions implanted so far, no patient has yet reported a negative dysphotopsia.

We consider this adequate proof of concept,” reported Dr Masket, of Advanced Vision Care and the UCLA Stein Eye Institute, Los Angeles, USA. However, of 39 eyes implanted with the original 90S design, three experienced capsule block, in which fluid trapped behind the lens distended the capsular bag, and two optic capture by the iris.

The 90S was redesigned with holes at the optic-haptic junction to prevent capsule block, Dr Masket said. In 48 cases no capsule block was seen, but iris-optic capture occurred in five.

Of the seven iris-optic captures in the first 87 cases, five were re-operated and two lenses explanted, Dr Masket said.

Potential causes for iris-optic capture included wound leak, pupil block and a thick hydrophilic acrylic optic, Dr Masket said. Potential cures included a thinner, hydrophobic acrylic lens material and thinner groove, an enlarged anterior optic and pupil miosis for the first few days after surgery.

The third version of the 90S IOL retained the fenestrations of the second version and increased the diameter of the anterior optic outside the capsule to 6.4mm from 6.0mm. Of 13 lenses

Courtesy of Samuel Masket MD

A

Revised design avoids capsule block, iris capture, may be available soon. Howard Larkin reports

implanted so far, no capsule block or optic capture have been observed, Dr Masket reported.

With the newer designs, capsule block has been eliminated and optic capture reduced or eliminated, Dr Masket said.

Samuel Masket: avcmasket@aol.com

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EUROTIMES | MAY 2018

CATARACT & REFRACTIVE

RELIABLE CALCULATION Using steep and flat meridians to improve refractive predictions.

Roibeard Ó hÉineacháin reports

A

new bicylindric intraocular lens calculation method based on the cornea’s steep and flat meridians appears to predict refractive outcomes with greater accuracy than the Haigis formula in cataract patients with low corneal astigmatism, said Jorge A Calvo-Sanz OD, MSc, Institute of Visual Sciences, Hospital La Zarzuela, Madrid, Spain.

“Bicylindric method showed an improvement in the refractive management of cataract patients predicting refractive outcomes up to 8% more accurately than classical IOL calculation methods,” Dr Calvo-Sanz told the 22nd ESCRS Winter Meeting in Belgrade, Serbia.

He presented the findings of a study in which he compared the predictability of bicylindric IOL power calculations with that of the Haigis formula in 62 eyes of 62 patients with a mean age of 71.63 years (49 to 87 years).

Four weeks after surgery, the mean difference between the spherical equivalent predicted by the Haigis formula and that achieved was -0.117 D, whereas the mean difference between the spherical equivalent predicted by the bicylindric approach and that achieved was -0.054 D, he noted.

Furthermore, the percentage of patients who achieved predicted refraction by the Haigis and the bicylindric method was 76.70% and 84.30% respectively. Moreover,

Courtesy of Jorge A Calvo-Sanz OD, MSc

10

Linear correlation between Achieved Spherical Equivalent and Bicilindric method prediction using both keratometry readings (A) and Achieved Spherical Equivalent and Biometry prediction using Haigis formula and mean keratometry (B).

Bicylindric method showed an improvement in the refractive management of cataract patients...

implantation of an acrylic monocular lens through a 2.8mm clear paralimbal corneal incision at 135 degrees.

Dr Calvo-Sanz noted that IOL lens power calculation for cataract surgery is generally performed using biometrical measurements such as mean keratometry and axial length, and several regression formulas to obtain IOL power to get emmetropia in spherical equivalent.

The bicylindric method of IOL power calculation uses both keratometry readings, steep and flat, to improve the reliability and precision of the prediction of refractive outcomes, he explained.

“IOL power calculation according to the bicylindric method of intraocular lens power calculation is a simple and reliable way to predict the final refractive outcomes in patients with low corneal astigmatism,” he concluded.

Jorge A Calvo-Sanz OD, MSc

Jorge A Calvo-Sanz: jacalvosanz@gmail.com

the linear correlation between bicylindric formula and achieved result was positive and statistically significant (p<0.001), but the correlation between Haigis prediction and the achieved outcome was also positive but not statistically significant.

None of the patients had undergone previous ocular surgery or had ocular pathology other than cataract. In addition, all had axial lengths greater than 21mm, and a flat keratometry axis between 0 and 90 degrees. Optical biometry was performed using the IOLMaster700 (Carl Zeiss Meditec). All patients underwent

ask the experts EUROTIMES | MAY 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.

VIENNA 2018 36 Congress of the ESCRS TH

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

Main Symposia n

Corneal Cross-Linking: Current Status and Future Perspectives

n

The Diabetic Eye

n

Glaucoma for the Cataract Surgeon

n

Extending Depth of Focus

n

Refractive Surgery for High Ametropia

n

The Enigma of Pseudoexfoliation

Ridley Medal Lecture Rudy Nuijts THE NETHERLANDS

Scientific Programme Registration & Hotel Bookings

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36th Congress of the ESCRS 22–26 September 2018

Saturday 22 September

Saturday 22 September

Sunday 23 September

Lunchtime Symposia

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Boxed Lunch Included

Boxed Lunch Included

Boxed Lunch Included

13.00 – 14.00

13.00 – 14.00

13.00 – 14.00

Dry Eyes – Targeted Treatment as a Key to Satisfied Patients

Rationalization of Prescriptive Behaviors in Ophthalmology for the Containment of Antibiotic Resistance

Glaucoma Treatment: From Eyes Drops to Surgical Intervention, When and What to do?

Moderators: F. Bandello ITALY B. Malyugin RUSSIA

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Innovative Solutions for Presbyopia and Refractive Errors Moderators: P. Stodulka CZECH REPUBLIC R. Shetty INDIA Sponsored by

14

CATARACT & REFRACTIVE

JCRS HIGHLIGHTS VOL: 44 ISSUE: 1 MONTH: JANUARY 2018

NEGATIVE DYSPHOTOPSIA Negative dysphotopsia (ND) is an enigmatic condition with no clearly established mechanism. US researchers conducted a retrospective study asking how best to manage ND linked with cataract surgery.

They compared various strategies in second eye surgery in patients who had reported IOL exchange, reducing posterior chamber depth, piggyback secondary IOL placement, bag-to-sulcus IOL exchange and reverse optic capture. ND was associated with acrylic or silicone IOLs of square- or round-edge design. It was reduced, eliminated or prevented when the IOL optic overlaid the anterior capsulotomy rather than when the capsule edge overlaid the optic. Bag-to-sulcus IOL exchange and reverse optic capture were highly successful in managing or preventing ND. S Masket et al., JCRS, “Surgical management of negative dysphotopsia”, Volume 44, Issue 1, 6–16.

OPTIMISING IOL POWER CALCULATION The Wang-Koch method for optimisation of IOL formulas was developed to reduce hyperopic surprises in eyes with long axial lengths (AL). The current study attempts to provide external validation for this approach. The study looked at 262 eyes with an AL of 25.0mm or longer and compared the predicted postoperative spherical equivalents as calculated from the Holladay 1 formula with the three-week postoperative spherical equivalents. The secondary outcomes of mean absolute error and median absolute error were also analysed. The refractive targets were achieved more often with use of the Wang-Koch adjustment in eyes with ALs longer than 27.0mm, but not in eyes with ALs between 25.0mm and 27.0mm. M Popovic et al., JCRS, “Wang-Koch formula for optimization of intraocular lens power calculation: Evaluation at a Canadian centre”, Volume 44, Issue 1, 17–22.

PAEDIATRIC TRAUMATIC CATARACT Between 12% and 46% of all paediatric cataracts are attributable to ocular injury. Cataract surgery with IOL placement, when possible, is considered the safest and best practice in cases of traumatic cataract.

However, because of the risk for amblyopia and the ongoing growth of the eye, refractive rehabilitation following surgery is clinically challenging. The current study evaluated 106 children, mean age 7.6 years, looking at refractive and visual outcomes of paediatric traumatic cataract requiring surgery and evaluating the factors influencing success. Seventy-nine children had open-globe injuries and 27 had closed-globe injuries. The study concluded that surgical intervention for traumatic cataract had generally good visual and refractive outcomes. Intraocular lens management as a secondary or staged procedure had low complication rates and can lead to higher accuracy of the target refraction. Closed-globe injuries and older age were associated with better visual outcomes and refractive accuracy.

A Yardley et al., JCRS, “Refractive and visual outcomes after surgery for Pediatric traumatic cataract”, Volume 44, Issue 1, 85–90.

THOMAS KOHNEN European editor of JCRS

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CORNEA

REDUCED NEED FOR REPEAT PK

w Ne ded an exp l-RBF Hil

Better EK, prosthetics, outcomes could cut need for full-thickness re-grafts. Howard Larkin reports

S

teadily improving outcomes for treating failed penetrating keratoplasty (PK) grafts with endothelial keratoplasty (EK) and corneal prosthetic implants could reduce the need for repeating PK, Donald Tan MD told the American Academy of Ophthalmology 2017 Annual Meeting in New Orleans, USA. “As the learning curve for DSAEK, and now DMEK, allows us to reduce complications and rejection rates of repeat grafting, it is likely that less repeat PKs will be performed,” said Dr Tan, of the Singapore National Eye Centre.

Singapore registry data show that long-term graft survival rates for PK vary dramatically by indication, with repeat PK among the worst (Tan et al, Ophthalmology 2008). In fact, at about 70%, PKs generally have about the same 10-year graft survival rates as kidney transplants, while high-risk PKs, including all repeat PKs, are only about 40% – worse than liver transplants, according to another study (Waldock A, Cook SD. BJO 2000;84:813-815).

“This is rather depressing,” Dr Tan said.

But are the alternatives better? The evidence is growing stronger, Dr Tan said.

Reported graft survival rates for Descemet’s stripping automated EK (DSAEK) after failed PK run as high as 96% at four years for patients without glaucoma (Anshu A, Price MO, Price FW. Ophthalmol 2011:18:2155-2160). Similarly, a study

by Dr Tan and colleagues found an 86.5% PK-EK survival rate compared with 51.3% for PK-PK at five years (Ang et al. AJO 2014;158:1221-1227).

“For us, EK was far superior,” Dr Tan said.

However, Australian registry data suggest the opposite, with repeat PK graft survival rates significantly higher than PK-EK for keratoconus and pseudophakic bullous keratopathy patients – though EK failure rates were much higher for inexperienced surgeons, suggesting learning curve is a factor, Dr Tan said (Keane MC et al.

BJO 2016;0:1-7). Looking down the road, Descemet’s membrane EK (DMEK) may further improve graft survival after failed Donald Tan PK, though this procedure, too, may be more challenging in post-PK eyes.

The Boston KPro 1 prosthesis success rate runs around 60% out to seven years (Aldave JA et al. Ophthalmol 2012; 119:1530-1538) and shows success rates similar to DSAEK out to five years (Ahmad et al.

Ophthalmology 2016).

“For severe PK failures with total stromal opacification, the Boston Type 1 KPro now appears to be a viable alternative to repeat PKs, with improved intermediate-term survival rates,” Dr Tan said.

However, additional follow-up is needed to determine how long-term success rates compare for the KPro versus EK surgery, he added.

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CORNEA

COMBINED OR SEQUENTIAL? Sequential surgery is the best option for most Fuchs’ endothelial cell dystrophy and cataract. Roibeard Ó hÉineacháin reports B

Courtesy of Iva Dekaris MD, PhD

A

Slit-lamp images of eye with Fuchs endothelial dystrophy submitted to sequential cataract and DSAEK surgery: a) pre-DSAEK and b) 1 month post-DSAEK.

T

he corneas of most Fuchs’ endothelial dystrophy patients appear to endure cataract surgery quite well.

Combining phacoemulsification with endothelial grafting in the same operation should be reserved for eyes where either or both conditions are at a more advanced stage, said Iva Dekaris MD, PhD, Svjetlost University Eye Hospital, Zagreb, Croatia.

“In our hands, the majority of our Fuchs’ endothelial dystrophy patients have good visual results for months and years after undergoing phacoemulsification alone,” Dr Dekaris told the 22nd ESCRS Winter Meeting in Belgrade, Serbia.

Dr Dekaris noted that when she and her associates retrospectively analysed their database of all Fuchs’ endothelial dystrophy patients at their centre who underwent phacoemulsification, they found that 66.0% of patients did not require Descemet’s stripping automated endothelial keratoplasty (DSAEK) in the first two years after their cataract procedure. At three-to-four months, 21.65% required DSAEK, as did a further 1.5% after eight-to-12 months and a further 10.82% after one year.

There were also significant differences between patients who later required DSAEK and those who did not, in terms of mean endothelial cell density (ECD) (1,225 cells/mm2 vs 1,742 cells/mm2), mean pachymetry (670µm vs 587µm) and anterior chamber depth (2.38mm vs 3.14mm).

Among the eyes that required DSAEK after phacoemulsification, the interval between the two procedures was three-tofour months in eyes with a corneal thickness greater than 700µm, compared to eight-to-14 months in those with central corneal thickness less than 600µm.

However, there appeared to be an uneven threshold of tolerance for phacoemulsification in terms of the preoperative Fuchs’ parameters, not only throughout the population but Iva Dekaris MD, PhD

...the majority of our Fuchs’ endothelial dystrophy patients have good results after undergoing phaco alone

EUROTIMES | MAY 2018

sometimes in the same patient. She cited the case of a man who required DSAEK in only one eye despite having very similar central corneal thickness, ECD and anterior chamber depth in both eyes.

Dr Dekaris noted that the advantages of performing endothelial keratoplasty and cataract procedures separately include the greater stability it affords the IOL, reduced vitreous pressure during the DSAEK procedure and better chamber stability and a lower risk of iatrogenic primary graft failure.

The advantages of a combined procedure are that it reduces costs and inconvenience and leads to faster visual rehabilitation.

However, as the current study shows, many patients do not need DSAEK after phacoemulsification surgery, she said.

The literature suggests that sequential surgery should be done in eyes where the cornea has guttae and minimal oedema, only mild endothelial cell loss and the cataract is immature. Combined surgery should be performed in eyes with corneal oedema with significant guttae, epithelial oedema, history of morning blurry vision plus visually significant cataract.

IMPROVEMENT IN VISION In eyes with very dense cataract and/or advanced endothelial dystrophy it is possible to determine the amount of visual loss attributed to each condition. However, in most eyes the distinction tends to be less clear.

Moreover, most patients will have an improvement in their vision following cataract surgery only, Dr Dekaris said.

She noted that although phacoemulsification can have a worsening effect on Fuchs’ endothelial dystrophy, treating a cataract when still immature can reduce that effect by reducing the need for phaco power. In addition, she noted that facility in performing the DSAEK afforded by the increased anterior depth following cataract extraction somewhat compensates for the injury to the endothelium phacoemulsification may induce.

She also cautioned that their study was limited by the small number of Fuchs’ endothelial dystrophy patients requiring grafts at their centre. Such patients only accounted for 2.3% of their corneal transplantations during the years 2010 to 2017. “Hopefully centres with higher surgical volume will perform retrospective randomised studies determine which option is better for a particular Fuchs’ endothelial cell dystrophy case,” Dr Dekaris said.

Iva Dekaris: iva.dekaris@svjetlost.hr

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Young Retina Specialists Day Saturday 22 September Including the Ophthalmologica Lecture

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RETINA

19

PERSONALISED THERAPIES Biomarkers may pave way to better management of diabetic retinopathy patients. Dermot McGrath reports

Courtesy of Gabor Mark Somfai MD, PhD

S

ystemic and ophthalmic biomarkers may facilitate a better understanding of diabetic retinopathy (DR), and pave the way towards more personalised therapies to prevent vision loss in people with diabetes, according to Gabor Mark Somfai MD, PhD. “There has been a lot of interesting research over the past few years into the mechanisms of diabetic microvascular complications. It is known by now that adipose cells are producing various proinflammatory cytokines that circulate in the blood and are responsible for insulin resistance. Vascular damage by the advanced glycation ultimately leads to diabetic macular oedema (DME) and proliferative diabetic retinopathy (PDR).

To prevent this, I believe one day we might be able to determine the adequate and optimal preventive steps or therapy for these patients by looking at the pattern of their metabolism,” Dr Somfai told delegates attending the 8th EURETINA Winter Meeting in Budapest.

The duration of diabetes and the severity of hyperglycaemia are the two major risk factors for developing retinopathy, said Dr Somfai. According to the pivotal studies in diabetes, approximately 25% of patients with type 1 diabetes will develop retinopathy after five years, rising to 60% after 10 years and 80% after 15 years.

For type 2 diabetes, 40% of patients with insulin control and 24% without insulin will have some form of retinopathy after five years, increasing to 84% with insulin and 53% without after 19 years.

“We need to bear in mind that control is the only controllable factor. Once diabetes is present, then the duration is less important than glycaemic control. A HbA1c blood glucose level of below 7% is recommended. In the United Kingdom

Automated segmentation of a macular OCT image, showing several retinal layers along with the outer boundary of the choroid

Prospective Diabetes Study (UKPDS) study, each 1% reduction in HbA1c with intensive glucose therapies was associated with a 37% reduction in the risk of retinopathy, which is very significant,” he said.

Dr Somfai said that research by Dr Katja Hatz (Basel, Switzerland) presented at the ARVO in 2017 has shown that the total HbA1c load over the entire course of diabetes correlates highly with the DR status of the patient even after adjusting for age, sex and duration of diabetes.

“The total load shows a strong correlation with DR status and may one day be used as a marker of glycaemic control in patients,” he said. The concept of “metabolic memory” should also be borne in mind when treating diabetic patients, said Dr Somfai.

“Essentially, this means that the cells will remember the past glycaemic control for at least five years, whether it is good or bad. Bad glycaemic control will have an influence on cell metabolism for this period, so the patient needs to be advised that prior glucose control has sustained effects that persist even after return to more usual glycaemic control,” he said.

Blood pressure and cholesterol control should also be closely monitored to help

reduce the risk of visual loss over the long term, added Dr Somfai.

Liquid biopsy of the vitreous could pave the way for a more personalised choice of intravitreal treatment for macular oedema, while systemic biomarkers could indirectly indicate the actual stage of diabetic retinopathy. Ophthalmic imaging biomarkers could also play an important role not only in the prediction but perhaps one day also in the choice of macular oedema treatment. The structural and topographic information obtainable by standard optical coherence tomography (OCT) and the quantitative information of the macular microvasculature delivered by OCT angiography may also play an important role not only in patient counselling in terms of outcome expectations but also in therapeutic decision making.

In the not so distant future, Dr Somfai concluded, all these biomarkers could potentially be used in a novel approach together with big data analysis and machine learning, which would serve as rocket fuel for better clinical decisions.

Gabor Mark Somfai: gabor.somfai@pallas-kliniken.ch

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RETINA

ANTI-VEGF COMPARISON Ranibizumab and aflibercept both effective in RIVAL study for nAMD. Dermot McGrath reports

B

oth ranibizumab (Lucentis, Novartis) and aflibercept (Eylea, Regeneron) are effective treatments for neovascular agerelated macular degeneration (nAMD) when used in a treat-and-extend protocol, according to the interim 12-month results of the RIVAL study presented at the 17th EURETINA Congress in Barcelona.

“This is the first randomised controlled trial to compare ranibizumab and aflibercept in nAMD patients using an identical treat-and-extend dosing regimen.

Significant visual acuity improvements were achieved by patients in both treatment arms and with the same mean number of injections,” said Mark Gillies MB, BS, PhD, FRANZCO, Director of Research, Save Sight Institute, and Director of the Macula Research Group at the University of Sydney, principal investigator of the RIVAL study.

The primary outcome of the RIVAL study is the development of geographic atrophy (GA) over a two-year period, said Prof Gillies. It follows the results of the Fight Retinal Blindness (FRB) Study Group’s report of a lower rate of

GA compared to the SEVEN-Up study, which looked at seven-year outcomes in ranibizumab-treated patients that had participated in the ANCHOR, MARINA and HORIZON trials.

“The SEVEN-UP study followed 65 patients who had been through these trials and they reported that macular atrophy was affecting the centre of the fovea in nearly 90% of cases, suggesting that this would eventually happen to practically all patients on chronic VEGF inhibition.

In our FRB study we followed a cohort of 120 eyes for seven years and found that geographic atrophy was the cause of a 10or greater letter loss in only around 40% of eyes,” he said.

Atrophy progression may be associated with loss of vision over time, said Prof Gillies. The mean visual acuity decline from baseline was -8.6 letters for SEVEN-UP compared to -2.6 letters for the FRB study, with 40% of FRB eyes achieving 20/40 or better, compared to 23% in SEVEN-UP. “The big difference between the studies was that we were treating much more intensively in Australia, with two or three times as many injections as patients

Practice Management

ESCRS

20

& Development

received in the final three years of SEVENUP,” he said.

Prof Gillies presented the 12-month data for 141 patients who received ranibizumab and 139 patients treated with aflibercept. Three markers of disease activity were used during the treat-andextend period: a loss of visual acuity of more than five letters compared to the best visual acuity recorded since treatment began; new retinal haemorrhage; and the presence of any intraretinal fluid or subretinal fluid on OCT. “If one marker was present the injection interval was reduced by two weeks, and if two or more criteria were present, the interval was back to four weekly injections,” said Prof Gillies.

Similar visual acuity improvements were achieved by month 12 in both treatment arms, with the same mean number of injections.

Prof Gillies said that the study was ongoing, and a full analysis would be carried out at the end of the 24-month follow-up period.

Mark Gillies: mark.gillies@sydney.edu.au

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GLAUCOMA

OCTA AND GLAUCOMA OCT angiography of perifoveal macular thickness reliably predicts early glaucoma. Roibeard Ó hÉineacháin reports

O

ptical coherence tomography angiography (OCTA) with the RTVue100 (Optovue) can distinguish between healthy eyes and those with early glaucoma.

Moreover, perifoveal macular thickness is more informative than peripapillary RNFL thickness, said Abubakar Bosso Usman MD at the XXXV Congress of the ESCRS in Lisbon, Portugal.

“Although the results of some researchers have shown limitations of the macular thickness parameters in the early diagnosis of glaucoma, this may be related to the technology, as OCT continues to evolve,” said Dr Usman, Department of Ophthalmology, 3rd Minsk City Hospital, Belarusian State Medical University, Republic of Belarus.

The prospective cross-sectional hospital-based study was conducted between January and June 2016. It included 40 eyes of 23 patients with early-stage primary open-angle glaucoma (POAG), 30 eyes of 17 glaucoma suspects and 20 eyes of 10 healthy patients. All of the patients were aged 40 years and older, had a best corrected visual acuity of 0.6 and better; spherical and cylindrical correction of plus or -2.5D and an open anterior chamber angle with no pigmentation and/or exfoliative material.

All eyes underwent OCTA scanning of the retina using the RTVue100 Optovue. The ‘ONH scan’ and ‘Retina Thickness

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Map program’ were respectively used to scan the 3.45mm peripapillary and a 5mm x 5mm region of the perifoveal macular regions. The parameters analysed included the retinal nerve fibre layer (RNFL) and perifoveal inner macular average total, superior, inferior, temporal and nasal thickness.

“Optical coherence tomography angiography is a new highspeed non-invasive imaging device with a high resolution and demonstrably better intraretinal layer separation. It also offers the ability of getting more sampling points of the macula, including determination of the full, inner and outer macular thickness, the fovea, and the perifoveal areas of the macula separately, at the same time maintaining a good scan quality,” Dr Usman said.

GREATER CHANGES IN PERIFOVEAL THAN PERIPAPILLARY THICKNESS Statistical analysis found that patients in the stage I POAG group had significant decreases in all parameters of the peripapillary RNFL and perifoveal macular thickness compared to the control group. However, inter-group analysis using Mann-Whitney criteria revealed statistically significant differences only between the main and control groups in superior (139μm vs 163μm, p<0.05) and inferior (12μm vs 136.5μm, p<0.05) RNFL thickness. Peripapillary RNFL thickness did not differ significantly between the early glaucoma and the glaucoma suspect groups, or between the control and the glaucoma suspect.

However, perifoveal inner macular thickness was significantly different between the glaucoma and the control groups in the average total (275μm vs 289μm), in the temporal (271μm vs 290μm) and nasal (289μm vs 303μm) regions. In addition, there were significant differences in perifoveal inner macular thickness between the glaucoma and glaucoma suspect groups in terms of average total macular thickness (275μm vs 285μm), in the temporal (271μm vs 287μm) and nasal (289μm vs 298μm) regions. The study showed no significant differences between the control and glaucoma suspect groups in terms of perifoveal inner macular thickness.

Dr Usman noted that structural changes precede functional changes in glaucomatous chronic optic neuropathy, and it is the death and damage in retinal ganglion cells that underlies the pathology. Optical coherence tomography detects the atrophy of the RGC axons as a thinning of the retinal nerve fibre layer.

“Using angiographic OCT in our study we were able to identify the thinning of peripapillary RNFL and perifoveal inner macular thickness in the early stages.

However, the macular parameters demonstrated higher areas under the curve,” he concluded.

Abubakar Bosso Usman: drbossoau@gmail.com

Optical coherence tomography angiography is a new high-speed non-invasive imaging device Abubakar Bosso Usman

GLAUCOMA

HOW TO TREAT IIH PATIENTS Lowering intracranial pressure is key for managing sight-threatening condition. Howard Larkin reports

P

atients with possible idiopathic intracranial hypertension (IIH) require a complete neurological workup to ensure proper diagnosis and treatment, Courtney E Francis MD told the American Academy of Ophthalmology Annual Meeting in New Orleans, USA. Idiopathic intracranial hypertension is a condition most often seen in overweight young women that can lead to permanent vision loss. However, venous sinus thrombosis, meningioma, meningitis and even very high blood pressure can cause similar signs and symptoms, noted Dr Francis.

IIH typically presents with papilloedema and headache often accompanied by nausea, Dr Francis noted. On fundus examination, it can look like hypotony, with disc oedema and choroidal folds, suggesting that a translaminar pressure difference may play a role in both. History also often includes transient vision obscurations and pulsatile tinnitus.

Papilloedema, sixth nerve palsy and visual field defects consistent with papilloedema also may be present – and nothing else.

“It is a diagnosis of exclusion,” she said.

RULING OUT SECONDARY CAUSES Since treatment for IIH differs significantly from treatment of intracranial hypertension secondary to other causes, Dr Francis recommended a diagnostic routine based on modified Dandy criteria. These include signs and symptoms of increased intracranial pressure, no localising findings on neurological exam, normal cerebrospinal fluid except for increased pressure above 20-25cm water, normal neuroimaging except for empty sella turcica, dilated optic nerve sheaths or venous sinus stenosis, patient awake and alert and no other cause of increased ICP identified (Friedman et al. Neurology 2013; 81: 1159-1165).

Imaging should include MRI of the brain with and without gadolinium contrast, and magnetic resonance venography of the head to identify potential anatomic abnormalities or tumours, Dr Francis said. She also recommended lumbar puncture with opening pressure measure, and cerebrospinal fluid analysis to rule out meningitis.

Treatment of IIH is aimed at lowering intracranial pressure, Dr Francis said. Diet to reduce weight and medication with carbonic anhydrase inhibitors are firstline therapies. In the Idiopathic Intracranial Hypertension Treatment Trial, which included 165 patients of which four were men, patients receiving acetazolamide had improved papilloedema grade and visual field function. The medication was mostly well tolerated up to 4.0gm per day (JAMA 2014; 311(16):1641-1651).

Potential surgical treatments for patients intolerant of medication or with more severe vision loss include optic nerve fenestration, CSF diversion surgery and venous sinus stenting, Dr Francis said. Further research into genetic markers as well as the efficacy of surgical interventions are needed to better understand and control IIH, she added.

ESCRS

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Courtney E Francis: francis3@uw.edu EUROTIMES | MAY 2018

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24

PAEDIATRIC OPHTHALMOLOGY

Accommodative

Esotropia

Experts debate the best approach for high AC:A ratio accommodative esotropia â&#x20AC;&#x201C; surgical or non-surgical. Soosan Jacob MD reports

C

linicians debated the relative merits of non-surgical management versus surgical management for high AC:A ratio accommodative esotropia at a session of the World Congress of Paediatric Ophthalmology and Strabismus in Hyderabad, India.

Dr David Newsham, Head of Orthoptics & Vision Science, University of Liverpool, UK, arguing in favour of non-surgical treatment, said that the first aim was to establish diagnosis and classification, determine refractive error (predominantly hypermetropia â&#x20AC;&#x201C; usually between 1.5-5 dioptres), measure visual acuity (usually equal in both eyes and without amblyopia unless anisometropia is present), check for amblyopia and establish the level of control of binocular vision, all of which determine the type of management chosen.

Though non-surgical management includes miotics, prisms, botulinum toxin and contact lenses, the most effective option is single-vision lenses and bifocals, he said. Orthoptic exercises are a useful adjuvant. He also said that it was important to fully correct hypermetropia, as even one dioptre of undercorrection could increase the angle of deviation, more so in cases of high AC:A ratio.

In case of bifocals, the minimum reading correction should be started with (about +1D) and then increased by 0.50D, so that binocular single vision is maintained and the print is seen clearly. A binocular visual

...glasses could be used if it was understood that at one point surgery would be needed to treat the condition Mustafa Mehyar

acuity test is used to assess control and to see if extra add is required.

He summed up by saying that bifocals had advantages of being effective in decreasing the angle of deviation, giving fusion while being inexpensive, noninvasive and readily available. He said that if well controlled and tolerated, they could be gradually reduced and stopped, and if poorly tolerated or controlled or in case of recurrence of esotropia after gradual reduction of bifocals, the option of surgical treatment could be exercised next without any negative effect.

Dr Newsham argued that with success rates of about 70% in surgical group and 66% with bifocals, a non-surgical option made sense as the first option.

Dr Mustafa Mehyar, a consultant paediatric ophthalmologist from Amman, Jordan, on the other hand, preferred surgical treatment, stating that less than half of patients with convergence excess esotropia would respond to additional plus lenses in clinic so as to qualify for bifocals.

He also argued that if long-term failure rate from optical treatment was high, there

Though non-surgical management includes miotics, prisms, botulinum toxin and contact lenses, the most effective option is single-vision lenses and bifocals David Newsham EUROTIMES | MAY 2018

was no reason to subject the patients to difficulties for years.

He quoted a 10-year study where only 61% could be weaned off glasses after five years, and further, surgical correction of deteriorated accommodative esotropia was needed in 50% of those weaned off glasses and one-third of those who continued to wear glasses. Several studies of surgical correction of convergence excess esotropia show a success rate of motor alignment with one operation of approximately 70-95%. Nearly half were able to eliminate glasses completely.

Disadvantages of optical correction included difficulty in getting the segment to bisect the pupil, difficulty in adjusting to the bifocal segment; having to assume a chin-up position for near work, blurring in downgaze; possibility of reduced near point of accommodation, cosmetic issues, especially with executive lenses, unsatisfactory correction for intermediate and very close distances, disruptions to emmetropisation etc. All of these factors may reduce the time glasses are used during the day and hence cause other visual problems.

Dr Mehyar admitted that in younger children, when it is difficult to take accurate measurements, glasses could be used if it was understood that at one point surgery would be needed to treat the condition.

David Newsham: D.Newsham@liverpool.ac.uk Mustafa Mehyar: mustafamehyar@hotmail.com

PAEDIATRIC OPHTHALMOLOGY

TREATING STRABISMUS Evaluating minimally invasive strabismus surgery versus Fornix incision. Soosan Jacob MD reports

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inimally invasive strabismus surgery (MISS) is an exciting new option for the treatment of strabismus, potentially offering several advantages over current conventional techniques, Simon Westby, University College London, UK, told the World Congress of Paediatric Ophthalmology and Strabismus in Hyderabad, India.

Mr Westby first detailed the technique itself. Two radial parainsertional keyhole incisions are made at the upper and lower borders of the muscle respectively, with a sub-Tenon tunnel connecting the incisions. A recession or plication is then performed. The theoretical advantages of this technique include more rapid healing, reduction in immediate postoperative complications and reduced long-term postoperative scarring.

He said that although previous data by Sharma et al. in 2014 suggested a benefit in the short-term complication rates for MISS as compared to the limbal incision, no studies have compared it to the Park’s fornix incision. This was especially important because the majority of the potential benefits of MISS could also be applied to Park’s fornix incision surgery.

His study therefore aimed at looking for any difference in effectiveness, quality of life, complication rates and surgical success between these two approaches.

This was a prospective study over nine months that included 14 patients, with seven in each group. The fornix recess-resect procedure was compared with a MISS recessplication procedure for horizontal strabismus surgery, as measured by dioptres achieved per mm moved, pre- and postoperative Adult Strabismus-20 (AS-20) questionnaires and postoperative complication rates.

The study found a significant difference in the effectiveness of the surgical procedures, with MISS showing reduced effect of surgery per mm. The significant difference in effectiveness could in part be explained by the fact that MISS patients underwent plication versus a resection for the fornix incision group.

MISS patients also had a smaller preoperative angle of deviation and it is known that higher angles of deviation generally respond better to surgery. In addition, there could be some effect of fascial pulleys that remain following incomplete dissection. He also highlighted that intraoperative target visualisation is reduced during MISS, and hence the distance that muscles are moved may be overestimated. Taken together, he emphasised that this finding should be taken into account during patient selection and when deciding on surgical dosage.

The study found no significant difference in postoperative complication rates, surgical outcome or in pre- and postoperative AS-20 scores. A lack of significant difference in postoperative complication rates likely reflected the short follow-up period of his study. Indeed, it was possible that with longer-term follow-up, MISS would show reduced fibrosis and scarring compared to Park’s fornix incision and thus provide easier access and better tissue quality for any redo procedures.

To conclude, he stressed the importance of the study as a step towards understanding the role of MISS and the need for larger, randomised studies with longer follow-up.

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Simon Westby: simon.westby.13@ucl.ac.uk EUROTIMES | MAY 2018

25

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PAEDIATRIC OPHTHALMOLOGY

KERATOPLASTY IN CHILDREN Evolving approaches to different indications for surgery.

Soosan Jacob MD reports

T

he overall success rate of keratoplasty in children ranges widely, from 40% to 90% in different studies.

The numbers are influenced by many pathological variables, and the influence of new procedures remains unclear, according to Merle Fernandes MD, Director, LV Prasad Eye Institute (LVPEI), Visakhapatnam, India.

Dr Fernandes discussed the outcomes of paediatric keratoplasty in a session of the World Congress of Paediatric Ophthalmology and Strabismus 2017 in Hyderabad, India.

The wide variety of outcomes of paediatric keratoplasty can be attributed to the fact that the child’s eye and the pathology that affects it are both different from that in adults. Indications for transplantation in a child are many and range from congenital causes to acquired, such as those secondary to trauma, infection or keratoconus. Depending on the pathology, some of these cases require endothelial keratoplasty, others require deep anterior lamellar keratoplasty and yet others, penetrating keratoplasty.

Advantages of anterior lamellar keratoplasty such as operating as a closed chamber procedure, lesser risk of rejection, retention of the precious host endothelial cells and greater graft survival that adult patients enjoy are also applicable in case of children, she said.

Advantages of endothelial keratoplasty include the transplantation of lesser volumes of antigenic tissue, less risk of rejection, the use of softer steroids, lesser astigmatism and lesser surface- and suture-related problems.

“Though changing trends reflecting the general changes seen in adult keratoplasties are also being seen in paediatric keratoplasties, paediatric data is not yet as clear as the adult data. Surgery requires greater skills, and problems such as management of amblyopia and difficulty in examination still persist after surgery,” Dr Fernandes cautioned.

Citing results from an LVPEI Hyderabad study, she reported that more than 62% patients had greater than 20/80 vision following deep anterior lamellar corneal surgery.

Common indications for anterior lamellar keratoplasty in children included keratoconus and trauma with scarring.

Complications included Descemet’s membrane detachments, graft-host junction dehiscence and infections.

She also showed an example of how epikeratoplasty could be done by tucking in a donor corneo-scleral rim 360 degrees into a scleral pocket following alcohol epitheliectomy, for a case of keratoglobus with pachymetry of 90 microns in the thinnest area.

One of the indications for endothelial keratoplasty is a failed graft, especially following therapeutic keratoplasty, which often tend to be larger grafts. Poor visibility is a challenge in these cases and an endoilluminator helps in improving visualisation.

Sharing her experience with Descemet’s stripping endothelial keratoplasty with the push-through technique in these cases, Dr Fernandes said that it was important to ascertain absence of interface fluid. Either good tamponade with a tight air bubble for 10 minutes or a longer tamponade followed by burping some air after one hour were choices. The latter though, had the disadvantage of requiring much longer anaesthesia.

WSPOS World Society of Paediatric Ophthalmology & Strabismus

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

Friday 21 September 2018, Vienna, Austria

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

Registration & Hotel Bookings www.wspos.org

Merle Fernandes: merle@lvpei.org EUROTIMES | MAY 2018

27

ESCRS NEWS

In 2012, Dr Rudy MMA Nuijts received the ESCRS Clinical Research Award for “PREvention of Macular EDema after cataract surgery: PREMED study”

ESCRS

NEWS

ESCRS CLINICAL RESEARCH AWARDS

The 2018/2019 ESCRS Clinical Research Awards is an initiative sponsored by the ESCRS to support and encourage independent clinical research in the field of cataract and refractive surgery.

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

The purpose of the Award is: to support, encourage and fund individuals that actively conduct clinical research in the field of cataract and refractive surgery; to facilitate and support an independent culture of clinical study for the ultimate benefit of patients with cataract and refractive disorders; to engage and encourage the networking potential of the ophthalmic clinical community across the EU to improve both patient care and outcomes. €750,000 is available over three years for the right project with suitable infrastructure and experience.

Ideas ranging from clinical research into the use of specific medical treatments and surgeries, or clinical research on the pharmaco-economic analysis of particular treatments, or research into the optimal management of national and global health care systems in ophthalmology; all such initiatives may be eligible for consideration in the Awards.

Previous winners of the ESCRS Clinical Research Awards include Dr Rudy MMA Nuijts MD, PhD, University Hospital Maastricht, Netherlands (2012), Prof Mats Lundström, Karlskrona, Sweden (2013) and Dr Jan-Willem M. Beenakker and Prof Dr Oliver Findl (2016).

The deadline for application is 31 May 2018. For more information visit http://clinicalresearch.escrs.org

∙ ∙ ∙

Paul Rosen

ESCRS MARKETING COMPETITION The deadline for the ESCRS Practice Marketing Competition is Monday 30 July 2018. The winner will be announced during the 36th Congress of the ESCRS in Vienna.

“The competition is an opportunity for ophthalmologists to make a contribution to the Practice Management and Development Programme,” said Paul Rosen, chair of the Committee.

“The competition enables ESCRS members to demonstrate what they have achieved with their entrepreneurial skills and show colleagues what they may be able to do in their own businesses.”

For more information visit: http://www.escrs.org/ vienna2018/programme

Reach the peak.

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

EUROTIMES | MAY 2018

29

INDUSTRY NEWS

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ZEISS EXPANDS DIGITAL SOLUTIONS PORTFOLIO Carl Zeiss Meditec showed the new OPMI Lumera 700 surgical microscope with built in swept-source OCT and CALLISTO eye toric IOL alignment system at the ASCRS 2018 Annual Meeting in Washington, DC, USA. The new IOLMaster 700 with swept-source OCT that can measure curvature of the posterior cornea was also on display. These features are available in Europe, but not yet in the USA. “We are continuing to expand our portfolio of integrated digital solutions that span from the office to the OR,” says Jim Mazzo, Global President Ophthalmic Devices at Carl Zeiss Meditec. “Our goal is to provide doctors and surgeons advanced technologies to help them care for their patients in the best way possible."

EVOLVING PLATFORM LENSAR has received 510(k) clearance from the US Food and Drug Administration for the LENSAR Laser System with Streamline IV, expanding the platform’s capabilities to include the creation of the corneal pockets and flaps used in ophthalmic procedures treating presbyopia.

“The continued expansion of capabilities with the LENSAR Laser System is the latest demonstration of our commitment to technological innovation,” said Nicholas Curtis, CEO of LENSAR. “It made sense to evolve our platform to support surgeons meeting the increasing patient demand with options for the treatment of presbyopia with corneal inlay devices.” http://www.lensar.com/

OZURDEX LAUNCHED IN CHINA FOR RVO Allergan has announced the launch of Ozurdex (dexamethasone intravitreal implant 0.7mg) in China for the treatment of adult patients with macular oedema secondary to retinal vein occlusion (RVO).

Ozurdex is the first approved intravitreal injection for RVO in China and is licensed for the treatment of macular oedema following BRVO and CRVO. “Providing millions of RVO patients access to Ozurdex is a significant step towards preventing blindness and meeting a critical unmet need in China,” said Marc Princen, Allergan International President. http://www.allergan.com/

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32

EXPLORING VIENNA

Figlmüller Wollzeile, home to one of the finest schnitzels Vienna has to offer

VIENNA

3

TO TASTE...

EXPERIENCE THE PERFECT STRUDEL One of the world’s most beloved pastries is the apple strudel, and Vienna is its home. The authentic Austrian strudel consists of layers of very thin pastry swirled around a filling of tart apples, raisins, breadcrumbs, sugar and cinnamon. ‘Strudel’ means ‘whirlpool’ and refers to its appearance when baked and sliced. The earliest recipe, dating from 1689, is preserved in Vienna’s town hall. Where to experience the perfect strudel in Vienna? One great choice is the Café Mozart, which has been a centre of Viennese society life since 1794. “Can’t we meet at Café Mozart” is a line in the film The Third Man; the author, Graham Greene, was a frequent guest. Café Mozart, Albertinaplatz 2.

THE APPRENTICE WHO BECAME A MASTER In 1832 – in what must rank as one of the most successful achievements of any pastry apprentice ever – the 16-year-old Franz Sacher created the Sacher torte. Instructed by Prince von Metternich, Chancellor of the Austrian Empire, to devise a cake that would impress the Prince’s guests, Franz came up with the combination of chocolate cake and apricot jam that has been impressing cake fanciers ever since. Years later, the apprentice’s son opened Vienna’s Sacher Hotel, where the authentic and original Sacher torte is still served. Packaged Sacher tortes of various sizes from mini to mega are also available for sale in the hotel or through their online shop, and make a tasty souvenir of Vienna.

Sacher Hotel, Philharmoniker Str. 4; https://www.sacher.com/

PANCAKES LIKE YOU’VE NEVER SEEN BEFORE A challenge to any sweet tooth, the Kaiserschmarrn is another Viennese speciality.

Shredded pancakes, served warm with fruit compote, it’s a dessert to enjoy with a cup of coffee. The name combines the world for emperor, in this case Franz Joseph I, whose favourite this was, with schmarrn meaning ‘mess’ or ‘nonsense’. While there are many tall tales around the origin, it is probably an upmarket version of a simple peasant dish. An excellent place to try Kaiserschmarrn is Café Central. Their fluffy version is served piping hot with a tart fruit sauce. The café, which has preserved its elegant 1876 atmosphere, is in itself worth seeing.

Café Central, Herrengasse 14.

EUROTIMES | MAY 2018

GUTER APPETIT

From schnitzel to strudel there’s much to enjoy at a Viennese dinner table. Maryalicia Post points the way The earliest recipe for Wiener Schnitzel is in a 19th-Century cookbook, which gives instructions for preparing a very thin, breaded and pan-fried cutlet.

Today, few tourists come to Vienna without sampling this dish. Many try it first in a Figlmüller restaurant.

The first, Figlmüller Wollzeile, opened in 1905 in the city centre. It’s still there but now it has three branches, one in Grinzing and the other two within steps of the original in the inner city. Figlmüller Bäckerstrasse, and Lugeck. On my most recent visit I tried Lugeck, where the decor is ‘modern’ – tile and beechwood as opposed to dark wood. I very much missed the cosy atmosphere of the other Figlmüllers, but the schnitzel with its classic potato salad accompaniment was just as good.

Figl in Grinzing is the newest in the group, run by the fourth generation of the family. It’s casual, fun and about 15 minutes by taxi from Reed. Beer drinkers can choose between seven beers from the barrel and a dozen exclusive bottled beers.

Viennese Schnitzel, spare ribs or the Figls Burger taste as good in winter next to a log fire as in summer under the chestnut trees.

A point to note; the classic ‘Viennese’ wiener schnitzel – a term protected by law – must be made with veal. It’s on the menu in three of the four Figl restaurants.

The flagship Wollzeile offers only its own version, the Figl-schnitzel, made from pork. Even so, Figlmüller Wollzeile is the most popular restaurant of the group. Best to book a few days in advance: contact this or any Figlmüller restaurant through http://www.figlmuller.at/ Restaurant 1070 is a self-declared ‘schnitzel-free zone’. It’s also menu free.

The owner/cook/hostess first asks if you

have any food dislikes or allergies, and after that what comes out in course after course is up to her and the kitchen.

Portions are small, but are offered in a sequence starting with a minimum of three courses. Hungry diners can go for as many as seven. My companion had four. I had three, and two of them I didn’t recognise.

They turned out to be (as I learned on enquiring afterwards) dishes I would not remotely have considered ordering had I known in advance what they were. But I enjoyed them and that was even more of a surprise. Perfectly paired wines are available.

It’s a small, candlelit room, an artful setting for an out-of-the-ordinary evening. Vegetarian, coeliac and vegan requirements can be accommodated. The restaurant is on a cobbled backstreet – Gutenberggasse 28, Vienna 1070. (The zip code is the restaurant’s name.) To reserve a table: +43 676 5661774 or through https://www.quandoo.at No schnitzels in sight at Restaurant 1070

RANDOM THOUGHTS

ROBOTICS IN SURGERY What does the future look like for technology and cataract surgery?

Aidan Hanratty reports

R

obots have a mixed history in popular culture.

From the Daleks of Doctor Who to The Iron Man and Futurama’s Bender, they can be terrifying, compassionate and comical. In the real world, their history is more mundane.

An editorial in the Paris Innovation Review defined robots as such: “[They] have a material existence inasmuch as they are endowed with perception (via sensors), can make decisions (via appropriate use of processors) and can undertake physical actions (using integrated motors).” The most common examples are robotic vacuum cleaners and driverless cars.

While automation has led to greater efficiency in some aspects of healthcare, in surgery, things are not quite there yet.

In a recent Eye Contact interview, Dr Richard Packard was asked if he saw robotics entering the field of cataract surgery.

He doesn’t see it happening soon.

“Patients are patients. And you can’t necessarily predict the way that their tissues are going to behave. We also know that there’s a significant cohort of complex patients out there that robots will simply not be able to deal with. The other issue is that if there is a problem during surgery, even if you’re a robot, your ability to adapt to the situation that you find yourself in is going to be quite difficult.”

Other doctors are more wary. Sorcha Ni Dhubhghaill MD believes that surgeons live under the same threat of automation as those in other industries. “I believe that a sophisticated diagnostic algorithm will eventually replace the clinician’s diagnosis just as a sophisticated robot will replace the surgeon.”

She believes that current limitations, as envisaged by Dr Packard, will be overcome by improvements and refinements. “I don’t think it is unreasonable to think that a robot will ultimately be able to perform every move a surgeon can, but better, with no tremor and no need for a lunch break.”

Where next for the surgeon, so? Dr Ni Dhubhghaill believes a pivot is necessary. “While the robots are seeking to perfect the established techniques, the humans will have to innovate and introduce new ideas.” Human-robot co-operation will ensure the value of each working towards an enhanced patient experience.

“I would envision a robo-surgeon and innovative ophthalmic surgeon working as a team.

The robot to provide the best results technically and the ophthalmologist to push the boundaries of the technology.”

Where the patient fits in remains to be seen. Would automated surgery be cheaper? Would such a robot have automated colleagues, such as robot anaesthetists and nurses?

O brave new world, that Sorcha Ni Dhubhghaill MD has such… machines in ’t!

I don’t think it is unreasonable to think that a robot will ultimately be able to perform every move a surgeon can

EUROTIMES | MAY 2018

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PRACTICE MANAGEMENT

MARKETING MASTERCLASS Rod Solar and Laura Livesey are the keynote speakers at the 36th ESCRS Congress. Colin Kerr reports

R

od Solar and Laura Livesey will deliver the ESCRS Practice Management and Development Masterclass at the 36th Congress of the ESCRS in Vienna.

Mr Solar and Ms Livesey founded LiveseySolar Practice Builders in 1997. The company specialises in helping cataract and refractive surgery clients, large and small, to grow.

They have been working with the ESCRS Practice Management and Development Programme since 2011 and have been among the most popular speakers on the programme since it was first established in 2008.

“We are delighted with this opportunity to speak at the leading ophthalmological conference in Europe,” Mr Solar told EuroTimes, “and we look forward to delivering a firstclass masterclass to delegates attending the Congress.”

The topic for this year’s Masterclass, which takes place on Sunday, September 23 from 8am to 5pm, is How to Master the Conversion Funnel: Marketing to patients at every stage of their journey, from information seeking through to surgical booking.

“Most clinics have some sort of funnel for generating leads and converting those leads into paying patients,” said Ms Livesey, “but very few have a truly optimised funnel that maximises customer service and treatments booked, while simultaneously reducing the overall acquisition costs of patients.”

The seven-hour course, split into seven modules, is designed to equip participants with the knowledge and tools they need to increase the growth potential of their refractive surgery practices.

Among the topics to be discussed are: the growth formula that doubles clinic revenues; how to craft a Statement of Value that positions a clinic’s services and gives your ideal patients exactly what they want; the right and wrong way to use discounts in healthcare marketing; the two types of doubt almost every patient experiences; how to deploy an automated follow-up system that converts more leads into patients; and a step-by-step plan to execute the ideas discussed in the Masterclass.

“The idea of the Masterclass is to encourage ophthalmologists to listen, learn and participate,” said Mr Solar. “While myself and Laura will lead the Masterclass, we will be encouraging those in attendance to share their ideas and experiences with us and to tell us what barriers they face when trying to grow their practices.

“At the end of the Masterclass, we hope they will leave the room with valuable take-home messages and actionable ideas that they can bring back to their practices and, most importantly, to implement them for the benefit of their practice staff and their patients.”

After the Masterclass on Sunday, September 23, ophthalmologists are invited to attend a full day of Practice Management and Development lectures delivered by leading marketing experts including Mike Malley, US, David Evans, US, Dr Soosan Jacob, India and Kris Morrill, UK. These lectures will discuss a wide range of topics including practice management, marketing, social media and website development. Both the Masterclass and the lectures are free of charge to all delegates attending the ESCRS Congress.

To register for the Congress, visit www.escrs.org. For more information on the Practice Management and Development Programme, contact Colin Kerr at colin@eurotimes.org EUROTIMES | MAY 2018

CALENDAR

↙

LAST CALL

MAY

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

SAFIR Congress

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

RCOphth Congress 2018

21–24 May Liverpool, UK https://www.rcophth.ac.uk/events-and-courses/ annual-congress-2018/

15th Congress of the South-East European Ophthalmological Society

The World Congress on Clinical, Pediatric and Neuro Ophthalmology and the 33rd Annual Meeting of the JSCRS will both take place in Japan

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

The Aegean Corneal Conference will take place in Mykonos, Greece

JUNE

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

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/

JUNE

WOC 2018

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

Aegean Cornea XIV

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

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

JULY

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

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

AUGUST

Baltic Eye Surgeons Talk Show Vol. 6

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

EUROTIMES | MAY 2018

35

36

CALENDAR

The AAO Annual Meeting will take place in Chicago, USA

SEPTEMBER

SEPTEMBER

ALACCSA-R LASOA

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

18th EURETINA Congress

SEPTEMBER

9th EuCornea Congress

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

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

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

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

AAO Annual Meeting 2018

↙

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

OCTOBER

Ophthalmic Imaging: from Theory to Current Practice

27–30 October Chicago, USA https://www.aao.org/

True innovation comes from good research.

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 | MAY 2018

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Alcon WaveLight® Technology Users Meeting 14-15 JUNE 2018, Barcelona, Spain *Post hoc analysis of postoperative UCVA compared to preoperative BSCVA of 230 eyes contained in the FDA T-CAT pivotal trial at 12 months. The primary end point evaluated changes in BSCVA. 1. Results from FDA T-CAT-001 clinical study for Topography-Guided vision correction (with the 400 Hz ALLEGRETTO WAVE® Eye-Q Excimer Laser).

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