EuroTimes Vol 24 Issue 2 Jan 2019

SPECIAL FOCUS CATARACT & REFRACTIVE LENS

February 2019 | Vol 24 Issue 2

What is the

Right IOL? CATARACT & REFRACTIVE | CORNEA | RETINA | GLAUCOMA PAEDIATRIC OPHTHALMOLOGY

Treq-Blue the purest of all dyes tested The Treq-Blue stain has been developed to enable clear visualization of the capsulorhexis rim. This added clarity helps prevent surgical complications.

Dye Treq-Blue

Impurities measured at 530 nm

Purity*

2%

98%

Competition Competitor 1

Western Europe

5%

95%

Competitor 2

Western Europe

13%

87%

Competitor 3

Southern Europe

20%

80%

Competitor 4

India

18%

82%

Conclusion

• Unmatched purity due to two-step purification process • High quality, ultra purified, safe surgical dye • Siliconized plunger and finger flanges for smooth intraocular injection

Treq-Blue is the purest of all dyes tested!

Competitor 1 contained twice as much impurities (measured at 530 nm) as Treq-Blue. All other dyes contain between six and nine times as much impurities as Treq-Blue.

* Purity of the dyes was monitored by HPLC chromatography, carried out at Department of Life Sciences and Chemistry, Jacobs University Bremen, Bremen, Germany.

Treq-Blue

Competition

Chromatography show the absence of foreign dyes in Treq-Blue

vitreq.com

bvimedical.com

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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 Ria Pollock 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

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS

RETINA

CATARACT & REFRACTIVE LENS

20 Advances in imaging

04 Choosing the right IOL

for you and your patient

06 New IOLS – a view from the industry

08 IOLs and the risk of retinal detachment

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

CATARACT & REFRACTIVE 12 Better understanding

of phaco fluidics improves the safety of the procedure

13 JCRS update 14 New FLACS approach

can reduce operating time

15 Using corneal refractive techniques to correct high astigmatism

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technology vital in the understanding and treatment of neovascular AMD

21 Treating highly myopic macular holes

22 Collaboration with

rheumatologists can aid treatment of uveitis

23 Opting for vitrectomy

earlier in cases of proliferative diabetic retinopathy

GLAUCOMA 24 New methods of drug

delivery should improve compliance and reduce side-effects

26 Consensus not universal on the net benefit of minimally-invasive glaucoma surgeries

REGULARS 31 Hospital diary 33 Books 34 Travel 35 Industry News 36 Society News 37 ESCRS News 38 Random thoughts 39 Calendar

28 Structural imaging is

CORNEA

being used to complement functional testing

Supplement February 2019

Supplement February 2019

RayOne Trifocal & Sulcoflex Trifocal:

16 Newer technologies

can improve results in moderate-to-high myopia

18 Rise in endothelial 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.

www.eurotimes.org

keratoplasty may be linked to increase in fungal endophthalmitis

Leading the Way to Offer More Patients a Trifocal Solution

PAEDIATRIC OPHTHALMOLOGY

Michael Amon (Austria) Early results from the new Sulcoflex Trifocal Fernando Llovet-Osuna (Spain) RayOne Trifocal: Premium lens outcomes in 150 eyes at Multisite Refractive Clinica Baviera Tiago Ferreira (Portugal) Prospective comparative study of bilaterally implanted RayOne Trifocal versus Finevison POD F in 60 eyes Alessandro Mularoni (Italy) RayOne Trifocal vs PanOptix: Visual Outcomes and IOL stability Martin Kacerovsky (Czech Republic) Comparing RayOne and PanOptix Trifocal outcomes Georges Cherfan (Lebanon) Contralateral implantation of the RayOne Trifocal IOL and FineVision Trifocal IOL

Diagnosing and Treating Ocular Surface Disease in Surgical Patients Supported by an unrestricted educational grant f rom

29 Updating the classification

Included with this issue...

30 Cross-linking in the

Rayner Supplement

system for Coats’ disease children with progressive keratoconus

ESCRS/EuCornea Education Forum Supplement

EUROTIMES | FEBRUARY 2019

2

EDITORIAL A WORD FROM OLIVER FINDL MD, MBA, FEBO

GUEST EDITORIAL

How do you know which IOL to use?

Deciding on the choice of IOL can be a difficult task, not only for the patient but also often for their surgeon

Oliver Findl

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-Lamard (France), Oliver Findl (Austria), Nino Hirnschall (Austria), Soosan Jacob (India), Vikentia Katsanevaki (Greece), Daniel Kook (Germany), Boris Malyugin (Russia), Marguerite McDonald (USA), Cyres Mehta (India), Sorcha Ní Dhubhghaill (Ireland) Rudy Nuijts (The Netherlands), Leigh Spielberg (The Netherlands), Sathish Srinivasan (UK), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Marie-José Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy)

I

am very pleased to be invited to write this editorial for EuroTimes, which has a special focus this month on IOLs. As my colleague Soosan Jacob points out in this issue, deciding on the choice of IOL to implant can sometimes be a difficult task, not only for the patient but also often for the surgeon who counsels the patient. The numerous types of available IOLs as well as relative advantages and disadvantages of each can be challenging.

As a surgeon, my advice to younger colleagues is always to use the lens that you are most comfortable with, but also the one that you think is best suited to the individual patient.

As we are all aware, as more exciting technologies come on the market our patients may have higher expectations of the improvement in vision that can result after a lens is implanted.

In my opinion, when talking to our patients before we enter the operating theatre, we must always stress that As a surgeon, my we can never guarantee advice to younger perfect vision or a dramatic colleagues is always improvement in vision after a lens is implanted. to use the lens We must always be honest that you are most with our patients and advise comfortable with them that while we will always do our best for them, there is no such thing as the perfect procedure. We should follow the motto “underpromise and overdeliver”.

As ophthalmologists, we are always looking for the next big innovation and with that in mind, I was also very interested to read Howard Larkin’s report from the Ophthalmology Futures Forum held in Vienna in September 2018.

At this forum, Julian Stevens said that designing successful accommodating IOLs remains daunting and he noted that several mechanical and flexible gel lens IOL designs have lost accommodative range over time due to capsule fibrosis. He also pointed out that lens mineralisation has developed as much as five years after implant. My personal experience with the so-called accommodating IOLs has been very disappointing, I do not use them at all. Even though electronic accommodating IOLs still appear futuristic, prolonged battery life may make them realistic sooner than expected.

This is a discussion that we will return to in the future, and as always part of the excitement of being an ophthalmologist is looking forward to what lies ahead and to see the benefits that years of research can bring in real life situations in our daily surgeries.

Oliver Findl is Secretary of the ESCRS and Chairperson of the Young Ophthalmologists Committee EUROTIMES | FEBRUARY 2019

ADVERTISING FEATURE

THE MOST BALANCED TRIFOCAL IOL STRONG NEAR VISION

DESIGN MATTERS

One of the main strengths of Liberty Trifocal IOL (Medicontur) in comparison to other trifocal IOLs is the higher and extended range of near vision. Patients achieve a higher depth of focus at near and this is the most important for us in a premium IOL implant that aims for spectacle independence. You will always find surprises with multifocal IOLs, but when you maintain a sufficient range of near vision focus these surprises tend to be less critical than those experienced with other trifocal IOLs from the past.

Premium technology also demands premium design. The square edges of the optic in Liberty (≤10 µ; 360°) are designed to prevent posterior capsule opacification (PCO), which is often one of the factors limiting success of multifocal IOLs.

EFFICIENCY THROUGH USING OCULAR PHYSIOLOGY We got used to incorrectly labelling IOLs as “pupil-dependent” or “pupil-independent” while we forget that it is the patient who is “pupil-dependent”, not the IOL design. The function of the pupil plays an important role in the performance of trifocal IOLs, as it controls the intensity of light going through the specific lens zones.

Once you measure the pupils you discover that Liberty can maintain near vision in low light conditions. We usually test our patients in low photopic light conditions (90 lux) and in these conditions they achieve a mean of 20/25 for near and 20/32 for intermediate monocular vision, and one additional line of visual acuity in binocular vision.

Liberty has an intermediate vision weakness in patients with pupils larger than 3.5 mm in low photopic conditions. In these cases patients should increase environmental light, which decreases pupil size leading to improved intermediate vision.

The large size of the IOL and its double loop haptic design are considered to be very important features for postoperative stability, particularly for toric MIOLs. After one year of experience with Liberty we have realised that not all hydrophilic IOLs produce the same rate of PCO. With Liberty, after 12 months 83% of our patients remained in grade 0 and 17% in grade 1 for PCO classification, whereas the previous hydrophilic IOL we implanted achieved percentages of 44% in grade 0, 29% in grade 1 and 27% with higher degrees of PCO after the same follow-up time. In short, with Liberty we reduced our PCO rates at 12 months.

CONTRAST SENSITIVITY, DYSPHOTOPSIA AND LIGHT SCATTERING There is always some level of compromise in contrast sensitivity with diffractive multifocal IOLs. Light scattering induced by IOLs is caused by each single diffractive step and, depending on the manufacturing quality, these light scatters can occur on multiple points on each step.

Therefore not only the quality but also the quantity of the manufactured steps can have a great impact on the amount of correctly utilized light energy within the eye and influence contrast sensitivity. Liberty achieves trifocality with only 7 diffractive rings which is the lowest number amongst the leading MIOLs today.

We are truly convinced that the 7-ring technology is enough to maximize visual performance at multiple distances with the main advantage of avoiding additional light scattering produced by the narrow peripheral rings in night vision. Although dysphotopsia with MIOLs is a topic which needs more relevant scientific evidence, theoretical simulations confirmed our expectations of reduced glare and halos with Liberty.

Nevertheless, in our experience dysphotopsia is a short-term phenomenon, decreasing in the long-term. Furthermore, while dysphotopsia and loss of contrast sensitivity are limiting factors for implantation of multifocal IOLs today, it should not be forgotten that dysphotopsia and contrast sensitivity reduction are also experienced by patients with cataract.

One of our main worries was to determine the proper age and preoperative degree of cataract that can lead to the highest positive experience after surgery, increasing not only close and intermediate range visual performance but also producing a positive experience in dysphotopsia and contrast sensitivity. With Liberty 50% of patients at around 60 years of age or with a cataract degree of CN1 on the LOCS III scale will actually improve their contrast sensitivity and experience less dysphotopsia in comparison to their preoperative vision with best spectacle refraction.

Joaquín Fernández, MD, PhD joaquinfernandezoft@qvision.es

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SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

What is the Right IOL? Choosing and using IOLs can be a daunting task.

Soosan Jacob MD sets out how to go about it

D

eciding on the choice of IOL to implant can sometimes be a difficult task, not only for the patient but also often for the surgeon who counsels the patient. The numerous types of available IOLs as well as relative advantages and disadvantages of each can be daunting.

At the outset, before explaining the EUROTIMES | FEBRUARY 2019

various types of IOLs available, it is wise to try and find out what activities matter most to the patient, how they feel about wearing glasses some/all of the time and to know if they want/ expect complete spectacle independence. This conversation helps in guiding patients towards the possible best choice for them as well as helps in setting realistic expectations preoperatively.

Questionnaires and informational videos

can help set the stage for a one-on-one direct discussion with the patient.

Understanding the patient’s lifestyle and visual preferences – whether there is a requirement for greater clarity at distance, intermediate or near vision is important. It is also important to set realistic expectations regarding a reasonably but not completely glasses-free life, and clear understanding that some activities will need glasses.

SPECIAL FOCUS: CATARACT & REFRACTIVE LENS It is generally advisable to focus on good distance visual acuity in the dominant eye and either have better intermediate or near vision in the non-dominant eye depending on the patient’s requirement.

Taller patients have a slightly farther requirement for their near point than shorter patients and the body build should also be considered.

Possible need for postoperative laser vision correction for any residual refractive error should be kept in mind by the surgeon and informed to the patient. There should be preoperative clarity about the financial considerations for this possible enhancement.

STANDARD MONOFOCALS I still use monofocal IOLs for many of my patients who do not want premium IOLs. Knowing their visual demands helps to plan better. Patients opting for monovision or micromonovision have the dominant eye focused for distance and the other for near/ intermediate by aiming for slight myopia. These patients should be given a monovision trial prior to surgery to check suitability and to get a first-hand preoperative experience of monovision.

PREMIUM IOLS Before choosing a premium IOL, I always try to make sure the patient is a good candidate. A healthy ocular surface allows accurate IOL power calculations and a satisfied patient post-operatively. History, variable measurements and irregular patterns on topography and ocular staining are important and any dry eye is treated pre-operatively if present. A macular OCT helps rule out early maculopathy. I also look for large-angle kappa and increased higher-order aberrations, which may result in unhappiness with multifocal IOLs. Astigmatism on topography and keratometry help determine the need for toric or multifocal toric IOLs. Multifocals: These IOLs use diffractive optics and split light into far and near foci, thereby creating peaks at individual focal points that the patient can focus on.

However, blurry vision in between the two foci and glare and haloes from the other images are disadvantages.

I prefer implanting multifocals after a detailed conversation with the patient about the expected benefits as well as the visual symptoms that may occur, especially during night driving.

A mix-and-match policy can help expand the range of vision offered by different multifocals. Newer rotationally asymmetric segmented bifocal IOLs with sector-shaped near vision segment give far and near (+3D add) focus zones for better depth of focus and include the Mplus, Mplus X (Oculentis) and SBL-3 (Lenstec).

Trifocals – AT LISA (Carl Zeiss Meditec), FineVision (PhysIOL, Belgium), PanOptix (Alcon), Alsafit

Fig A: Toric IOL seen being implanted. Alignment marks on cornea are visible (yellow arrows); B: IOL implanted in-the-bag. Alignment marks on IOL are visible (black arrows); C: IOL is rotated to lie short of the corneal alignment marks following which viscoelastic is completely removed; D: IOL is rotated into its final position

(Alsanza) and Acriva Reviol (VSY Biotech) – provide better intermediate vision with fewer side-effects. Most also have toric versions.

Extended Depth of Focus (EDOF) IOLs: I like EDOF IOLs because of the better intermediate vision they provide with lesser side-effects of glare, halos or loss of contrast as compared to multifocals.

EDOFs would be preferred more than multifocal IOLs in maculopathy or irregular corneas, though monofocals would still be the first choice in these cases.

They have an elongated focal area, giving an extended depth of focus, minimal effect on peak resolution and give reasonably clear vision at all distances (especially far and intermediate). However, near vision with a higher add multifocal is better, therefore, bilateral EDOF with -0.5 to -0.75D micromonovision strategy or a mix-and-match strategy with EDOF in the dominant eye together with +3.25 near add multifocal in the non-dominant eye may be used if the patient desires more near vision.

I like both the Tecnis Symfony IOL (AMO, California) and the AT LARA 829MP (Carl Zeiss Meditec).

Postoperatively, patients can show over minus values on both autorefractor and manifest refraction. The highest plus possible should therefore be prescribed by using a fogging technique.

Toric IOLs: When astigmatic correction is also required, toric IOLs provide a good

option. Standard toric IOLs are available in the range of 1.5D to 6.0D cylinder (to correct 0.75D to 4.75DC). Higher powers are available when required. It is important to assess posterior corneal astigmatism to avoid errors in IOL calculation.

FUTURE Preoperative decision making needs to become yet more refined in terms of extremely precise IOL power calculations in complex eyes as well as in having the ability to preoperatively simulate realistically to each patient the kind of vision they can expect postoperatively from a particular lens choice. This becomes especially important with presbyopic IOLs as these patients form the most demanding group and it would definitely help decrease chair time if they could be made precisely aware as to what to expect postoperatively.

Intraoperative and postoperative factors such as toric IOL alignment, postoperative rotation etc are other factors which need to be perfected yet more. Another problem that also needs to be further refined is postoperative IOL power adjustment and the ability to have effective dropless surgery via canalicular or punctal sustained release drug-delivery systems.

Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India and can be reached at dr_soosanj@hotmail.com EUROTIMES | FEBRUARY 2019

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SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

NEW IOL

TECHNOLOGIES There may be many paths forward, though technical challenges remain.

Howard Larkin reports

M

ultiple intraocular lens (IOL) technologies, including multifocal, EDOF, adjustable, and both mechanical and electronic accommodating lenses, will continue developing over the next few years as industry and ocular surgeons seek better treatments for presbyopia, according to presenters at the Ophthalmology Futures Forum Vienna 2018.

However, designing IOLs that provide reliable and durable presbyopia correction remains daunting, said Julian Stevens MRCP, FRCS, FRCOphth, DO of Moorfields Eye Hospital. He noted that accommodating mechanical and flexible gel lens IOL designs that rely on ciliary contraction to physically move or reshape lenses often lose accommodative range as capsules contract and stiffen over time due to fibrosis.

Similarly, lens implants can develop long-term unpredictable change with shift in position, and recently for one manufacturer mineralisation developing as much as five years after surgery.

This severely degrades multifocal performance and makes lens exchange extremely difficult, particularly following posterior capsulotomy, Dr Stevens said. Attempts to induce multifocality in adjustable lenses after implantation can result in optical complexities and optical irregularity, which is challenging for patients and very difficult to correct, he added.

Detecting such problems lengthens development time, but is necessary, Dr Stevens said. “Given that we are implanting these lenses in younger and younger people for refractive reasons, how long would you like to see outcomes data? Forget the regulations, in the real EUROTIMES | FEBRUARY 2019

MK Raheja PhD, Jan Willem de Cler and Julian Stevens MRCP, FRCS, FRCOphth, speaking at the Ophthalmology Futures Forum in Vienna

world what do we need for safety and efficacy? How many years do you wait before you say ‘yes, that’s good enough’?”

There should be a European database for long-term follow-up at 10, 15 and 20 years and beyond, he believes.

MULTIPLE SOLUTIONS How much development time is needed depends on the technology, said MK Raheja PhD, head of ophthalmic implants R&D for Johnson & Johnson Vision.

Mechanical accommodating designs rely on performance of the capsular bag and ciliary muscles, which can deteriorate with time and therefore require more time to demonstrate efficacy. Multifocal, EDOF and adjustable lens technology involves

optical trade-offs that may be more acceptable for some patients than others, and this takes time to assess. “We need to better understand patient needs as well as physiology of their eye to increase the probability of success with the presbyopia solution that we provide”.

Laurent Attias, senior vice president for corporate development at Alcon, sees merit in continuing development of lightsplitting, accommodating and adjustable lenses. “Each has its own challenges,” he said. Multifocals must balance a mix of near, intermediate and far vision while minimising dysphotopsias, mechanical accommodating lenses must preserve an acceptable range of movement and the precision and long-term safety

SPECIAL FOCUS: CATARACT & REFRACTIVE LENS of adjustable lenses must be proven.

“The good news is each are viable routes toward the same golden egg called presbyopia.”

Dr Stevens believes electronic accommodating IOLs that adjust refractive power by varying lens refractive index will be an attractive solution. However, battery technology must improve to provide a 40-to-50-year lifespan with enough energy density to be light enough to implant.

“Once that comes in it will be a total gamechanger,” he said. However, any electronic lens implant will not be compatible with MRI scanning, and this will likely be a serious drawback.

Alcon is making progress on electronic accommodating IOLs and contact lenses, Attias said. “The battery technology is

not that far off… we’ve seen [lifespan] improvements from four years to 20 years.”

Rapid progress is also being made on other issues that will make electronic accommodating lenses usable. These include managing the speed and precision of accommodation, which are critical to patient acceptance, and developing foldable electronics that will enable insertion accommodating IOLs through monofocalsize incisions of 2.5mm or so.

In fact, Attias sees electronic accommodating IOLs pulling ahead of contact lenses due to the challenges of keeping contacts comfortable. “Unless you solve for comfort, nothing else matters.”

Raheja believes that future presbyopic IOL solutions may combine approaches.

Every technology has its advantages and limits and all are at an early stage, he said. “We need to push forward on every front.”

We need to simplify using [presbyopiacorrecting IOLs] and simplification will take time. We are counting on the early adopters to demonstrate the concepts Julian Stevens, MRCP, FRCS, FRCOphth

SIMPLIFYING SURGERY

We need to better understand patient needs as well as physiology of their eye to increase the probability of success with the presbyopia solution that we provide MK Raheja, PHD

According to Carl Zeiss Meditec, another critical factor in boosting acceptance of presbyopia-correcting lenses is providing diagnostics that support predictable patient outcomes. The company reports that it is very important not to look at the IOL in isolation as it is also a process of diagnostics, using information to perfect the technique so the end result is what is expected.

Failing to recognise this can lead to the avoidance of prescribing presbyopiacorrecting IOLs not because of any problem with the lens itself, but a lack of knowing how to implant it accurately.

Attias agreed. Even today’s toric lenses require extra time and skill to implant, and

this becomes a barrier to use. “We need to simplify using [presbyopia-correcting IOLs] and simplification will take time.

We are counting on the early adopters to demonstrate the concepts.”

Dr Stevens said lenses optimised to fit into a precision-cut anterior capsulotomy are a step toward increasing success because they allow centring the lens precisely and permanently on the visual axis. “You don’t have lateral movement and you don’t have decentration.” He believes that optimising lens design to take advantage of the potential precision offered by femtosecond laser technology will eventually increase use of presbyopiacorrecting and other speciality lenses.

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SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

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Refractive surgery for high myopia Differences in risk something to consider when weighing alternatives.

Cheryl Guttman Krader reports

E

ach of the surgical options for correcting high myopia has a unique set of pros and cons, but only refractive lens exchange (RLE) appears to be associated with an increased risk of retinal detachment.

Speaking at the 18th EURETINA Congress in Vienna, Austria, Andrzej Grzybowski MD, PhD, MBA, reviewed the literature on risk of retinal detachment in high myopes and with cornea and lens-based refractive surgery techniques. He concluded that RLE increases the risk significantly, while phakic IOL implantation does not.

Although excimer laser keratorefractive surgery might be excluded from consideration for other reasons, there is no evidence that it increases the risk of retinal detachment, said Dr Grzybowski, Chair of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland.

According to published reports, the risk of retinal detachment in non-operated myopic eyes ranges between 0.71% and 3.2%. Compared with the general population, the risk of retinal detachment is estimated to be about 50-fold higher in the subgroup with myopia <-15D and 110-fold higher in eyes with myopia >-15D. “In addition, the risk of retinal detachment in myopes is particularly high during the second, third and fourth decades of life, mainly owing to atrophic retinal holes,” Dr Grzybowski said.

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In an article reviewing published data on RLE, Dr Grzybowski and colleagues found that the reported rate of retinal detachment ranged from 0% in some studies to 8.1% in one paper (Alió JL, Grzybowski A, Romaniuk D. Eye Vis (Lond). 2014 Dec 10;1:10.).

“It is quite well known that phacoemulsification itself increases the risk of retinal detachment by 10-fold, and young age is one of the risk factors,” said Dr Grzybowski.

The proposed mechanism involves induction of posterior vitreous detachment, which might occur in close to 80% of highly myopic patients undergoing RLE, he explained.

Traumatic effects resulting from placement of the microkeratome suction ring combined with the shockwave and thermal effects of the excimer laser create a mechanistic basis for an increased risk of retinal detachment after excimer laser keratorefractive surgery.

However, the rate of retinal detachment after LASIK for up to -10D myopia was very low in a study of almost 12,000 eyes (Arevalo JF, Lasave AF, Torres F, Suarez E. Graefes Arch Clin Exp Ophthalmol. 2012;250(7):963-970.).

“Studies comparing PRK and LASIK found no difference between the procedures in the rate of retinal detachment,” Dr Grzybowski said.

Only a few studies evaluated the rate of retinal detachment in myopic eyes that underwent phakic IOL implantation, and they did not find an increased risk, he added.

Andrzej Grzybowski: ae.grzybowski@gmail.com

EUROTIMES | FEBRUARY 2019

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Passionate about his profession, Dr. Yeoh is committed to providing cataract patients with the best possible outcome.

The superb imaging and markerless toric IOL alignment capabilities of the OPMI LUMERA® 700 and CALLISTO® eye from ZEISS enable him to deliver on patient expectations.

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ADVERTISING FEATURE

HOYA Evening Symposium, Vienna 2018

Clinical Research and Product Innovation Update At a symposium held during the 36th ESCRS Congress in Vienna, a group of world experts on intraocular lens performance met to provide an update on HOYA’s research into IOL technology, with presentations on the new multiSert™ injector system and studies comparing the Vivinex™ lens to other lenses in terms of rotational stability, PCO and glistenings

Performance of the new HOYA multiSert™ Preloaded Injector System for the Vivinex™ IOL Gerd U Auffarth MD FEBO International Vision Correction Research Centre (IVRC) The David Apple International Laboratory University Eye Clinic University Eye Clinic Heidelberg, Germany

T

he new multiSert ™ Injector System for the Vivinex™ IOL provides an increased range of flexibility to the cataract surgeon, allowing injection with either a single-handed push mode or a two-handed screw mode. Previous preloaded injectors from the HOYA iSert® series like model PY-60AD or model 251 were designed for the two-handed screw mode only.

The multiSert™ injector’s tip has an outer diameter of 1.7mm, allowing delivery of the IOL into the capsular bag through a sub-2.2mm incision. At The David Apple International Laboratory, we observed a

very controlled and consistent delivery of the IOL into the capsular bag for both push and screw modes. The multiSert™ injector system adds further options with an adjustable mechanism, the insert shield, that serves as a depth-limiting device when choosing to perform a woundassisted IOL implantation. Moreover, the Vivinex™ lens comes preloaded with the device, which requires only a very simple preparation prior to the injection.

In summary, by combining the options of both a push and a screw mode for IOL injection, the 4-in-1 multiSert® provides the best of two worlds in cataract

Defining and Assessing True Rotational Stability of Toric IOLs Rupert Menapace, MD Professor of Ophthalmology & Optometry University of Vienna Medical School, Vienna General Hospital, Vienna, Austria

S

ignificant secondary rotation of an implanted toric lens once it has been implanted is uncommon in most of the leading IOL models on the market, but some of the lenses have outliers that can be enough to annihilate the anti-stigmatic effect of the lens.

Therefore, it is important to determine the true rotational stability of a lens.

We have compared the amount of postoperative rotation for each of four different single-piece hydrophobic IOL models. The patients all underwent examination of their implanted lens

position directly after implantation and then at one hour, one day, one week, one month and six months afterwards, using haptic junctions and fixed landmarks on globe as reference points.

We found that in eyes with the HOYA Vivinex™ IOL, the mean rotation at to-six months was only 1.5 degrees, and in no eyes was there rotation greater than five degrees. By comparison, although the mean rotation in eyes with the Alcon AcrySof® IQ lens was only 1.7 degrees at six months postoperative, in a few outliers the lens rotated by up to 15.8

The glistening-free hydrophobic Vivinex IOL

surgery. Screwing two-handed or pushing single-handed are both possible with or without use of the advanced insert shield for insertion through the wound tunnel or direct implantation in the capsular bag.

degrees. Similarly, in eyes with the Johnson & Johnson Vision TECNIS® 1-Piece IOL the mean rotation was only 2.2 degrees but there were two outliers with around 40 degrees of rotation.

Furthermore, in eyes with the Bausch + Lomb EnVista® lens there was a mean rotation of 3.2 degrees but there were outliers of up to 44.9 degrees.

Most of the rotation with all lens types occurred in the first hour after surgery and almost none occurred after the first postoperative week. That is because by one week the capsule is closed and by one month the capsular leaves have fused. Therefore, what counts is not the deviation from the intended axis but the positional change starting from the end of surgery, and not from one hour, one day or even later. What also count are the outliers, not the mean values or standard deviations.

ADVERTISING FEATURE

Comparative PCO Performance Analysis of the HOYA Vivinex™ IOL and a Leading Competitor Michael Wormstone FARVO Professor of Ophthalmology, School of Biological Sciences, University of East Anglia, Norwich, UK

T

he human capsular bag model is one of the premier in vitro systems to understand the biological regulation of PCO and how implanted IOLs can influence this common condition. This model was first pioneered by a team of scientists and clinicians at the University of East Anglia (UEA) in the 1990s and has developed in to several iterations since, through continued work at UEA and

contributions from Prof David Spalton’s group in St Thomas’ Hospital in London.

Based on the findings of studies using flare measurements of protein concentrations in the anterior chamber following cataract surgery, the team at UEA have developed a graded culture system whereby the delivery of human serum and transforming growth factor-β levels is carefully controlled over time.

This approach is designed to closely

mimic post-surgical inflammatory events, and allows for the observation and definitive measurement of different phases of PCO formation following IOL implantation in an in-vitro setting.

This improved graded culture system has been used to compare the PCOperformance of the Vivinex™ lens with that of a leading competitor in a series of match-paired human capsular bag experiments. The team found cell growth on the posterior capsule to be slower on the HOYA Vivinex™ when compared to the leading competitor. Cell growth on the posterior capsule was retarded, light-scatter in the central visual axis was found to be lower and growth on the IOL surface was markedly reduced with Vivinex™ versus the leading competitor.

Comparison of Two Hydrophobic Intraocular Lenses: A Prospective Study Dominique Monnet MD PhD Université Paris Descartes, l’hôpital Cochin, Paris, France

T

he two-year interim results of a prospective, ongoing threeyear multi-centre study we are carrying out indicates that new Vivinex™ IOL is highly resistant to PCO and is less prone to glistening than the AcrySof® lens. The trial involves an intent-totreat population of 85 patients with a mean age of 73.6 years. All underwent randomised implantation of the Vivinex™ IOL in one eye and the implantation of the AcrySof® lens in their fellow eyes.

The two IOLs investigated are similar in being single-piece lenses composed of a hydrophobic material and having a sharp optic edge. In the Vivinex™ lens, the optic’s posterior surface has additionally undergone an “active oxygen” surface treatment.

At two years’ follow-up in 34 eyes, we found that both lenses performed almost identically in terms of refractive predictability and stability. The mean BCDVA of both lenses was equivalent with 0.0±0.1 logMAR at two years.

The two lenses also had identical and very low, quantitative PCO scores.

However, there was a trend towards less PCO in the Vivinex™ group, and the only YAG-laser capsulotomy carried

out so far was in an eye implanted with the AcrySof® lens. The Vivinex™ lens also developed significantly less “glistenings”, which by two years were absent or of low-grade density in eyes with the Vivinex™ lens but were present and of a high-grade density in most eyes with the AcrySof® eyes.

The 4-in-1 multiSert™ preloaded delivery system

How to Optimise Monovision Outcomes?

Peter Hoffmann MD Castrop-Rauxel, Germany

W

e tested the visual acuity and subjective reports of 46 bilaterally pseudophakic patients under simulated monovision conditions. We measured their emmetropised monocular and binocular visual acuity at 6m, 80cm and 40cm, first with 0.5D add in the dominant eye and then with the same add in the nondominant eye. We also performed the same sequence of testing with a 1.0D add.

“...63% of participants reported a worse sensation of binocularity with a myopisation of 1.0D compared to emmetropia...”

We found that with a binocular acuity with a 0.5D add was identical whether the dominant or non-dominant eye was

myopised. However, with a 1.0D add, myopisation of the non-dominant eye resulted in a slightly lower intermediate visual acuity than when the dominant eye was myopised. In addition, 63% of participants reported a worse sensation of binocularity with a myopisation of 1.0D compared to emmetropia, compared to only 2% when myopised by 0.5D. Moreover, in a study of fusional amplitude in 12 bilateral pseudophakic patients, we found that good binocularity would be achieved in most eyes if anisometropia was limited to 0.75D.

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CATARACT & REFRACTIVE

Cataract and glaucoma Optimised fluidics key to safe and uncomplicated surgery in glaucomatous eyes.

Roibeard Ó hÉineacháin reports

T

he fluidics of the phacoemulsification system in cataract patients with glaucoma should be optimised to ensure a stable, low-pressure anterior chamber during surgery and prevent damage to the optic nerve, Roberto Bellucci MD, Verona, Italy, told the 36th Congress of the ESCRS in Vienna.

“Better understanding of phaco fluidics improves the safety of cataract surgery especially in glaucomatous eyes,” he emphasised.

Microincision cataract surgery (MICS) is the best option in glaucomatous eyes because it has gentler fluidics than standard incision surgery, whether using a Venturi or peristaltic pump settings.

Femtosecond laser-assisted cataract surgery is indicated in glaucoma eyes with shallow anterior chambers, pseudoexfoliation and low endothelial cell counts, he said.

FLUIDICS OPTIMISATION But what is most important is the optimisation of fluidics to avoid IOP elevation and anterior chamber oscillation, which can further damage the already compromised optic nerve, Dr Bellucci stressed.

Using a high bottle height is a poor solution. Raising the bottle height one metre above the eye will increase the pressure within the anterior chamber to 70 mmHg. If the bottle is raised to 1.3m the pressure will rise to 100 mmHg. Raising the bottle in this way will not only increase the patient’s pain but will also increase the oscillation of the anterior chamber depth. That, in turn increases the difficulty of the surgery and raises the risk of complications and damage to the optic nerve head. The potential complications include posterior capsule rupture and cystoid macular oedema.

Fluidics optimisation can instead be achieved by reducing the aspiration ports and system hysteresis, separate control of aspiration and ultrasound, avoiding occlusion, allowing some leakage and varying infusion pressure according to the pressure in the anterior chamber, Dr Bellucci summarised.

In MICS procedures, rigid low hysteresis tubing must be used, together with low hysteresis pumps possessing small ports and pressure sensors and double venting systems.

Separate control of aspiration and ultrasound allows the activation of ultrasound power at any vacuum level and also avoids excessive pressure within the anterior chamber and resulting hydration of the vitreous. Venturi pumps and peristaltic pumps perform equally well in separately controlled aspiration and ultrasound systems, provided that they are properly adjusted.

The use of micro-pulse ultrasound delivery and small phaco tips will generate very small fragments, thereby avoiding occlusion of the aspiration line. Phaco tips with transverse/ rotational needle movement appear to work very effectively when used with a peristaltic pump, Dr Bellucci said.

He added that some incision leakage during surgery can be helpful. It avoids excessive pressure and deepening of EUROTIMES | FEBRUARY 2019

Roberto Bellucci MD

the anterior chamber. Furthermore, leakage provides a reservoir of fluid, which helps in avoiding chamber collapse when aspiration increases abruptly. It also maintains some fluid stream within the anterior chamber during occlusion or clogging.

PRESSURE SENSORS The latest evolution in phaco fluidics control are irrigation systems that use feedback from sensors that detect the anterior chamber pressure. The result is better and more delicate fluidics control. The increase of vacuum that the system allows and the small tip improve fragment hold-ability, and the reduced flow improves fragment follow-ability.

“What is nice is that you can select the IOP you want; I use 25mmHg, which corresponds to a bottle height of 40mmHg. Nobody was using such low bottle heights before these machines came along,” Dr Bellucci said.

The choice of IOL also requires special consideration in cataract patients with glaucoma. For example, “soft” hydrophilic IOLs with weak haptics are contraindicated in eyes with weak zonules, as in eyes with pseudoexfoliative glaucoma, because they will not resist capsular bag contraction.

IOLs that decrease contrast sensitivity like multifocal IOLs are also contraindicated in patients with glaucoma. On the other hand, aspheric IOLs that enhance contrast sensitivity are beneficial in such cases.

At the conclusion of surgery, thorough viscoelastic removal is essential to avoid post-op IOP spikes. IOP should be brought under control the same day, with attention to possible aqueous misdirection syndrome, he advised.

Roberto Bellucci: robbell@tin.it

CATARACT & REFRACTIVE

CONGRATULATIONS! THOMAS KOHNEN European editor of JCRS

JCRS HIGHLIGHTS VOL: 44 ISSUE: 12 MONTH: DECEMBER 2018

PREDICTING POSTERIOR CAPSULE RUPTURE Anterior segment OCT (AS-OCT) can successfully predict the risk for posterior capsule rupture during phacoemulsification in eyes with posterior polar cataract, a recent study suggests. The prospective observational study included 64 eyes of 62 patients with posterior polar cataract who had phaco. All underwent preoperative AS-OCT to assess the integrity of the posterior capsule. Phaco was performed by the same surgeon, who was masked from the AS-OCT findings, and who evaluated the integrity of the posterior capsule intraoperatively. Preoperative AS-OCT showed eight eyes (12.5%) to have probable posterior capsule dehiscence and 56 eyes (87.5%) to have intact posterior capsules. Intraoperatively, the surgeon noted posterior capsule dehiscence in five eyes (7.8%) and an intact posterior capsule in 59 eyes (92.2%). The sensitivity and specificity of AS-OCT for detecting posterior capsule dehiscence was 100% and 94.92%, respectively. The negative predictive value of AS-OCT was 100%. GP Kumaret al., JCRS, “Can preoperative anterior segment optical coherence tomography predict posterior capsule rupture during phacoemulsification in patients with posterior polar cataract?”, Vol. 44, Issue 12, 1441-4.

HOAs AND HIGH MYOPIA A new study looking at corneal aberrations in high myopes provides support for using aspheric IOLs in those cataract patients. The study of 287 high myopia patients found no negative primary spherical aberrations of the total or anterior corneal surface. The study did note differences between the myope group and control group in terms of central corneal thickness, astigmatism, primary spherical aberration, vertical coma and oblique trefoil. However, these differences were not consistent between different age subgroups. Higher-order aberrations were correlated with age. Posterior corneal vertical coma was correlated with axial length. M Zhang et al, JCRS, “Analysis of corneal higher-order aberrations in cataract patients with high myopia”, Vol. 44, Issue 12, 1482-90.

CXL – ON OR OFF? Epi-off corneal collagen cross-linking might be better than the transepithelial technique for the treatment of progressive corneal ectasia in terms of steepest keratometry, a new metaanalysis concludes. The meta-analysis included seven randomised clinical trials involving 505 eyes that met eligibility criteria for the review. The epi-off CXL group showed significantly better outcomes in post-op changes in maximum keratometry during one-year observation periods. Transepithelial CXL resulted in significantly greater post-treatment central corneal thickness and best spectacle-corrected visual acuity. The presence of a post-op demarcation line was significantly more frequent after epi-off CXL than that after transepithelial CXL. H Kobashi et al., JCRS, “Transepithelial versus epithelium-off corneal crosslinking for corneal ectasia”, Vol. 44, Issue 12, 1507-16.

2017 OBSTBAUM AWARD FOR BEST ORIGINAL ARTICLE

Functional magnetic resonance imaging to assess neuroadaptation to multifocal intraocular lenses Andreia M. Rosa, Ângela C. Miranda, Miguel M. Patrício, Colm McAlinden, Fátima L. Silva, Miguel Castelo-Branco, and Joaquim N. Murta J Cataract Refract Surg 2017; 43:1287–1296

2017 ROSEN AWARD FOR BEST TECHNICAL ARTICLE

Artificial iris implantation in various iris defects and lens conditions Christian Mayer, Tamer Tandogan, Andrea E. Hoffmann, and Ramin Khoramnia J Cataract Refract Surg 2017; 43:724–731

The JCRS as we know it today was born out of the amalgamation of two peer-reviewed journals, the Journal of Cataract & Refractive Surgery from the ASCRS and the European Journal of Implant and Refractive Surgery from ESCRS. The merged journal, which marked its 20th year in 2016, is the direct outcome of the spirit of friendship and cooperation that developed between the two societies, in particular between the editors at the time of the merger, Stephen A. Obstbaum, MD, in the United States and Emanuel S. Rosen, MD, FRCSEd, in Europe.

In honor of their passion and foresight, the editors are pleased to announce the creation of two annual awards for articles published in the JCRS, the Obstbaum Award for Best Original Article and the Rosen Award for Best Technique Article.

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

EUROTIMES | FEBRUARY 2019

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CATARACT & REFRACTIVE

FLACS and dense cataract Randomised, controlled study finds grid pattern reduces phaco time and endothelial cell loss.

Howard Larkin reports

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

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the ECCTR Registry

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your Surgical Results

F

ragmenting very dense cataract nuclei with a femtosecond laser using a grid pattern before phacoemusification significantly reduced effective phaco time (EPT) and endothelial cell count loss (ECC) compared with manual phacoemulsification or femtosecond laser-assisted cataract surgery (FLACS) using a 16-segment fragmentation approach, Soon-Phaik Chee MD told the 36th Congress of the ESCRS in Vienna.

In a prospective, randomised, controlled study, Dr Chee and colleagues at the Singapore National Eye Centre assigned 94 patients with nuclear cataracts of LOCS III NO grade 5, 6 or more to receive manual phacoemulsification, FLACS using a 600-micron grid fragmentation pattern (FLACS grid) or FLACS using a 16-segment pattern (FLACS 16) followed by phacoemulsification in a 2:1:1 ratio.

All FLACS patients were treated with a Victus femtosecond laser (Bausch + Lomb, Munich, Germany), and all patients received phacoemulsification using a Stellaris system (Bausch + Lomb, Rochester, New York, USA). All procedures were done by Dr Chee using a direct phaco chop technique. The study examined corneal safety using the three approaches, examining effective phaco time and endothelial cell loss one month after surgery.

EPT RESULTS The study found nuclear density and treatment method both affected effective effective phaco time, Dr Chee reported.

Perhaps not surprisingly, the 49 cases with NO5-6 required significantly less mean phaco time than the 44 of higher than grade 6 (p<0.005) regardless of treatment method.

However, while the 22 patients in the FLACS grid group had a statistically significantly lower effective phaco time than the 71 patients in combined manual and FLACS 16 groups (p=0.043), there was no significant effective phaco time difference between the two FLACS groups, or between the manual phaco and combined FLACS groups.

ECC RESULTS

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

Similarly, the FLACS grid group showed significantly less endothelial cell loss than manual phaco (mean 173 v 305, p=0.018), but there was no significant difference between FLACS groups, or manual phaco and the combined FLACS groups. No significant difference in endothelial cell loss was found between the NO5, 6 group and the NO>6 group.

These results vary from two non-randomised studies in the literature, which found reduced effective phaco time and endothelial cell with FLACS, Dr Chee noted. However, these studies examined softer cataracts, and used 300-micron grid patterns and a stop-and-chop phaco approach, which may have influenced the outcomes (Hatch KM et al. J Cataract Refract Surg. 2015;41:1833-1838. Chen X et al. J Cataract Refract Surg. 2017;42(4):486-491.). â&#x20AC;&#x153;FLACS grid but not FLACS 16 segment significantly reduced mean effective phaco time and lowered mean endothelial cell loss at one month compared with manual phacoemulsification in dense cataracts,â&#x20AC;? Dr Chee concluded.

Soon-Phaik Chee: chee.soon.phaik@snec.com.sg

EUROTIMES | FEBRUARY 2019

CATARACT & REFRACTIVE

Corneal astigmatism options Correction of high astigmatism is now feasible with a variety of corneal refractive techniques. Roibeard Ó hÉineacháin reports

S

urgeons have a number of corneal refractive procedures to choose from that can produce good results in eyes with regular and irregular high astigmatism, Jesper Hjortdal MD told the 36th Congress of the ESCRS in Vienna, Austria.

The general aim in correcting regular astigmatism is to flatten the steep axis of the cornea or compensate for the astigmatism intraocularly with a toric IOL, said Dr Hjortdal, Aarhus University Hospital, Denmark.

Whichever technique is used, accurate determination of the correct axis pre- and intraoperatively is necessary to bring about the desired effect. If the actual alignment axis is off the target alignment axis by 30 degrees, the procedure will have no anti-stigmatic effect at all, he pointed out.

Indications for surgery in eyes with high astigmatism include poor vision with spectacles, intolerance or discomfort with contact lenses and concomitant cataract.

The corneal surgical techniques include Jesper Hjortdal MD incisional and photoablative varieties, and most recently stromal lenticule excision, he said.

LIMITED EFFECT OF ARCUATE KERATOTOMY The oldest of the techniques currently in use is paired arcuate keratotomy. The approach involves the creation of almost fully penetrating incisions in the peripheral steep axis of the cornea. It can achieve very good reductions in high astigmatism, although it can leave considerable amount of residual astigmatism in highly astigmatic eyes and there can be considerable scatter in the technique’s predictability.

As an illustration, he cited a study he and his associates conducted 20 years ago involving highly astigmatic post-PK eyes.

It showed that arcuate keratotomy reduced mean keratometric cylinder by 50%, from 7.0D to 3.25D. However, the procedure was safe and he noted that the greater the magnitude of preoperative astigmatism, the greater was the anti-astigmatic effect (Hjortdal et al, Acta Ophthalmol. Scand. 1998: 76: 138-141).

In a more recent study arcuate keratotomy incisions produced with a femtosecond laser produced a similar reduction in corneal astigmatism, from 9.45D to 4.64D, and despite the precision of the technique there remained some scatter in the results (Loriaut et al, Cornea 2015:34:1063-1066).

PRK VS LASIK VS SMILE Photoablative techniques like PRK and LASIK can correct higher amounts of astigmatism and with greater accuracy than incisional techniques and their results appear to be roughly comparable, he noted. In a study comparing the two techniques in eyes with more than 3.0D of astigmatism, there was no statistically significant difference between the efficacy and the two techniques had similar predictability. That is, in the PRK and LASIK groups, 39% and 54%, respectively, had less than 0.5D of astigmatism postoperatively, and 88% and 94% had less than 1.0D (Katz et al, J Refract Surg. 2013;29(12):824-831).

The results with SMILE® appear to be comparable to LASIK in eyes with high myopic astigmatism. In a recent retrospective study, Dr Chan and his associates found no significant between-group difference in uncorrected distance visual acuity and manifest spherical equivalent in patients undergoing the procedures for myopic astigmatism. At three months, 90% and 95.4% of eyes in the SMILE and LASIK groups, respectively, were within ±0.5D of the attempted cylindrical correction (p=0.423) (Chan et al, J Cataract Refract Surg. 2018 Jul;44(7):802-810).

Topography-supported customised laser PRK is another technique that has been used in eyes with irregular astigmatism due to PK or keratoconus. However, early results in a study involving penetrating keratoplasty patients showed significant haze following the procedure.

More recently Dan Reinstein MD, PhD, UK, has introduced transepithelial phototherapeutic keratectomy (TE-PTK).

The ablation is based on population epithelial thickness measurements determined using very high-frequency digital ultrasound. Results to date with the technique suggest that TE-PTK can be a safe and effective method of reducing stromal surface irregularities by taking advantage of the natural masking effect of the epithelium.

Last but not least are intracorneal ring segments (ICRS) for the treatment of keratoconus. Several studies confirm safety and efficacy of ICRS. However, predictability remains a key challenge and current nomograms are insufficient to cover all cases.

Jesper Hjortdal: jesper.hjortdal@clin.au.dk EUROTIMES | FEBRUARY 2019

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CORNEA

High myopic correction Results of corneal refractive surgery improving in the treatment of high myopia.

Roibeard Ó hÉineacháin reports

N

ewer technologies and knowledge gained from experience are improving the results of corneal refractive surgery in moderate to high myopia, reports Jodhbir S Mehta MD, Singapore National Eye Centre, Singapore.

The three main corneal laser refractive surgery techniques for myopia – PRK, LASIK and SMILE® – have all evolved considerably since their early days. A consequence of that may be that a higher degree of myopia can now be treated more safely and effectively than was the case in the first decade of this century, Dr Mehta told the 36th Congress of the ESCRS in Vienna, Austria.

In an 18-year prospective audit of LASIK outcomes for myopia in 53,731 eyes treated between 1998 and 2015, the proportion of high myopes achieving an uncorrected visual acuity of 20/40 rose from 50% in 1998 to more than 99% in 2015. During the same period, the proportion of high myopes achieving 20/20 rose from 8% to 50%. The predictability of the procedure in high myopes also rose, with only 40% within 1.0D of target refraction in 1998, compared to 80% in 2015.

Results with surface ablation have also improved over the past

...high myopes are at an increased risk of regression because of the high degree of sphere associated with long axial length, steeper central cornea, and altered corneal biomechanics Jodhbir S Mehta

EUROTIMES | FEBRUARY 2019

decade. For example, in a 2009 study that compared long-term outcomes after PRK and LASIK to correct -6.0D to -10D of myopia showed that at 10 years’ followup, 88% of LASIK-treated eyes were within one dioptre of target refraction compared to only 71% of PRK-treated eyes. By comparison, in a 2018 study involving high myopes, 88% eyes with 6.0D of myopia and 82% were within 0.5D of target refraction.

The advantages of PRK include a greater residual stromal bed and, therefore, less risk of ectasia and more tissue reserved for enhancement surgery if needed. The disadvantages include slow recovery, risk of haze, more postoperative visits and longer postoperative medication regimen.

Dr Mehta cautioned that high myopes are at an increased risk of regression because of the high degree of sphere associated with long axial length, steeper central cornea and altered corneal biomechanics. Therefore, a long follow-up is necessary to determine the stability of corneal refractive procedure in these patients, which is a limitation of current literature.

FEMTOSECOND FRONTIERS Newer femtosecond laser-based procedures like refractive lenticule extraction (ReLEx®) appears slightly more accurate than LASIK, especially for higher degrees of myopia.

Dr Mehta noted that he and his associates have been performing ReLEx since 2012. In their first 150 cases, ReLEx, was more accurate and predictable for eyes with -5.0D to -10.0D of myopia.

That is, 100% of cases were within 0.50D of the intended compared to 85.8% in the LASIK group.

SMILE may be more stable than LASIK, he continued. He noted that in a study comparing the two treatments, refraction regressed in the LASIK group by 0.89D between one month and three years postoperatively compared to a change of only 0.14D in the SMILE treated eyes over the same period.

Dr Mehta pointed out that, unlike the excimer laser used in LASIK and surface ablation, the femtosecond laser in SMILE procedures operates in a ‘closed

laser system’. As a result, there is less stromal dehydration during the refractive correction. In addition, the energy with a femtosecond laser is more stable, with less variation related to environmental changes.

Moreover, since the eye’s position is fixed with the femtosecond laser, it is less sensitive to eye movements so there is no need for an eye tracker. Moderate-to-high myopes are particularly prone to fixation fatigue, he noted.

Dr Mehta suggested that there is a reduced wound healing/inflammatory response after SMILE procedures when compared to LASIK. He noted that in a study using a rabbit model, he and his associates observed that in LASIK-treated eyes there was an increased intensity of wound healing and inflammation with increased refractive correction which they did not observe in eyes that underwent SMILE procedures.

Subsequent studies have borne out the Singapore Eye Research Institutes (SERI)’s results and shown that although moderate myopes have better results than those with higher degrees of myopia, the higher myopes also achieved good results with similar safety and efficacy. However, higherorder aberrations and spherical aberration tend to be more pronounced following LASIK compared to SMILE, although the postoperative mean coma RMS tends to be higher following SMILE, which is an issue with centration.

SMILE also may also have a slight advantage over surface ablations. In a recent comparative study in which 26 eyes underwent LASEK and 24 underwent SMILE to correct a mean -8D of myopia, there was no significant difference between the treatment groups in terms of safety, efficacy or contrast sensitivity.

However, there was a greater amount of higher-order aberrations and spherical aberration after LASEK than after SMILE. There were no reports of postoperative haze in eyes that underwent LASEK procedures, which involved the use of mitomycin-C. The ocular surface index and MTF were better in the SMILE group, but the difference was not significant.

10th EuCornea Congress

Abstract Submission Deadline: 15 March 2019 Paris Expo Porte de Versailles

www.eucornea.org

CORNEA

Endophthalmitis and keratoplasty Rise in fungal endophthalmitis reflects changing keratoplasty practice.

Dermot McGrath reports

T

he trend in corneal transplantation towards endothelial keratoplasty (EK) procedures at the expense of penetrating keratoplasty may be partially responsible for an increase in cases of fungal endophthalmitis in recent years, according to Sathish Srinivasan FRCOphth.

“Although fungal infections can occur with all types of transplant, whether penetrating keratoplasty (PK) or lamellar transplants, the evidence in the scientific literature indicates that endophthalmitis after EK is primarily fungal in nature whereas infection after PK is mostly bacterial,” Dr Srinivasan told delegates attending the 9th EuCornea Congress in Vienna.

Analysing 354,930 transplants performed in the United States from 2007 to 2014, the Eye Bank Association of America (EBAA) found primary graft failure the most common adverse reaction (319 cases or 0.09%) followed by endophthalmitis in 99 cases or 0.028%.

The procedure type predominantly associated with endophthalmitis was endothelial keratoplasty in 61%, followed

by PK in 37% and keratoprosthesis in 1%.

Of the 77 culture-positive cases in the EBAA report, the majority were caused by fungal infection in 65% versus bacterial infection in 35%.

The high association between fungal infection and EK and tissue prepared in the eye bank merits further study, said Dr Srinivasan, Consultant Corneal Surgeon at University Hospital Ayr, Ayr, Scotland.

“We need more data from Europe and elsewhere to confirm the data from the US on the increased risk of using precut tissues from eye banks compared to surgeon-prepared tissue after EK. Several factors such as the corneal storage medium, increased use of antibiotics and increased warming period time to prepare tissue have all been suggested as possible reasons for the increased incidence of fungal causative pathogens,” he said.

Expanding on these factors, Dr Srinivasan said that there is currently no routine use of an antifungal agent to EUROTIMES | FEBRUARY 2019

Courtesy of Sathish Srinivasan FRCOphth

18

Fungal infiltrate following DSAEK (top); fungal infiltrate following PK (above)

supplement corneal storage medium in the United States, while the increased use of broad-spectrum antibiotics before and after surgery creates a non-competitive environment that allows fungi to thrive.

Finally, the increased warming period time associated with preparing EK tissue in the eye bank is thought to favour increased fungal proliferation, he added.

The scientific literature on endophthalmitis after keratoplasty is quite threadbare, noted Dr Srinivasan, with only a handful of papers putting the spotlight on one of the most feared complications of ocular surgery.

“The majority of studies deal with endophthalmitis after PK, so there is a clear need for better data to reflect changing trends in corneal transplantation. Unlike

cataract surgery, where there is only one single intervention, the causes of endophthalmitis following keratoplasty are multifactorial and can be related to donor, recipient and storage media factors, which vary greatly in different parts of the world,” he said.

Looking at the incidence of endophthalmitis after keratoplasty, a UK study of 11,320 transplant recipients between 1999 and 2006 reported an endophthalmitis incidence of 0.67% after primary PK. The incidence of endophthalmitis occurring within six weeks of surgery was 0.16% and graft survival after endophthalmitis was 27% at five years, noted Dr Srinivasan.

“I think this is one of the key takehome messages – if the surgery was a PK and the patient develops bacterial endophthalmitis then the final survival rate is dramatically reduced. Of the 76 cases in the UK study the predominant bugs found were pseudomonas, staphylococcus and streptococci in about 69% of cases,” he said.

Factors associated with endophthalmitis were donor cause of death (infection), high-risk cases and indication for corneal transplantation.

“What stood out was that all the patients who had interventions for therapeutic keratoplasty had a slightly higher risk of developing postoperative endophthalmitis.

It was also interesting to note that if the donor’s cause of death was infection such as septicaemia then the donor's corneas were at higher risk of developing infection,” he said.

Summing up, Dr Srinivasan said that endophthalmitis remains a serious issue after corneal graft surgery, with those affected having reduced graft survival and poor visual outcomes.

“Management of the identified recipient and donor risk factors are important to reduce endophthalmitis risk, so we definitely need more data to shed light on these factors in the future,” he said.

Sathish Srinivasan: sathish.srinivasan@gmail.com

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RETINA

AMD diagnosis and treatment Imaging tools vital in management of neovascular AMD. Dermot McGrath reports

C

ontemporary management of neovascular agerelated macular degeneration (AMD) has evolved significantly over the last few years, with advances in imaging technology helping to greatly enhance current knowledge about pathophysiological mechanisms contributing to vision loss due to AMD, according to Edoardo Midena MD. “Clinicians are using many treatment strategies to minimise intravitreal injections without sacrificing visual outcomes.

Using the latest imaging tools such as optical coherence tomography angiography (OCT-A) alongside traditional fluorescein angiography (FA) is very helpful in the diagnosis and management of choroidal neovascularisation (CNV),” Dr Midena told delegates attending the 18th EURETINA Congress in Vienna.

Choroidal neovascularisation, the hallmark of ‘wet’, ‘exudative’ or ‘neovascular’ AMD, is responsible for approximately 90% of cases of severe vision loss due to AMD. While fluorescein angiography remains the gold standard for diagnosing CNV, non-invasive technology such as OCT-A now enables detailed mapping of CNV flow with different patterns such as “medusa”, “seafan”, “indistinct network pattern” and “pruned vascular tree” described according to specific morphologic features, said Dr Midena.

Dr Midena added that previous models of disease in AMD were incomplete in that they did not account for subretinal drusenoid deposits, subtypes of neovascularisation, and polypoidal choroidal vasculopathy. He noted that recent work in this domain by Richard Spaide MD has proposed new aspects in the AMD construct to include specific lipoprotein extracellular accumulations, namely drusen and subretinal drusenoid deposits, as early AMD. The deposition of specific types of deposit seems to be highly correlated with choroidal thickness and topographical location in the macula.

Apart from the diagnosis in terms of the size and the shape of the vascularisation present, Dr Midena said that it is perhaps more important for the treatment follow-up to be able to distinguish active from inactive disorder.

Although the current EURETINA Guidelines on AMD state that the effect of anti-VEGF therapy can be efficiently monitored by non-invasive SD-OCT alone once the initial diagnosis of CNV has been established by FA, there is a lot that can be learned from OCT-A, said Dr Midena.

“These technologies are complementary and help us to build up a more complete picture of the disease course and the antiVEGF treatment effect. From the imaging point of view it is very nice to have OCT-A and be able to compare to FA in terms of lesion size and development,” he said.

Dr Midena emphasised the importance of rapid intervention once exudative AMD had been diagnosed, with better outcomes associated with a shorter duration between initial symptoms and anti-VEGF treatment initiation.

EUROTIMES | FEBRUARY 2019

Edoardo Midena MD

“We know today the importance of the visual acuity results we obtain from the initial anti-VEGF dosing. The message is clear – if you don’t follow the induction phase you are not on the right side of your medical profession, because this is the most important factor in terms of the long-term results,” he said.

Dr Midena said that recent research has suggested that patients with better visual function at the end of treatment for choroidal neovascularisation are those where the choroidal vessels are still present, rather than those where the vessels are not completely destroyed or fibrotic.

Another breakthrough in recent years has been the identification of valid biomarkers relevant for visual function, disease activity and prognosis, which can provide guidance for therapeutic management. Observing changes in foveal thickness is no longer enough, said Dr Midena.

“We now know about intraretinal and subretinal fluid and pigment epithelial detachment, which are very important biomarkers in terms of the visual function. Intraretinal fluid seems the most important because it induces a neuro-retinal degeneration and has a negative impact on visual acuity,” he said.

Dr Midena urged the delegates present to test baseline visual acuity at both normal and low luminance, as the gap between normal and dim vision at baseline may predict the patient’s response to treatment.

“Recent research has shown that low light deficit (LLD) is a simple, inexpensive and rapid measure of visual function and is a strong predictor of the subsequent risk for losing visual acuity in eyes with geographic atrophy,” he said.

Edoardo Midena: edoardo.midena@unipd.it

RETINA

Highly myopic macular holes High closure rates achieved using autologous platelet-rich plasma.

Cheryl Guttman Krader reports

A

utologous platelet-rich plasma (aPRP) appears to be a valuable aid in the management of macular holes in highly myopic eyes, said Marta S Figueroa MD, at the 18th EURETINA Congress in Vienna, Austria.

“Two surgical approaches – the inverted internal limiting membrane (ILM) flap technique and autologous ILM transplantation – have been described as methods for improving results when treating highly myopic macular holes,” said Dr Figueroa, Medical Director, Vissum Madrid, Madrid, Spain.

“The use of aPRP as an adjunct to vitrectomy with ILM peeling is an easier approach that in our experience is associated with excellent surgical outcomes,” she reported.

Dr Figueroa and colleagues demonstrated the efficacy of aPRP as an adjuvant in surgery for high myopic macular holes in a prospective interventional case series that included 20 treatment-naïve eyes and eight eyes with a persistent macular hole after vitrectomy with ILM peeling. The treatment-naïve eyes underwent ILM peeling and fluid-air exchange, and received injection of three drops of aPRP over the macular hole followed by gas tamponade with 12% C3F8. Eyes with persistent macular holes were treated with aPRP and received silicone oil tamponade.

Closure after the single procedure was achieved in 19 (95%) of the naïve cases and in seven (87.5%) of the eight eyes with a persistent macular hole. Discussing the single eye with the persistent hole that failed to close, Dr Figueroa presented images showing a large dome-shaped macula that she suggested might have limited the amount of PRP reaching the macular hole.

After a mean follow-up of 21 months, visual acuity was significantly improved from 0.75 logMAR before the procedure to 0.51 logMAR. Subfoveal external limiting membrane was visible after the surgery in 19 (68%) eyes, the ellipsoid zone was visible in 15 (53%) eyes; these structures were more often seen in naïve eyes than in the group with a persistent macular hole.

5-8 September 2019 Abstract Submission Deadline 14 March 2019

MECHANISM OF ACTION APRP becomes activated on interaction with tissues, forming a fibrin clot that releases trophic factors. It has shown to stimulate retinal wound healing and retinal regeneration.

“We believe that the healing capabilities of aPRP are especially useful for macular holes in highly myopic eyes,” said Dr Figueroa.

Dr Figueroa proposed that there are two mechanisms involved in macular hole closure with aPRP. One is the mechanical effect when activated aPRP forms a fibrin clot that covers the macular hole acting as a barrier. The second is the biological effect when aPRP releases trophic factors that may enhance Müller cells activation.

Marta S Figueroa: figueroa@servicom2000.com

We believe that the healing capabilities of aPRP are especially useful for macular holes in highly myopic eyes

Le Palais des Congrès Paris, France

www.euretina.org

Marta S Figueroa MD EUROTIMES | FEBRUARY 2019

21

22

RETINA

Improving outcomes in uveitis Interdisciplinary relationships key to successful use of biologics.

Priscilla Lynch in Kilkenny

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phthalmologists can learn much from their rheumatology colleagues in how to use biologics to successfully treat serious inflammatory eye conditions like uveitis, the Irish College of Ophthalmologists 2018 Annual Conference heard.

Speaking during the dedicated uveitis symposium was Dr Millicent Stone MD, a Consultant Rheumatologist in the Department of Ophthalmology, Guys and St Thomas Hospital, UK, who was recruited in 2014 to create a programme to support patients with inflammatory eye diseases who require immunosuppressant drugs, the first of its kind in the UK. Not only may uveitis lead to loss of sight, it may be associated with loss of life because of underlying lifethreatening systemic diseases that drive the inflammation in the eye, Dr Stone explained.

She noted that biologic agents have revolutionised the treatment of rheumatology conditions like rheumatoid arthritis and ankylosing spondylitis since their introduction to clinical care more than two decades ago.

The treatment approach to inflammatory eye diseases is now undergoing a similar “revolutionary change” with the recent approval of adalimumab, an anti- tumour necrosis factor (TNF) biologic agent, for use in adultand childhood-onset noninfectious uveitis, she said.

It has now been shown that biologic agents may help dramatically where systemic disease is an important driver behind sight-threatening inflammatory eye disease, and ophthalmologists can learn much about these “new” agents Dr Millicent Stone MD from rheumatologists who have long-term experience in using them, Dr Stone said.

Thus, for ophthalmologists setting up their own biologic services, rapid access to services like rheumatology, which is familiar with dealing with complex cases and potentially toxic drugs, is important.

“Together with new drugs, novel technologies and a more effective multidisciplinary way of working we can all greatly enhance how we manage our uveitis patients with systemic disease and improve their outcomes,” she said.

Cross-specialty referral is also very important for patients presenting early on with either inflammatory eye diseases or rheumatoid conditions, given their disease connections.

Dr Stone told EuroTimes: “Rheumatologists should make sure to ask the patient if they have any visual problem or any blurred vision or does the light affect their eyes. As an ophthalmologist it is always worthwhile asking them about back pain.

“So, awareness is the key component here, and thinking about associated diagnosis and being willing to refer onwards and develop good working relationships with each other.”

...we can all greatly enhance how we manage our uveitis patients with systemic disease and improve their outcomes

RETINA

23

Vitrectomy in PDR Improved techniques and equipment are driving earlier vitrectomy in proliferative diabetic retinopathy. Dermot McGrath reports

I

Florid proliferative diabetic retinopathy: such cases may be better with a vitrectomy before they develop either traction or a vitreous haemorrhage Courtesy of Alistair Laidlaw MD FRCS FRCOphth

mproved techniques, along with major advances in minimally invasive vitreoretinal surgery and the use of intravitreal bevacizumab, are all driving a trend towards earlier vitrectomy in proliferative diabetic retinopathy, according to Alistair Laidlaw MD FRCS FRCOphth.

“About 20% of diabetics will benefit from a vitrectomy at some point for non-clearing vitreous haemorrhage or tractional retinal detachment. It is much safer than it was before and it is getting better still. The use of anti-VEGF injections has been a gamechanger in that respect, but pre-existing macular damage still limits the visual outcome,” Dr Laidlaw told delegates attending the 8th EURETINA Winter Meeting in Budapest.

Dr Laidlaw added that there may also be a case for pre-emptive vitrectomy in selected florid high-risk PDR cases in order to prevent the angio-fibrotic switch and subsequent traction, and thereby improve visual outcomes.

In a broad overview of the evolution of pars plana vitrectomy (PPV) in PDR over the past 30 years, Dr Laidlaw, Consultant Ophthalmic Surgeon at St Thomas’ Hospital London, United Kingdom, explained that the classic role of surgery for diabetic retinopathy was defined in 1985 by the Diabetic Retinopathy Vitrectomy Study (DRVS).

That study randomised 616 eyes with recent vitreous haemorrhage and visual acuity of 5/200 or less for at least one month, to undergo early vitrectomy within six months versus observation. The greatest benefit from surgery was found in type 1 diabetics, who tended to be younger and had more severe disease, whereas no such advantage was found in the type 2 diabetes group.

While the DRVS study showed the benefits of early PPV in vitreous haemorrhage, with greater probability of visual acuity improvement or stabilisation, a disturbingly large proportion of patients ended up with no light perception, said Dr Laidlaw.

“The study did show that you were a bit better off having a vitrectomy at one and two years, but with 20% rates of no perception of light. This means that you were as likely to go completely blind as you were to get back 6/12, so it was not a particularly good advert for vitrectomy in diabetic patients,” he said.

With improved surgical techniques and instrumentation, the results of Diabetic PPV have considerably improved compared to the DRVS era, noted Dr Laidlaw.

“It is completely different now. We now have routine endolaser, and we are in the era of small-gauge vitreoretinal surgery, with improved fluidics and high-performance vitreous cutters. We can stain the retina for better visibility, and we have chandelier lighting and wide-angle viewing systems. We also have bimanual surgery and anti-VEGF augmentation to enhance surgery. We also have a certain corporate experience now with so many surgeons who have performed vitrectomies that it has inevitably got better,” he said.

The enhanced surgical environment is reflected in more recent results for PPV in diabetic patients, said Dr Laidlaw.

Data from the UK’s National Ophthalmology Database report on diabetic vitrectomy, which looked at 939 eyes of 834 patients who underwent primary vitrectomy for PDR between 2001 and 2010, showed that of 420 eyes that underwent vitrectomy without delamination the intraoperative complication rate was 13.1%, with 30% of eyes requiring an intravitreal tamponade and 11.7% undergoing further vitrectomy. Almost 18% of 127 phakic eyes developed cataracts within a year, with 63.6% achieving visual success and 8.2% visual loss.

OCT showing severe tractional complications of proliferative diabetic retinopathy: ideally such complications would be prevented from happening

Of the 519 eyes that underwent vitrectomy with delamination, the intraoperative complication rate was 30.4%, with 57.6% requiring an intravitreal tamponade and 15.0% undergoing further vitrectomy.

Just over 21% of 126 phakic eyes developed cataracts within a year, with 62.8% achieving visual success and 14.9% visual loss.

“This study showed the results are pretty good – there were not more patients without light perception at the end of the study compared to before the study, and the visual acuity got a lot better for the majority of patients. One of the key messages to emerge from this is that you don’t get the vision back if the retina is already crunched up, so there may be a case for earlier intervention,” he said.

In the DRIVE UK study, which identified 185 eyes of 158 patients who underwent vitrectomy from January 2007 to December 2009 due to diabetes-related complications, 50% of the eyes with tractional retinal detachment and non-clearing vitreous haemorrhage, and 87% of the eyes with non-clearing vitreous haemorrhage, improved by at least three ETDRS lines at 12 months, said Dr Laidlaw.

Recent studies have shown that pre-treatment of anti-VEGF agents before vitrectomy for complicated PDR facilitates surgery, with less early recurrent vitreous haemorrhage and quicker absorption of recurrent vitreous haemorrhage.

“This really has been a game-changer if you are going to have to manipulate the retinal surface. With anti-VEGF in the eye prior to surgery, the difference is like removing sticky tape off a table top compared to taking chewing gum off wet newspaper. It makes the surgery so much easier, with less bleeding and easier fibrovascular membrane dissection,” he concluded.

Alistair Laidlaw: alistair.laidlaw@gstt.nhs.uk EUROTIMES | FEBRUARY 2019

24

GLAUCOMA

Improvements in drug delivery New drugs and slow-release devices could improve compliance, reduce side-effects. Leigh Spielberg MD reports

A Take control of your future.

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

new generation of drugs and delivery systems should help improve compliance and reduce sideeffects associated with conventional glaucoma treatments, said Antonio Fea MD, PhD, at the 36th Congress of the ESCRS in Vienna.

With recent studies indicating that only 30% of glaucoma patients had refilled their initial medication three years after the first dispensing, the time has come for new approaches, said Dr Fea, Turin University Eye Clinic, Italy.

One approach is to develop agents that do a better job of lowering intraocular pressure, he noted. For example, Vyzulta (latonoprostene bunod 0.024% solution), which is commercially available in the USA but not yet in Europe, is a prostaglandin analogue that releases nitric oxide. It acts via the uveoscleral pathway and induces relaxation of the trabecular meshwork.

In the VOYAGER study, Vyzulta demonstrated statistically significant greater mean IOP reduction compared with Xalatan 0.005% at day 28, with a similar safety profile and only 1% discontinuation.

“However, the ultimate goal is to develop drugs with alternate mechanisms and low systemic side-effects. After all, up to 50% of an eye drop is lost immediately upon instillation, and less than 5% reaches the aqueous humour,” he said.

Therefore, a primary focus of research has been into other treatment modalities that cover the area between topical application and surgical intervention.

Dr Fea outlined newer treatments that may reduce dependence on topical drops. Research into long-term release of drugs is very active, he said. Anatomical locations for depot implants include the ocular surface (contact lenses), the fornices (periocular inserts), the upper or lower punctum and canaliculi (plugs and inserts), the subconjunctival space (depots), the anterior chamber and supraciliary space (reservoirs) and even the posterior segment.

Contact lenses can be imprinted with medication or infused with nanoparticles. Subconjunctivally injected reservoirs of latanoprost and bimatoprost liposomes are in phase I studies and suggest that scleral penetration of drugs is better than corneal, said Dr Fea. The iDose, from Glaukos Corporation in California, is a titanium drug reservoir anchored in the trabecular meshwork that elutes bimatoprost for a period of up to six months. In a US Phase II trial of 154 patients, there were no reports of hyperaemia, the most common problem with prostaglandin analogues, he reported.

“Which method will gain acceptance will depend on a combination of medical concerns such as safety, efficacy and sideeffects, as well as logistical concerns like availability, cost and reimbursement,” he concluded.

Antonio Maria Fea: antoniofea@interfree.it

EUROTIMES | FEBRUARY 2019

...the ultimate goal is to develop drugs with alternate mechanisms and low systemic side-effects Antonio Fea MD, PhD

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The device is safe and effective when implanted in combination with cataract surgery in those subjects who require intraocular pressure reduction and/or would benefi t from glaucoma medication reduction. The device may also be implanted in patients who continue to have elevated intraocular pressure despite prior treatment with glaucoma medications and conventional glaucoma surgery.

REFERENCES: 1. iStent inject ® Trabecular Micro-Bypass System: Directions for Use, Part #45-0176. 2. Hengerer FH. Personal experience with second-generation trabecular micro-bypass stents in combination with cataract surgery in patients with glaucoma: 3-year follow-up. ASCRS 2018 Presentation. © 2018 Glaukos Corporation. Glaukos and iStent inject are registered trademarks of Glaukos Corporation. PM-EU-0031

26

GLAUCOMA

A debate on MIGS Can MIGS reach treatment goals?

Consensus not universal on the net benefit of MIGS in terms of safety, efficacy and expense. Roibeard Ó hÉineacháin reports

T

he rationale behind the use of minimally invasive glaucoma surgery (MIGS) is to provide IOP reduction with reduced requirement for medication with a quick recovery time and few complications. The question of whether MIGS actually achieves those goals was the topic of a debate held in a Glaucoma Day session at the 36th Congress of the Vienna, Austria.

Opening the debate, Julian Garcia Feijoo MD, PhD, argued that MIGS does achieve its desired goals when the treatment is tailored to the patient’s needs. For example, ab interno MIGS devices that improve drainage via Schlemm’s canal can achieve satisfactory results in eyes with target IOP in the mid-teens, suprachoroidal devices could add 1-2 extra mmHg decrease, whereas ab interno and ab externo devices that direct aqueous into the subconjunctival space can provide IOP reductions nearly on a par with trabeculectomy.

“The decision to treat and how aggressively to treat depends not just on the diagnosis and IOP level, but also on the stage of disease at diagnosis, the rate of progression, the age and life expectancy of the patient and additional risk factors,” said Prof Feijoo, Hospital Clinico San EUROTIMES | FEBRUARY 2019

The decision to treat and how aggressively to treat depends not just on the diagnosis and IOP level...

Julian Garcia Feijoo MD, PhD

Carlos, Universidad Complutense Madrid, Madrid, Spain.

Numerous studies have demonstrated that ab interno MIGS, whether involving a subconjunctival bleb or enhanced drainage through Schlemm’s canal, can reduce glaucoma patients’ medication requirements.

For example, in a randomised study involving 100 eyes of 100 patients with glaucoma and cataract, 73% of eyes were using no hypotensive medications at 24 months after undergoing implantation of the Hydrus (Ivantis) Schlemm’s canal micro-stent combined with cataract surgery, compared to a medication-free rate of 38% among eyes in the cataract surgery group (p=0.0008).

For patients whose target IOP is in the mid-to-low teens, ab interno or

ab externo devices that direct aqueous outflow through a subconjunctival bleb have a high rate of success. In a recent study involving patients undergoing Xen® gel stent (Allergan) implantation there was a mean reduction in mean IOP from 21.4 to 13.8mmHg (p< 0.0001) and a reduction in mean number of topical medications from 2.6 to 0.6 (p<0.0001).

There are also minimally penetrating ab externo subconjunctival drainage devices (Innfocus, SANTEN) that involve considerably less tissue dissection than filtration procedures.

Summarising, Prof Feijoo maintained that MIGS and minimally penetrating glaucoma surgery techniques are a useful addition to the continuum of glaucoma treatments from the least invasive to the most invasive.

MIGS NOT YET ACHIEVING TREATMENT GOALS Assigned the task of presenting the opposing view, Chelvin Sng, MBBChir (Cantab), FRCSEd, pointed out that the current MIGS implants are not yet achieving the original treatment goals determined at the conceptualisation of MIGS. When MIGS was first introduced several years ago, the treatment goals included: at least moderate efficacy, high safety profile, ease of use and minimal invasiveness. With the current repertoire of MIGS devices, these treatment goals are only partially but not completely achieved. However, with continual innovation and improvements, Dr Sng is optimistic that MIGS will eventually reach all its treatment targets.

Efficacy: In the FDA iStent® (Glaukos) Inject study, the mean reduction in unmedicated IOP at 24 months was 6.9mmHg in the iStent group compared to 5.4mmHg in those undergoing cataract surgery alone. The reduction in medications at 24 months was -1.4 vs -1.0 in the phaco alone group. Although the differences were statistically significant, it is debatable whether they were clinically significant in terms of slowing progression and preserving vision. In addition, the cost of an iStent Inject in Singapore is €1,250, which is equivalent to the cost of an eightyear supply of latanoprost (100 bottles).

Safety: Although subconjunctival MIGS implants are more effective than trabecular bypass procedures and are potentially capable of achieving IOP comparable with trabeculectomy, they are inevitably associated with bleb-related complications. For instance, there have been reports in the literature of bleb-related infections associated with the XEN implant, albeit at a lower incidence compared with trabeculectomy. Meanwhile,

27 Images courtesy of Julian Garcia Feijoo MD, PhD

GLAUCOMA

The InnFocus device in place in the anterior chamber

Bleb 12 months postoperatively

...the current MIGS implants are not yet achieving the original treatment goals determined at the conceptualisation of MIGS Chelvin Sng, MBBChir (Cantab), FRCSEd

Alcon has announced the voluntary global market withdrawal of the suprachoroidal CyPass micro-stent because of increased endothelial cell loss detected among those with the implant compared with those who underwent cataract surgery alone. This was of particular concern because the CyPass micro-stent was indicated for patients with mild-to-moderate glaucoma, in whom safety was of paramount importance.

Ease of Use: The iStent Inject and other trabecular bypass MIGS devices may appear easy to use, but it is challenging to implant them precisely in the Schlemm’s canal.

Similarly, XEN implantation appears much easier to perform than trabeculectomy, but there are nuances in the surgical technique and postoperative management that are essential for achieving optimal outcomes, and these may be difficult to master.

Minimal Invasiveness: While sparing of the conjunctiva was initially considered a cardinal feature of MIGS, it is now recognised that subconjunctival MIGS devices (eg. InnFocus microshunt, XEN bleb revision) require conjunctival peritomy to attain good outcomes with low IOP. From the above examples, it appears that MIGS is not yet able to achieve all its original treatment goals determined at its conceptualisation. Nevertheless, even in their current iterations, Dr Sng believes that the current MIGS devices are still useful tools in our glaucoma surgical armamentarium. With appropriate patient selection, MIGS still constitutes a large part of her clinical practice. As MIGS comes of age, the treatment goals will also evolve with time.

Chelvin Sng: chelvin@gmail.com

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28

GLAUCOMA

Glaucoma imaging Real-life role of OCT in glaucoma care: structural imaging used as a complement to functional testing. Cheryl Guttman Krader reports

A

lthough the diseaserelated functional loss is what matters to patients with glaucoma, because of the variability that can occur with measurements of function, complementary information from structural imaging with OCT is useful for resolving uncertainty that can arise when using visual field test results to diagnose glaucoma and monitor for progression, said David Garway-Heath, MD. Speaking at Glaucoma Day during the annual ESCRS Congress in Vienna, Dr Garway-Heath noted, however, that the diagnostic precision of OCT is also not perfect. He described a systematic approach for reviewing the OCT report and emphasised the importance of considering the information in the context of clinical parameters.

“The take-home message is that machines don’t have brains. You do, and you have to use your intelligence when interpreting the printouts,” said Dr Garway-Heath, IGA Professor of Ophthalmology, University College London, London, England.

The first step in the systematic approach is to check the retinal nerve fibre layer (RNFL) segmentation in the scan to assess image quality.

“If image quality is poor, there can be erroneous segmentation in the image and therefore erroneous analysis by the software,” he said.

Once segmentation errors and artefacts

David Garway-Heath MD

are ruled out, the next step is to look for the region of RNFL thinning in the en face and thickness maps and to compare it with the circle scan. Next, clinicians should look for topographical correspondence between the RNFL thinning and visual field sensitivity loss. In addition, they should look for macula damage, especially in the macula vulnerability zone that is especially susceptible to developing loss in early glaucoma, and then check for correspondence between the macula and RNFL maps.

“The key is to be cross-checking all of the time for concordance between findings,” Dr Garway-Heath.

Discussing the use of OCT to monitor for glaucomatous progression, Dr Garway-

Heath explained that its performance relative to functional testing depends on stage of disease. He reviewed findings from a study showing that OCT was more likely than visual field testing to detect progression in eyes with early glaucoma.

The performance of the two methods was similar when the baseline mean deviation was about -10dB. Functional testing was more likely to detect progression in eyes with more advanced disease.

“Realise that neither structural imaging or visual field testing is 100% accurate, and so both methods need to be used across the disease spectrum to increase the likelihood of identifying progression if it is occurring,” Dr Garway-Heath said.

CALL JOHN FOR HENAHAN PRIZE 2019 ENTRIES

Young ophthalmologists are invited to write an essay on “How To Balance Opthalmology And Family Life” First prize is a €1,000 travel bursary to the 37th Congress of the ESCRS in Paris, France.

CLOSING DATE: FRIDAY 29 MARCH 2019 Entries to be sent to: henprize@eurotimes.org For further information visit: www.escrs.org EUROTIMES | FEBRUARY 2019

PAEDIATRIC OPHTHALMOLOGY

29

Coats’ disease

T

he onset of Coats’ disease in children of a younger age is associated with more severe manifestations, more advanced disease stage at diagnosis and worse visual outcome. Age, correlated with disease stage, should be considered a prognostic marker in Coats’ disease, according to Alejandra Daruich, MD (Daruich A et al. Retina 2018).

“Coats’ disease is a rare condition, affecting about one in every 100,000 children, it is usually unilaterally and affects young boys with a mean age of 5 or 6 years. In children younger than 4 years old leukocoria or Proposed update for Shields classification of Coats disease. Two subcategories have been introduced within Stage 2B, without or strabismus are the main manifestations, but with subfoveal nodule (blue circle). The presence of a subfoveal nodule means a higher risk of macular fibrosis and poor visual outcome compared with patients with flat exudation (100% vs 15%, p<0.0001) older children could be asymptomatic so we need to be particularly vigilant with these patients,” she told delegates attending the World Society of cases of Coats’ disease, its use may carry a higher risk of vitreoretinal Paediatric Ophthalmology and Strabismus (WSPOS) subspecialty fibrosis and tractional retinal detachment. day at the 36th Congress of the ESCRS in Vienna.

“We need more data to be able to support anti-VEGF treatment Peripheral telangiectasias of the retinal vasculature are the as an adjunctive therapy in these young patients,” she concluded. main manifestation in Coats’ disease, noted Dr Daruich, adding that the telangiectatic vessels are rarely located in the macula.

Alejandra Daruich: adaruich.matet@gmail.com These telangiectasias consist of dilated capillaries that provoke intraretinal and subretinal exudation. This process may eventually lead to exudative retinal detachment, neovascular glaucoma and profound vision loss.

Intraretinal and subretinal exudates often affect areas of the retina remote from the telangiectasias and tend to migrate toward the macula, although there is no clear explanation as to why the exudation preferentially accumulates in the macula, she said.

The most commonly used classification system for Coats’ disease derives from work by Shields et al. and takes into account the presence and location of lipid exudates at presentation to stratify the visual prognosis of the disease.

“We have proposed updating Shields’ classification of Coats’ disease to include two subcategories within Stage 2B relating to foveal exudation. These categories would be with or without subfoveal nodule as we have shown (Daruich A et al. Retina. 2017) that the presence of a subfoveal nodule means a higher risk of macular fibrosis and poor visual outcome for these patients,” she said.

Although Coats’ has long been considered an unilateral disease, some recent studies using optical coherence tomography angiography (OCTA) and fluorescein angiography (FA) indicate contralateral abnormal peripheral vasculature in some patients.

“The presence of bilateral asymmetric disease may be higher than previously thought although this needs further investigation,” she said.

Treatment for Coats’ disease is usually laser photocoagulation to the telangiectasias or cryotherapy depending on the stage of the disease. Although anti-VEGF has been used as adjuvant therapy in advanced Alejandra Daruich, MD

...older children could be asymptomatic so we need to be particularly vigilant with these patients

EUROTIMES | FEBRUARY 2019

Courtesy of Alejandra Daruich, MD

New classification for the rare condition proposed.

Dermot McGrath reports

30

PAEDIATRIC OPHTHALMOLOGY

Cross-linking in paediatric cases CXL is safe and effective in children with keratoconus but follow-up is required. Dermot McGrath reports

C

WSPOS World Society of Paediatric Ophthalmology & Strabismus

S U B S P E C I A LT Y DAY Friday 13th September 2019 Preceding the 37th Congress of the ESCRS, 14 – 18 September 2019

www.wspos.org

orneal collagen cross-linking (CXL) may be considered a safe and effective procedure in the paediatric population with progressive keratoconus, although these younger patients require particularly close follow-up, according to Meena Lakshmipathy MD. “There is a possibility that repeat treatment may be and this needs to be explained to parents. Extra care is also needed as children are more prone to infections and a heightened allergic response,” she told delegates attending the World Society of Paediatric Ophthalmology and Strabismus (WSPOS) subspecialty day at the 36th Congress of the ESCRS in Vienna.

There is a strong rationale for treating progressive keratoconus in a young population, said Dr Lakshmipathy.

“The hope is that by performing CXL we can avoid the need to perform keratoplasty in these young patients. Some studies have shown that it has already halved the indications of keratoplasty in children,” she said.

Dr Lakshmipathy advised seeing patients at least once every six months, with progression determined on the basis of at least two of the following criteria being met: an increase of at least 1.5D in maximum keratometry, an increase of at least 1.5D in the retinoscopic or topographic cylinder or a reduction in thickness of more than 15mm at the thinnest point of the cornea.

Contraindications to performing CXL in paediatric patients include herpetic eye disease, significant scarring, neurotrophic keratopathy, autoimmune disorders, severe dry eye and active vernal keratoconjunctivitis (VKC), she added.

Dr Lakshmipathy’s group, Medical Research Foundation, Sankara Nethralaya, Chennai, India, has already published data in Cornea. Totally, 377 eyes of 336 patients with progressive keratoconus underwent CXL. Of these, 194 patients had a follow-up of two years up to 6.7 years. In that study, patients with a minimum pachymetry of 450mm underwent the standard “epithelium off” Dresden protocol of CXL using 0.1% riboflavin, while eyes with a minimum pachymetry between 350 and 450mm underwent CXL using hypoosmolar riboflavin.

CXL was effective at stabilising the disease and improving visual acuity in a majority of eyes, noted Dr Lakshmipathy.

“We found that there was improvement in best-corrected visual acuity. The K-Maximum readings also showed a significant reduction after CXL treatment,” she said.

The need for long-term follow-up in young patients was emphasised.

“After three months, there was progressive flattening of the cornea up until about two years. If we look at the data after four years, however, there was a clear trend toward steepening of the cornea in 24% of patients and 31% of eyes showed a reduction in visual acuity,” she said.

Meena Lakshmipathy: meepath@hotmail.com

EUROTIMES | FEBRUARY 2019

The hope is that by performing CXL we can avoid the need to perform keratoplasty in these young patients Meena Lakshmipathy MD

HOSPITAL DIARY

Desert sands

E

The harsh daylight and intense night-time darkness of the desert can play tricks on your eyes. Leigh Spielberg reports

Illustration by Eoin Coveney

very time I bright light allows for super-fast look directly at shutter speeds, eliminating the that very faint possibility of motion blur. cluster of stars, Desert vistas are marvellous the one to the in all directions. But there are left of Orion’s Belt, it seems also elements of surprise hiding to disappear,” said my wife, in plain sight. A strolling camel pointing at a spot high in the is surprisingly difficult to see. It desert sky. “Why can’t I see it blends into the sand and dunes when I look straight at it?” with a naturally camouflage so Good question. I had noticed common in nature, like a lion it as well, and had mulled it in the grasses of the African over while waiting for our savannah. It blends in until the host to prepare the traditional last moment and all of a sudden, cardamom-flavored coffee there it is, stepping on to the road, that is ubiquitous in Oman. its beige, lumbering silhouette My answer involved the finally contrast with the black spatial distribution of rods pavement of the street ahead. and cones in the retina, and “Watch out!!” screamed my their relative sensitivities in wife. I slammed on the brakes scotopic conditions. and was nearly rear-ended by It then occurred to me why a a truck. It was a near miss. fellow traveller in our Bedouin Judging from the camel’s height camp had been wearing a as compared to our 4x4 desert red headlamp to read after cruiser, I tried not to think about sunset; red light leaves rods’ what would happen if we were to dark adaptation undisturbed, hit one as it crossed the road. But allowing him to look right back thereafter, we both broadened up at the stars without having our visual horizon to spot camels to wait for his rods to start before they crossed our path. ‘working’ again.

Travelling in Oman is a visual It got me thinking about delight. The sun is stunningly the reasons why we like to bright, and the light sand and The night sky above the Omani dunes travel. Everyone has their white buildings make sunglasses is spectacular. The clear, cloudless skies, own preferences: exoticism, essential. But in the desert, many luxury and warmth are high things are not as they appear. dry air and the absence of light pollution on most peoples’ list. I enjoy Distances are difficult to judge. allow the stars to shine as they did all the above, but my favorite Objects often seem closer than reason to travel is to see. they really are. Beige goats are for our earliest ancestors Who knows, maybe it’s just nigh-on impossible to see as they the ophthalmologist in me scamper up and down the rocky talking right now, but I like the views to jostle me out of my outcroppings of the arid mountain highlands. I thought our guide standard mental routine. Views and contrasts. A desert day’s was joking when he first pointed them out to us. I didn’t see anything bright white light and its night’s pitch black seem to delineate until I “learned” how to look for them, by scanning the diagonal the two ends of the full spectrum of what our retinas were ridges in the direction that they slope rather than horizontally, intended to perceive. which is what our plains-evolved gaze is designed to do.

The night sky above the Omani dunes is spectacular. The clear, What looks like a small sandbank nearby is in fact a huge dune cloudless skies, dry air and the absence of light pollution allow in the distance. Mirages on the surface of the highway mesmerise the stars to shine as they did for our earliest ancestors. There and distract. Caused by unusual diffraction of light due to are so many stars that the familiar constellations are difficult to temperature differences between the road and our eyes, they can distinguish. They seem to get lost in a riot of stellar illumination. confuse drivers and caravans alike.

The only celestial bodies I could identify with confidence were the The people of Oman seem to have taken this all into account, brightest planets. and everything manmade is a study in contrasts. The pale camels I love the desert. Love it. Mostly because of the intensity of the are often decorated with bright red harnesses that match the seats light and the purity of the colors. The bright blue sky, the pale on their humps, where we sat during our desert treks. beige sand and the seemingly random, occasional spots of green Whoops, gotta go! Our camels are ready to take us to see the are a pleasure to behold. The same dry air and clear skies that make sunrise from the top of the region’s tallest dune. Voilà! stargazing so intense allow for dazzling photographs of a quality that Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at I just can’t seem to reproduce when I visit the jungle, with its thick Ghent University, Belgium humidity and hazy light. My photos look crisp and colorful. The EUROTIMES | FEBRUARY 2019

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BOOK REVIEWS

PUBLICATION PRE-DESCEMET’S ENDOTHELIAL KERATOPLASTY (PDEK) EDITORS AMAR AGARWAL

LEIGH SPIELBERG MD Books Editor

COMBINING TEXT AND VIDEO WITH AN EYE ON THE FUTURE

BOOK

Reviews PUBLICATION FUNDAMENTALS OF INTRAVITREAL INJECTIONS

PUBLISHED BY JAYPEE

A very useful tool

The intravitreal injection boom shows no signs of abating. Whereas injections were once the task of the ophthalmologist alone, they are currently performed by trainees and nurses as well. This, however, requires PUBLISHED BY WORLD SCIENTIFIC proper training and instruction that can be timeconsuming and costly. A concise, well-written text could thus be a very useful educational tool.

Intended as “a guide for ophthalmic nurse practitioners and allied health professionals”, the new book, Fundamentals of Intravitreal Injections (World Scientific), describes all that one needs to know about how to safely perform the procedure.

Written by Salman Waqar and Jonathan C. Park, this 90-page text informs the reader about the basic medical and scientific background of intravitreal injections and the technique and complications. For further training, very fundamental instructions are given on how to set up a wetlab and how to organise a dedicated clean room.

Particularly helpful was the section on complications, which covers everything from the relatively frequent subconjunctival haemorrhage to the mercifully rare retinal detachment and endophthalmitis.

This book is ideal for nurses who will participate in the injection clinics as well as for junior ophthalmology trainees who need to be brought up to speed regarding the procedure and management of complications.

EDITORS SALMAN WAQAR AND JONATHAN C. PARK

It seems that every year, a new corneal transplantation technique is developed and introduced. How can we keep up? Books can help inform, offering a wealth of information that would take forever to gather from journals & conference presentations. But a book only tells half the story.

Videos of surgical procedures offer a nearly firsthand account of the expert surgeon’s procedure.

Pre-Descemet’s Endothelial Keratoplasty (PDEK) (Jaypee) is a 220-page introduction to PDEK. It guides the reader through each step: corneal anatomy and ultrastructure, surgical (contra) indications, surgical technique and variations, special situations, complications and preparation of grafts.

Nearly each chapter is accompanied by a video contained on the accompanying DVD. Most useful are the surgical videos, which allow the viewer to clearly see how, for example, endoilluminatorassisted PDEK is performed.

This text is intended for corneal specialists who aim to keep up with the rapid pace of development in lamellar corneal transplantations and corneal fellows with an eye on the future.

PUBLICATION SMALL-INCISION LENTICULE EXTRACTION (SMILE) EDITORS CLAUDIO ORLICH DUNDORF, ANTONIO MENDEZ AND ARTURO RAMIREZ-MIRANDA

BRIDGING THE GAP BETWEEN TEXT AND JOURNAL

PUBLICATION VITREORETINAL DISORDERS EDITOR GLENN YIU PUBLISHED BY SPRINGER

EUROTIMES | MONTH YEAR

The 240-page book, Vitreoretinal Disorders (Springer) is part of the Current Practices in Ophthalmology, a series of uniform handbooks covering the latest clinically relevant developments in each subspecialty. Edited by Glenn Yiu, this edition aims to bridge the gap between standard texts, which tend to get outdated rapidly, and journals, which contain a great deal of information of questionable clinical relevance.

What I found particularly useful and engaging were the very recently updated information on newly described clinical entities such as pachychoroid; explanations on the advantages and limitations of swept-source OCT and angio-OCT; the concepts behind adaptive optics; and the most up-to-date insights into difficult problems such as submacular haemorrhage and retained perfluorocarbon.

What struck me about this book is an assumption of a high level of sophistication in the reader. The authors do not waste time describing what all readers already know, such as the cause of a retinal detachment. The chapter “Retinal Detachment Surgery” jumps straight into topics like chandelier-assisted scleral buckling and suprachoroidal buckling.

This book is intended for general ophthalmologists interested in getting up to date regarding progress in vitreoretinal disease; retina fellows and highly motivated ophthalmology trainees; and retinal specialists who would like a concise summary of recent developments in their field.

PUBLISHED BY JAYPEE HIGHLIGHTS

AN EDUCATION ON A POPULAR TECHNIQUE As SMILE® takes off, so do the publications dedicated to educating ophthalmologists about the technique.

Small-Incision Lenticule Extraction (SMILE) (Jaypee Highlights) is a recent addition.

This 200-page book covers it all. After discussing the history of laser refractive surgery and SMILE itself, important concepts such as the principles of femtosecond laser and corneal biomechanics after SMILE are considered. But refractive surgery is not only about the procedure itself, as suggested by the chapter entitled “Management of Expectations”.

Each surgeon wants to know as much as possible about complications. These are all considered, from the dry eye to the more serious corneal ectasia.

This book is ideal for refractive surgeons who are considering adding SMILE to their armamentarium, refractive surgery fellows looking for additional information and general ophthalmologists who are considering entering the field of refractive surgery.

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 | FEBRUARY 2019

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EXPLORING PARIS

Gehry Museum

PARIS

3

WALKS ...

THE SIGHTS AT SPEED If you’d rather run than walk, Paris Running Tours offer a range of sightseeing runs – two, three or four hours long – taking in the iconic sights of Paris. Each tour is personalised for you (or your group), beginning and ending at your hotel. The guide will be an experienced runner who will share his or her knowledge of the city. As a souvenir, you receive a map of your route and photos taken by the guide.

Delegates to the ESCRS Congress who are committed runners might consider a 6am, five-mile, Expo-Eiffel tour. For details of this and all the running tours visit www.parisrunningtour.fr

NEW WAYS OF SEEING French speakers take note: Julie Boulanger, a long-time resident of the 15th arrondissement, guides very popular walking tours of the area.

While the principal language of the tour is French, Julie speaks some English having lived in Québec (where she also runs tours). As the result of a childhood illness, Julie is only partially sighted, nevertheless, she believes she sees more than many sighted people.

Julie is usually accompanied by her guide dog.

An interesting background article on Julie, in French, is at http://bit.ly/ET-Paris-Julie. Her two-hour tour is called ‘Avec Les Yeux de Julie’.

Reservations required (phoning is best). For contact details: http://aveclesyeuxdejulie.fr

TAKE A WALK – OR JOG – THROUGH HISTORY A walk of little more than a kilometre from Expo Porte Versailles leads you to Parc Georges-Brassens, where you can run or walk various attractive paths, one leading past a vineyard, another to beehives. Named for the beloved French singer, songwriter and poet who lived in the 15th arrondissement, the park was once an abattoir; the sculpted bulls flanking the principal gate are by the 19thCentury artist Isadore Bonheur, brother to the famous painter, Rosa Bonheur. One of the last skirmishes between Nazis and resistance forces took place here the day Paris was liberated in August, 1944. A plaque at 61, rue des Morillons commemorates one of two who died – 34-year-old Emile Plaisant. In September, the park is open daily 08:00 to 20:30.

EUROTIMES | FEBRUARY 2019

Paris hoists its sails Delegates to the 37th ESCRS Congress will be blown away by new architectural icons. Maryalicia Post reports The newest museum in Paris, the Louis Vuitton Foundation (LVF), opened in the Bois de Boulogne in 2014. As the architect was Frank Gehry, you wouldn’t expect it to look like any building you’ve ever seen – and it doesn’t. You think of a fish, a bubble, a cloud. Gehry himself compares it to a ‘kind of regatta’, with the ship’s sails billowing in the wind.

Critics have called the building a vision and a triumph, but not everyone feels the magic. Construction was interrupted by legal challenges about its suitability to the site and planning permission restricted the height to two storeys. However, encased in the 12 glass sails, these two storeys soar skyward 46 metres.

The museum, sponsored by the LVMH group, was built principally to house LVF’s corporate collection of modern art. (Ownership of the building transfers as a gift to the city of Paris in 55 years.)

An interior assemblage of 10 white rooms provides space for permanent and temporary exhibitions. There’s a dramatic waterfall inside and terraces outside with views of Paris glimpsed between the sails.

The bookshop offers specially-designed souvenirs in an artistically restricted range of colours and materials.

If you’ve just come to see the exterior, the best vantage point is the park at the rear of the building. If you plan to visit an exhibition, consider buying a ‘Premium Access’ admittance ticket online. Otherwise you’ll need stamina and patience. Queues are long. http://bit.ly/ET-Paris-LVF The museum is a half-hour walk from the Palais de Congress. A shuttle for ticket holders departs Place Charles de Gaulle, on the corner of Avenue de Friedland, every 20 minutes.

Closed Tuesdays. For full details and to read about ‘Le Frank’, the museum’s restaurant, visit https://www. fondationlouisvuitton.fr In the spring of 2017 a new music venue opened on an island in the Seine. Designed

by Shigeru Ban in partnership with Jean de Gastines, La Seine Musicale is a long narrow structure like a boat moored in the river.

This, too, features a sail, this time a solar sail capable of producing 80,000 kilowatt-hours a year. It moves on rails around a donutshaped structure atop the building At the heart of La Seine Musicale is a major concert hall and a jewel-like auditorium for classical music performances.

Other features: an outdoor screen where the public can watch performances ranging from musical theatre and rock concerts to ballet and classic music and a spectacular roof garden, open to all, Wednesday to Sunday from 11 until sunset.

La Seine Musicale is 15 minutes by taxi from Expo. Website in French: www.laseinemusicale.com The principal gate of Parc Georges-Brassens

INDUSTRY NEWS

INDUSTRY

2019

NEWS

Unique communication

One of the companies showcasing its products at the 23rd ESCRS Winter Meeting in Athens, Greece, is Kite Hellas.

“Kite Hellas is a modern family business, which constantly introduces innovative and high-quality products, while communicating in a quite astonishing way,” said a company spokesman. “The unique approach, offering revolutionary therapeutic approaches while having surprisingly innovative marketing strategies, has really drawn the attention,” he said.

“Many of the ideas and approaches that Kite Hellas introduces are supported by some of the world’s greatest ophthalmologists, such as Profs IG Pallikaris and AJ Kanellopoulos, who together described the new generation of multivitamin artificial tears during the Panhellenic OMMA Congress in Athens in 2017.” https://healthy-scoop.com/

EXPANDING PORTFOLIO

TECHNOLOGY SOLUTIONS

Oculis SA has entered into an agreement to license a novel topical anti-TNF alpha antibody from Novartis.

The compound, LME 636, is based on a proprietary single-chain antibody fragment technology specifically designed for topical delivery. Efficacy and safety were evaluated in three clinical trials.

Dr Riad Sherif, Oculis CEO, said: “This agreement is part of our ongoing strategy to access multiple sources of technologies and compounds that bolster our portfolio of innovative products to treat eye diseases.”” www.oculis.com

Carl Zeiss Meditec has completed the acquisition of ianTECH, a privately held company focused on technology solutions for micro-interventional cataract surgery headquartered in Reno, Nevada.

“Cataract surgery has been dependent on phaco technology for over 50 years.

ZEISS believes that the market needs a fresh, innovative approach in the field of phaco. ianTECH’s surgical technology is designed to change the future of managing cataracts,” said a spokeswoman. www.zeiss.com/med

Applications are open for the Peter Barry Fellowship 2019. 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 trainee member for 3 years by the time of starting the Fellowship.

The Fellowship will be awarded at the ESCRS Annual Congress in Paris in September 2019, to start in 2020.

To apply, please submit the following:  





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 2019 Applications and queries should be sent to Danielle Maher at danielle.maher@escrs.org

EUROTIMES | FEBRUARY 2019

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SOCIETY NEWS

ICO marks centenary The Irish College of Ophthalmologists recently commemorated the 100th anniversary of the society that would later become the ICO

O

n Friday November 16 the Irish College of Ophthalmologists formally commemorated the 100th anniversary of the founding of the Irish Ophthalmological Society (IOS) in 1918, the forerunner to the ICO, with a series of special events.

The ICO Winter Meeting and Royal Academy of Medicine Ophthalmic Section session preceded the Annual Montgomery Lecture and Centenary Reception held that evening at the Royal College of Surgeons in Ireland.

Of great significance to the specialty of ophthalmology in Ireland in the early 20th Century was the establishment of the Montgomery Lecture in 1916. The 2018 Lecture, entitled “When Irish Eyes are Smiling”, was delivered by Dr Michael Brennan, Past President of the American Academy of Ophthalmology, and presented a fitting occasion for the College to commemorate the Society’s centenary.

The Montgomery Lecture was the first medical Dr Micheal Brennan, Past President of the American Academy of Ophthalmology, is pictured with Dr Alison Blake, President lecture founded in Trinity College Dublin. Through of the Irish College of Ophthalmologists, at the Montgomery Lecture 2018 this lectureship, the small Montgomery family have retained their influence in ophthalmology and the most numerous in the Irish health service. The ICO has strongly name of Sir Robert Montgomery has become widely known, advocated on the urgent need for extra resources necessary to particularly in contemporary ophthalmology, alongside other Irish ensure avoidable cases of sight loss are kept to a minimum.” ophthalmological luminaries such as Sir Arthur Jacob, Sir Henry A key priority for the ICO is to ensure the required funding is Rosborough Swanzy and Sir William Wilde. made available to implement the recommendations outlined in the The lecture was initially given as a research lecture by early Model of Eye Care document and HSE Primary Care Eye Services career ophthalmologists; however, since World War II it has been Review Group Report, published in June 2017. presented by the leading figures in ophthalmology from both She continued : “The implementation of these keys actions will Ireland and abroad including neurologists, behavioural scientists be essential in addressing the current unacceptably high waiting and molecular ophthalmologists, to the immeasurable advantage lists. The ICO welcomed the recent opening of two dedicated, of Irish ophthalmology. It was a great honour for the College to consultant-led cataract units in Ireland, aimed at significantly welcome Dr Michael Brennan, who has served as the American reducing wait times for patients on the surgical wait list. Continued Academy of Ophthalmology’s international envoy for many years, investment in order to bring the facilities to full operational capacity and on the AAO Global Advisors Committee. is however essential if waiting lists nationally are to be fully tackled To mark the occasion, the ICO created a special commemorative and to ensure sustainable improvements to the service.” booklet, providing an overview of the evolution and the delivery of ophthalmic services to patients in Ireland over the last number of decades.

INFLUENTIAL IRISH FIGURES Commenting on the importance of the occasion, Dr Alison The establishment of the Irish Ophthalmological Society is Blake, President of the ICO, said: “It is a great honour and credited to Irish Ophthalmologist Dr John Benjamin Storey in privilege to be president of the ICO at a time when we mark this 1918. Dr Storey was among the many influential Irish figures significant milestone in the history of our specialty in Ireland. in ophthalmology at this time, alongside Sir Henry Rosborough There have been many incredible advances in eye care for patients Swanzy, Sir Arthur Jacob and Sir William Wilde, father of famous over the past 100 years and Irish ophthalmologists have much to Irish poet and playwright, Oscar Wilde. be proud of in this timeframe. Many eye conditions, which would Dr Storey served as President of the Royal College of Surgeons have previously led to certain sight loss for patients in the past, are in Ireland from 1918-20 and during the same period, as President now manageable or preventable as a result of significant advances of the Ophthalmological Society of the United Kingdom. Almost in treatments and technologies. Our focus remains on continued certainly, the prospect of this honorary office underlined for Dr evolution in the training of eye specialists in response to the eye John Benjamin Storey the lack of an equivalent society in Ireland, care needs of our population and to ensure the highest standards prompting him to found the IOS in 1918. He was elected President of eye care delivery in Ireland are safeguarded.” of the Society from 1921-23.

Dr Blake added : “In tandem with the fast pace in advances for The IOS would later merge with the younger Faculty of the treatment of eye diseases has come the challenge of providing Ophthalmology in 1992 to form the Irish College of the required services to a growing and ageing population. The Ophthalmologists, the accredited postgraduate training body in demand for specialised medical eye care in Ireland greatly exceeds Ireland for ophthalmologists. The ICO is now the professional and current capacity and waiting lists in ophthalmology are among the representative body for eye doctors in Ireland.

EUROTIMES | FEBRUARY 2019

ESCRS NEWS

ESCRS President Béatrice Cochener-Lamard (centre) with the ESCRS/Industry Medical Affairs Working Group at their annual meeting during the 36th Congress of the ESCRS in Vienna, Austria

ESCRS

NEWS My Mentor

What makes a great mentor?

JOHN HENAHAN PRIZE 2019 Entries are invited for the 2019 John Henahan Writing Prize. The topic for the essay is ‘How To Balance Ophthalmology And Family Life’.

The competition is open to ophthalmologists who are members of the ESCRS and aged 40 years or under on January 1, 2019. The winner will receive a €1,000 travel bursary to the 37th Congress of the ESCRS in Paris, France.

To enter see http://www.escrs.org/ paris2019/programme/JOHN-HENAHANWRITING-PRIZE.asp The closing date for entries is Friday 29 March 2019

The winner of the 2018 John Henahan prize was Dr Joséphine Behaegel

Mentoring is a two-way street that needs commitment from both mentor and trainee.

There’s is a unique relationship that only they will understand. And while the trainee will be hoping that their mentor will make them a better ophthalmologist, and a better person, the mentor too will need to benefit from the partnership. There will be good days and bad days, but, hopefully, more good than bad.

EuroTimes has launched a new series of articles where young ophthalmologists can talk about the person who inspired them when they took their first steps in training. YOs who want to take part should mail a Word document of 400 words telling your reflections on your first/best mentor and how he or she shaped your career to colin@eurotimes.org, along with a picture of the mentor.

The best submissions will be published in EuroTimes in the coming months.

Keep learning.

Stay relevant.

Learn online in your own time, with self-paced and assessed ESCRS iLearn courses on:

∙ Cataract Surgery ∙ Cornea

∙ Refractive Surgery ∙ Visual Optics

Learn more at http://elearning.escrs.org EUROTIMES | FEBRUARY 2019

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RANDOM THOUGHTS

OLD MEETS NEW

at 23rd ESCRS Winter Meeting We take a look back at medical approaches to cataract in Ancient Greece.

Aidan Hanratty reports

T

he 23rd ESCRS Winter Meeting will take place in Athens in February, 2019.

This will be the fourth Winter Meeting in the city, once the centre of the ancient western world. There will be many topics up for discussion including ocular surface disease, complications in corneal graft surgery, advances in glaucoma as well as didactic courses and practical workshops.

The Hellenic Society of Intraocular Implant and Refractive Surgery will also host a symposium entitled “Advanced technology – better results?” This is an interesting question, especially in the context of the history of medicine in Greece.

The term “glaukos” was a non-specific descriptor meaning blue, green or light grey, and its use in medical terms came from the colour produced in angleclosure glaucoma. The goddess Athena was referred to throughout Homer’s Iliad as “Glaukopis Athena” for her bright or “flashing” eyes. Speaking more generally, the word “ophthalmos” was the Greek for eye, and combined with “logos” meaning word or study, it forms ophthalmology.

Writing about “The Cataract Operation In Ancient Greece” in Histoire des sciences médicales in 1982, Jean Lascaratos and Spyros Marketos describe the understanding of and methods to treat cataract in Ancient Greece.

Hippocrates, known as the father of western medicine, mentions the term “glaucosis”, they write, but it is believed

that he was in fact referring to what we now call cataract. Galen, who came several hundred years later in the 2nd Century AD, believed that hypochyma (as cataract was then called) was a coagulation of the aqueous humour, while glaucoma was the transformation of humours existing in the eye to a sea-green colour.

Galen wrote that a treatment for cataract was discovered by accident: “That is, a goat suffering from hypochyma saw again when it fell upon a thorn that pierced its eye.”

His standard was as follows: “We pierce the cornea with a needle on the periphery until it has entered the anterior chamber.

Then we pierce the hypochyma, which we push aside.” Another method described by Galen was called depression, which consisted of moving the cataract away from its original position. He also writes that some doctors tried to remove the cataract by opening the cornea, yet this was a rare, risky approach.

To think it would be some 1,600 years before Jacques Daviel successfully extracted cataracts, and another 100 after that before the advent of phacoemulsification, the Ancient Greeks deserve a lot of credit for their efforts.

What they might make of the advances made today, and on show at the 23rd ESCRS Winter Meeting, we will never know.

Türkiye

TURKISH LANGUAGE EDITION ONLINE Visit: www.eurotimesturkey.org

EUROTIMES | FEBRUARY 2019

CALENDAR

↙

LAST CALL

FEBRUARY 2019 6–10 February Florida, USA www.CSTellingItLikeItIs.com

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

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

MARCH 9th EURETINA Winter Meeting

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

↙

Cataract Surgery: Telling It Like It Is

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

Retina World Congress

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

APRIL

8th World Glaucoma Congress

46th EFCLIN Congress Exhibition

27–30 March Melbourne, Australia www.worldglaucomacongress.org

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

17th Congress of the Black Sea Ophthalmological Society 19–21 April Istanbul, Turkey http://bsos-istanbul2019.org

25–27 April Brussels, Belgium www.efclin.com

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

NEW 17th SOI International Congress 23–25 May Rome, Italy https://www.congressisoi.com/

NEW 16th South East European Congress of Ophthalmology May 31–June 2 Prishtina, Kosovo http://www.shofk.org/

The 45th Annual Meeting of the European Paediatric Ophthalmological Society May 30–June 1 Riga, Latvia https://www.epos-focus.org/

17th Congress of the Black Sea Ophthalmological Society which will take place in Istanbul, Turkey

EUROTIMES | FEBRUARY 2019

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40

CALENDAR

JUNE SOE Congress 2019 13–16 June Nice, France www.soevision.org

SEPTEMBER 19th EURETINA Congress 5–8 September Paris, France www.euretina.org

10th EuCornea Congress 13–14 September Paris, France www.eucornea.org

WSPOS Subspecialty Day 13 September Paris, France www.wspos.org

37th Congress of the ESCRS 14–18 September Paris, France www.escrs.org

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

NEW Ophthalmic Imaging: from Theory to Current Practice

4 October Paris, France https://www.vuexplorer.com/en/congres

The 38th Congress of the ESCRS, 20th EURETINA Congress and 11th EuCornea Congress will each take place in Amsterdam, The Netherlands

2020 MAY ASCRS•ASOA Symposium and Congress 15–19 May Boston, USA www.ascrs.org

JUNE World Ophthalmology Congress (WOC) 26–29 June Cape Town, South Africa http://woc2020.icoph.org/

OCTOBER

OCTOBER

20th EURETINA Congress

38th Congress of the ESCRS

1– 4 October Amsterdam, The Netherlands www.euretina.org

11th EuCornea Congress 2–3 October Amsterdam, The Netherlands www.eucornea.org

WCPOS V 5th World Congress of Paediatric Ophthalmology and Strabismus 2– 4 October Amsterdam, The Netherlands www.wspos.org

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Eye Contact Interviews

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player.escrs.org EUROTIMES | FEBRUARY 2019

3–7 October Amsterdam, The Netherlands www.escrs.org

NOVEMBER AAO Annual Meeting 2020 14–17 November Las Vegas, USA www.aao.org

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Abstract Submission Deadline 15 March 2019

P A R I S w w w. e s c r s . o r g

THE ULTIMATE EXPERIENCE OF CONTROL AND CLARITY Clareon® AutonoMe™. Automated delivery of unsurpassed clarity.§,1-4

Introducing the Clareon® IOL with the AutonoMe™ automated, disposable, preloaded delivery system. With its intuitive, ergonomic design, the AutonoMe™ delivery system enables easy, single-handed control of IOL advancement and preserves incisions as small as 2.2 mm.1,5-8 Preloaded with the Clareon® IOL, it delivers a new monofocal lens with an advanced design and unsurpassed optic clarity.1-4,9-12

Talk to your dedicated Alcon representative to learn more about Clareon® AutonoMe. TM

1. Clareon® AutonoMe™ Directions for Use. 2-12. Alcon Data on File.

§Based on aggregate results from in vitro evaluations of haze, SSNGs and glistenings compared to TECNIS§§ OptiBlue§§ ZCB00V (Abbott), TECNIS§§ ZCB00 (Abbott), Eternity Natural Uni§§ W-60 (Santen), Vivinex§§ XY-1 (HOYA) and enVista§§ MX60 (B&L; Bausch & Lomb). §§Trademarks are the property of their respective owners.

© 2017 Novartis 11/17 GL-CAM-17-MK-0486-EU