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SPECIAL FOCUS RETINA

March 2019 | Vol 24 Issue 3

THE DIABETIC EYE CATARACT & REFRACTIVE | CORNEA GLAUCOMA | PAEDIATRIC OPHTHALMOLOGY


Making the difference in eYe SUrgerY Oertli makes the difference. With surgical platforms and instruments of impressive quality that make cataract, glaucoma and vitrectomy surgery even safer, easier and more efficient. With lasting innovations and new technologies that have long term impact on ophthalmology. With superb service and real added value for surgeons and OR personnel. And in consistent persuit to accomplish the very best for users and patients.

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E yE surgEry. swis s madE .


P.22

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

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

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS

RETINA

4 How to optimise

surgical outcomes in diabetic patients

7 Link between diabetic retinopathy and clinically significant macular oedema

8 DME has entered a

new paradigm of individualised care

9 Research examines

link between stress and central serous chorioretinopathy

10 Tissue transplantation

explored as a regenerative therapeutic strategy for AMD

11 When to operate in cases of myopic foveoschisis

12 Recounting the history of OCT and anti-VEGFs

17 New rhexis-fixated lens

achieves very good visual acuity and rotational stability

18 LASIK vs SMILE – the debate continues

19 All-laser cataract surgery shows less endothelial cell loss than femtophaco surgery

20 Where next for lasers in refractive surgery?

21 JCRS update 22 All the news from the 23rd ESCRS Winter Meeting in Athens, Greece

CORNEA 24 Intraoperative anterior segment OCT in keratoplasty – is it worth it?

26 Controlling inflammation in cases of severe dry eye disease

www.eurotimes.org

GLAUCOMA 27 How the distal

aqueous drainage tract affects IOP

PAEDIATRIC OPHTHALMOLOGY 28 Secondary IOL

implantation in paediatric cataract patients

29 Remembering

Jack Kanski (1939–2019)

REGULARS 31 ESCRS news 33 Industry news 34 Outlook on industry 35 Random thoughts 37 Travel 38 Society news 39 Calendar

13 Ophthalmologica update

CATARACT & REFRACTIVE

P.37

14 How to master the

complication of an errant rhexis in phacoemulsification

16 Refractive lens 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.

exchange offers low complication rates and high patient satisfaction for presbyopia EUROTIMES | MARCH 2019


2

EDITORIAL A WORD FROM SEBASTIAN WOLF MD

GUEST EDITORIAL

Sebastian Wolf

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)

A positive environment

I

Exciting initiatives planned as Society celebrates 19 years

am delighted to get this opportunity to write this editorial for EuroTimes, which has a special focus on retina in its March edition. At our first congress in 2001, we welcomed 300 delegates in Hamburg, Germany. Last year in Vienna, Austria, we welcomed more than 5,600 delegates at our 18th Congress, confirming its position as the largest retina meeting in the world. The environment has been very positive for retina in the past 20 years and from around 2005 onwards, the introduction of anti-VEGF therapy has sparked a revolution in At our first congress the field of retina. This year marks the 19th in 2001, we welcomed anniversary of the Society 300 delegates in and we have many exciting initiatives planned. Hamburg, Germany. Some of you will have Last year in Vienna, recently returned from our Winter Meeting, Austria, we welcomed which was held this year more than 5,600 in Prague in the Czech delegates... Republic. Our focus now turns to the 19th EURETINA Congress, which will be held in Paris, France, from 5-8 September, 2019. I am delighted to announce that Francesco Bandello, a founder member of the society, will present the EURETINA Lecture at the Opening Ceremony in Paris, entitled ‘Diabetic retinopathy today’. Our Programme Committee has been very busy preparing for what should be another memorable Congress and exciting topics to look out for in Paris are Artificial Intelligence in Retina, The Diabetic Retina and Retinal Gene Therapy. Education, as always, is at the centre of our activities and under the EURETINA Observership Scheme, 10 grants are awarded annually in March. EURETINA is also awarding grants for two research projects this year. One is the EURETINA Submacular Haemorrhage Clinical Research Grant and the other is the Retinal Medicine Clinical Research Funding Call In the past year, EURETINA has launched a new website – www.euretina.org – which keeps members up to date with all of the Society’s activities. Please also note that membership is free for under 40s through the YOURS initiative or, if your national society is a partner, a 20% discount can be availed of for members of their national society. Details of how to join are available on the website. I look forward to seeing you in Paris and as always welcome any ideas that you may have that will help us to keep EURETINA at the forefront of retina education and research.

Sebastian Wolf is President of EURETINA EUROTIMES | MARCH 2019


NOW WITH THE OPTION TO

T R E AT & E X TEND

IN YEAR 11

For TREATMENT-NAΪVE patients with wAMD1

WHAT YOU

START TODAY MAKES A DIFFERENCE TOMORROW

UKEYL09180137 © Bayer AG, September 2018.

Reference: 1. EYLEA (aflibercept solution for injection) Summary of Product Characteristics Berlin, Germany: Bayer Pharma AG; July 2018. Eylea 40 mg/ml solution for injection in a vial (aflibercept) Prescribing Information. (Refer to full Summary of Product Characteristics (SmPC) before prescribing). Presentation: 1 ml solution for injection contains 40 mg aflibercept. Each vial contains 100 microlitres, equivalent to 4 mg aflibercept. Indication(s): Treatment of neovascular (wet) age-related macular degeneration (wAMD), macular oedema secondary to retinal vein occlusion (branch RVO or central RVO), visual impairment due to diabetic macular oedema (DMO) in adults and visual impairment due to myopic choroidal neovascularisation (myopic CNV). Posology & method of administration: For intravitreal injection only. Must be administered according to medical standards and applicable guidelines by a qualified physician experienced in administering intravitreal injections. Each vial should only be used for the treatment of a single eye. Extraction of multiple doses from a single vial may increase the risk of contamination and subsequent infection. The vial contains more than the recommended dose of 2 mg. The extractable volume of the vial (100 microlitres) is not to be used in total. The excess volume should be expelled before injecting. Refer to SmPC for full details. Adults: The recommended dose is 2 mg aflibercept, equivalent to 50 microlitres. For wAMD treatment is initiated with 1 injection per month for 3 consecutive doses. The treatment interval is then extended to 2 months. Based on the physician’s judgement of visual and/or anatomic outcomes, the treatment interval may be maintained at 2 months or further extended using a treat-and-extend dosing regimen, where injection intervals are increased in 2- or 4-weekly increments to maintain stable visual and/ or anatomic outcomes. If visual and/or anatomic outcomes deteriorate, the treatment interval should be shortened accordingly to a minimum of 2 months during the first 12 months of treatment. There is no requirement for monitoring between injections. Based on the physician’s judgement the schedule of monitoring visits may be more frequent than the injection visits. Treatment intervals greater than 4 months between injections have not been studied. For RVO (branch RVO or central RVO), after the initial injection, treatment is given monthly at intervals not shorter than 1 month. Discontinue if visual and anatomic outcomes indicate that the patient is not benefiting from continued treatment. Treat monthly until maximum visual acuity and/or no signs of disease activity. Three or more consecutive, monthly injections may be needed. Treatment may then be continued with a treat-and-extend regimen with gradually increased treatment intervals to maintain stable visual and/or anatomic outcomes, however there are insufficient data to conclude on the length of these intervals. Shorten treatment intervals if visual and/or anatomic outcomes deteriorate. The monitoring and treatment schedule should be determined by the treating physician based on the individual patient’s response. For DMO, initiate treatment with 1 injection/month for 5 consecutive doses, followed by 1 injection every 2 months. No requirement for monitoring between injections. After the first 12 months of treatment, and based on visual and/or anatomic outcomes, the treatment interval may be extended such as with a treat-and-extend dosing regimen, where the treatment intervals are gradually increased to maintain stable visual and/or anatomic outcomes; however there are insufficient data to conclude on the length of these intervals. If visual and/or anatomic outcomes deteriorate, the treatment interval should be shortened accordingly. The schedule for monitoring should therefore be determined by the treating physician and may be more frequent than the schedule of injections. If visual and anatomic outcomes indicate that the patient is not benefiting from

continued treatment, treatment should be discontinued. For myopic CNV, a single injection is to be administered. Additional doses may be administered if visual and/or anatomic outcomes indicate that the disease persists. Recurrences should be treated as a new manifestation of the disease. The schedule for monitoring should be determined by the treating physician. The interval between 2 doses should not be shorter than 1 month. Hepatic and/or renal impairment: No specific studies have been conducted. Available data do not suggest a need for a dose adjustment. Elderly population: No special considerations are needed. Limited experience in those with DMO over 75 years old. Paediatric population: No data available. Contraindications: Hypersensitivity to active substance or any excipient; active or suspected ocular or periocular infection; active severe intraocular inflammation. Warnings & precautions: As with other intravitreal therapies endophthalmitis, intraocular inflammation, rhegmatogenous retinal detachment, retinal tear and iatrogenic traumatic cataract have been reported. Aseptic injection technique is essential. Patients should be monitored during the week following the injection to permit early treatment if an infection occurs. Patients must report any symptoms of endophthalmitis or any of the above mentioned events without delay. Increases in intraocular pressure have been seen within 60 minutes of intravitreal injection; special precaution is needed in patients with poorly controlled glaucoma (do not inject while the intraocular pressure is ≥ 30 mmHg). Immediately after injection, monitor intraocular pressure and perfusion of optic nerve head and manage appropriately. There is a potential for immunogenicity as with other therapeutic proteins; patients should report any signs or symptoms of intraocular inflammation e.g pain, photophobia or redness, which may be a clinical sign of hypersensitivity. Systemic adverse events including non-ocular haemorrhages and arterial thromboembolic events have been reported following intravitreal injection of vascular endothelial growth factor (VEGF) inhibitors. Safety and efficacy of concurrent use in both eyes have not been systemically studied. No data is available on concomitant use of Eylea with other anti-VEGF medicinal products (systemic or ocular). Caution in patients with risk factors for development of retinal pigment epithelial tears including large and/or high pigment epithelial retinal detachment. Withhold treatment in patients with: rhegmatogenous retinal detachment or stage 3 or 4 macular holes; with retinal break and do not resume treatment until the break is adequately repaired. Withhold treatment and do not resume before next scheduled treatment if there is: decrease in best-corrected visual acuity of ≥30 letters compared with the last assessment; central foveal subretinal haemorrhage, or haemorrhage ≥50%, of total lesion area. Do not treat in the 28 days prior to or following performed or planned intraocular surgery. Eylea should not be used in pregnancy unless the potential benefit outweighs the potential risk to the foetus. Women of childbearing potential have to use effective contraception during treatment and for at least 3 months after the last intravitreal injection. In patients presenting with clinical signs of irreversible ischaemic visual function loss, aflibercept treatment is not recommended. Populations with limited data: There is limited experience in DMO due to type I diabetes or in diabetic patients with an HbA1c over 12% or with proliferative diabetic retinopathy. Eylea has not been studied in patients with active systemic infections, concurrent eye conditions such as retinal detachment or macular hole, or in diabetic patients with uncontrolled hypertension. This lack of information should be considered when treating such patients. In myopic CNV there is no experience with Eylea in the

treatment of non-Asian patients, patients who have previously undergone treatment for myopic CNV, and patients with extrafoveal lesions. Interactions: No available data. Fertility, pregnancy & lactation: Not recommended during pregnancy unless potential benefit outweighs potential risk to the foetus. No data available in pregnant women. Studies in animals have shown embryo-foetal toxicity. Women of childbearing potential have to use effective contraception during treatment and for at least 3 months after the last injection. Not recommended during breastfeeding. Excretion in human milk: unknown. Male and female fertility impairment seen in animal studies with high systemic exposure not expected after ocular administration with very low systemic exposure. Effects on ability to drive and use machines: Possible temporary visual disturbances. Patients should not drive or use machines if vision inadequate. Undesirable effects: Very common: Visual acuity reduced, conjunctival haemorrhage (wAMD phase III studies: increased incidence in patients receiving anti-thrombotic agents), eye pain. Common: retinal pigment epithelial tear (known to be associated with wAMD; observed in wAMD studies only), detachment of the retinal pigment epithelium, retinal degeneration, vitreous haemorrhage, cataract (nuclear or subcapsular), corneal abrasion or erosion, increased intraocular pressure, blurred vision, vitreous floaters, vitreous detachment, injection site pain, foreign body sensation in eyes, increased lacrimation, eyelid oedema, injection site haemorrhage, punctate keratitis, conjunctival or ocular hyperaemia. Serious: cf. CI/W&P - in addition: blindness, culture positive and culture negative endophthalmitis, cataract traumatic, transient increased intraocular pressure, vitreous detachment, retinal detachment or tear, hypersensitivity (during the post-marketing period, reports of hypersensitivity included rash, pruritus, urticaria, and isolated cases of severe anaphylactic/anaphylactoid reactions), vitreous haemorrhage, cortical cataract, lenticular opacities, corneal epithelium defect/erosion, vitritis, uveitis, iritis, iridocyclitis, anterior chamber flare, arterial thromboembolic events (ATEs) are adverse events potentially related to systemic VEGF inhibition. There is a theoretical risk of arterial thromboembolic events, including stroke and myocardial infarction, following intravitreal use of VEGF inhibitors. As with all therapeutic proteins, there is a potential for immunogenicity. Consult the SmPC in relation to other side effects. Overdose: Monitor intraocular pressure and treat if required. Incompatibilities: Do not mix with other medicinal products. Special Precautions for Storage: Store in a refrigerator (2°C to 8°C). Do not freeze. Unopened vials may be stored at room temperature (below 25°C) for up to 24 hours before use. Legal Category: POM. Package Quantities & Basic NHS Costs: Single vial pack £816.00. MA Number(s): EU/1/12/797/002. Further information available from: Bayer plc, 400 South Oak Way, Reading RG2 6AD, United Kingdom. Telephone: 0118 206 3000. Date of preparation: July 2018. Eylea® is a trademark of the Bayer Group

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. Adverse events should also be reported to Bayer plc. Tel.: 0118 2063500, Fax.: 0118 2063703, Email: pvuk@bayer.com


4

SPECIAL FOCUS: RETINA

TIMING & PREPARATION FOR THE DIABETIC EYE While it is not the ophthalmologist’s role to manage a patient’s diabetes, there are things they can do to optimise surgical outcomes. Leigh Spielberg MD reports

A

s a vitreoretinal and cataract surgeon, reading “diabetes mellitus” in a medical chart sets all the alarm bells ringing even before the patient enters the examination room. Undesirable scenarios pop into my head: early-onset cataract with suboptimal pupillary dilation, postoperative macular oedema, systemic comorbidities and anticoagulant use... It always takes a moment or two before I manage to reassure myself that our current, collective knowledge of the ocular complications of the disease is sufficient to manage (or, preferably, EUROTIMES | MARCH 2019

prevent) anything we come across these days. But is this true? Can we? The risks of cataract surgery in the diabetic patient can be divided into the standard surgical complications and diabetes-related complications, the latter of which can be further subdivided into progression of diabetic retinopathy and appearance or worsening of DME. And although diabetic retinopathy does not seem to worsen due to cataract surgery, diabetes itself is a risk factor for disappointing visual outcomes. “Poor visual outcome after cataract surgery in diabetics is more closely correlated with poor metabolic control

rather than the surgical trauma itself,” said Professor Morten la Cour, University of Copenhagen, Denmark, during the ESCRS/ EURETINA Symposium: The Diabetic Eye at the combined 18th EURETINA Congress and 36th Congress of the ESCRS in Vienna in September 2018. “Diabetes mellitus, even in the absence of diabetic retinopathy or pre-existing DME, is the most significant risk factor for postoperative macular oedema,” said Dr la Cour. The risk of postoperative diabetic macular oedema (pDME) is 1.8 times higher after cataract surgery in diabetics, and increases with the severity of the diabetic retinopathy. This risk increases


SPECIAL FOCUS: RETINA

Diabetes mellitus, even in the absence of diabetic retinopathy or pre-existing DME, is the most significant risk factor for postoperative macular oedema Professor Morten la Cour

with longer duration of diabetes and poorer metabolic control. As ophthalmologists, we have a very limited role in the management of the diabetes itself. However, there are several things that we can do to optimise surgical outcomes. “Before referring my diabetic patients for cataract surgery, I make sure that the retinal situation is as good as it can possibly be,” says Julie De Zaeytijd, a medical retina specialist at Ghent University Hospital in Belgium. She tailors the treatment plan to each individual patient depending on their prior history and the current situation.

DME “In diabetic patients with no prior history of DME, the preoperative preparation does not differ from that of non-diabetic patients: preoperative NSAID drops suffice,” says Dr De Zaeytijd. Perioperative topical NSAID is superior to topical steroid monotherapy in the prevention of postoperative CME in both diabetics and non-diabetics, so NSAID prophylaxis should thus be used in all diabetics. However, pre-existing DME should be treated prior to performing cataract surgery. “If the patient is already suffering from DME, I prescribe three monthly antiVEGF injections. I then plan the phaco one week after the last injection and pre-plan an appointment to see my patient three weeks after surgery,” she says. What about patients with a history of DME but whose foveas are currently ‘dry’ when cataract surgery is planned? “These patients receive an anti-VEGF injection one week prior to cataract surgery,” she says, the timing of which her administrative staff coordinates with the surgeon’s planning team. The same thing goes for patients with proliferative diabetic retinopathy (PDR) and a fundus that is difficult to visualise due to advanced cataract. “A preoperative anti-VEGF decreases the chances of haemorrhage and it buys us a bit of time until laser can be performed two weeks after surgery,” she said. It is useful to note that there is no advantage of performing panretinal photocoagulation (PRP) prior to surgery. Further, preoperative PRP is often difficult due to lens opacities.

SURGERY Although standard surgical complications, such as capsular rupture, are not encountered

more frequently in diabetic eyes, despite previous literature suggesting the opposite, some small adjustments might need to be made more frequently in diabetic eyes. Thierry Derveaux, a cataract specialist at Ghent University Hospital, speaks from the surgeon’s point of view. “In patients who have received intravitreal injections, we have to remember to be wary of occult lens touches or punctures of the posterior capsule. When in doubt, perform hydrodelineation rather than hydrodissection,” Dr Derveaux recommends, which will help avoid putting pressure on a posterior capsule that might be compromised. “Preoperatively, it’s important to determine the maximum obtainable mydriasis. A pupil that doesn’t sufficiently dilate pharmacologically is not likely to respond to additional intracameral mydriatics, so be prepared to use devices such as iris retractors if necessary,” says Dr Derveaux. In patients with diabetes, it’s very important that the retinal specialist can continue examining the retina for years after surgery. “In order to prevent anterior capsular phimosis, I enlarge my capsulorhexis if it is smaller than 5mm and carefully remove all lens epithelial cells from the anterior capsular rim to the equator,” he says. “And in cases of zonular weakness or large, stretched capsular bags, I have a low threshold to implant a capsular tension ring in an attempt to prevent phimosis,” although he adds that this is not necessarily supported by the literature.

POSTOPERATIVE CARE As for postoperative care: “Whereas I generally only see my patients one day and one month post-op, I am more likely to see my diabetic patients one week after surgery and will exchange the topical NSAID for preservative-free artificial tears if the corneal epithelium is suffering,” he says. OCTs are performed at one month and two months post-op to detect the occurrence or recurrence of macular oedema. Close collaboration between the doctor treating the diabetic macular oedema or diabetic retinopathy are paramount, and both communication and advanced planning are crucial. “I make every effort to streamline everything during the perioperative

period, which includes making the surgeon’s life as easy as possible so (s)he doesn’t have to think about what has to happen a few weeks after surgery,” said Dr De Zaeytijd. This includes writing her preferred treatment plan in the patient’s chart and working closely with her support staff to make sure post-op appointments are already made before referral to the surgeon. Despite the increased risks encountered in patients with diabetes, most studies agree that cataract extraction results in visual improvement in the clear majority of diabetics with modern minimally invasive cataract surgery.

World Diabetes Day (WDD) was created in 1991 by the International Diabetes Federation and the World Health Organization in response to growing concerns about the escalating health threat posed by diabetes. It is marked every year on 14 November, the birthday of Sir Frederick Banting, who co-discovered insulin along with Charles Best in 1922. WDD is the world’s largest diabetes awareness campaign reaching a global audience of more than one billion people in more than 160 countries. The campaign draws attention to issues of paramount importance to the diabetes world and keeps diabetes firmly in the public and political spotlight. For more information visit: https://www.worlddiabetesday.org The International Diabetes Federation (IDF) is an umbrella organisation of more than 240 national diabetes associations in 168 countries and territories. It represents the interests of the growing number of people with diabetes and those at risk. The Federation has been leading the global diabetes community since 1950. IDF’s mission is to promote diabetes care, prevention and a cure worldwide. IDF is engaged in action to tackle diabetes from the local to the global level – from programmes at community level to worldwide awareness and advocacy initiatives. For more information visit: https://www.idf.org

EUROTIMES | MARCH 2019

5


5-8 September 2019 Abstract Submission Deadline 14 March 2019

Le Palais des Congrès Paris, France

www.euretina.org


SPECIAL FOCUS: RETINA

7

Treatment strategies New clinical trial evidence guides treatment to CME in diabetics. Leigh Spielberg MD reports

T

Mean CSMT (µm) was the main outcome of the study 310

290

Control TA Bevacizumab Combination

270

250 Baseline

6 wks

CSMT and the incidence of CSME was lowest in patients who received both treatments, said Dr Nuijts. The incidence of CSME within 12 weeks postoperatively was 5.1% in the dexamethasone group, 3.6% in the bromfenac group and combination treatment reduced the incidence to merely 1.5% in non-diabetic patients. PREMED study report #2 describes prophylaxis in diabetic patients. All patients received a combination therapy of topical bromfenac and dexamethasone and were randomised to receive no additional treatment; subconjunctival triamcinolone acetonide (TA); intravitreal bevacizumab; or the combination of both subconjunctival TA and bevacizumab. Mean postoperative CSMT was the main outcome of the study. “Mean postoperative CSMT was lowest in patients who received TA prophylaxis, with 0.0% of patients having CSME within both six and 12 weeks after surgery,” said Dr Nuijts (see above). There was a statistically significant increase in mean intraocular pressure (IOP) in these patients, however: +1.7mmHg at six weeks and +2.5mmHg at 12 weeks, with 7.1% of patients experiencing an IOP of ≥25mmHg. “A single subconjunctival TA injection effectively prevents the development of CME after cataract surgery in diabetic patients. However, the risk of developing CME should be carefully weighed against the risk of developing an increased IOP.” Intravitreal bevacizumab alone had no significant effect in preventing CME after cataract surgery, and there was no added benefit of bevacizumab when added to subconjunctival TA. This agrees with previous studies stating that intravitreal

12 wks

anti-VEGF injection did not decrease the incidence of CME at three and six months after cataract surgery in type 2 diabetic patients with stable non-proliferative DR. What about DME in a patient scheduled for cataract surgery, and treatment of postoperative macular oedema if prophylaxis has failed to prevent it? Differentiating DME from postoperative pseudophakic CME (PCME) is crucial, he said. “Whereas both DME and PCME display a central macular oedema pattern, the oedema in DME is primarily located in the outer nuclear layer, without retinal nerve fiber layer thickening.” The appearance of DME stands in contrast with PCME, in which subretinal fluid is more commonly seen. PCME is characterised by central and symmetric macular oedema, typically located in the central 1mm area of the macula. Central cystoid changes are confined to the inner nuclear layer. Dr Nuijts also had several tips for treating macular oedema, based on the literature. “Treat DME preoperatively with anti-VEGF injections, laser, steroids or a combination thereof prior to cataract surgery. Intravitreal anti-VEGF drugs and steroids can be combined with cataract surgery and are effective if DME is still present postoperatively. In patients without CME preoperatively, topical NSAIDs are effective, but additional oral NSAIDs (indomethacin), acetazolamide or sub-Tenon steroid injections do not improve the results.” This research was carried out by Laura Wielders MD, PhD, on behalf of ESCRS PREMED Study Group Rudy Nuijts: rudy.nuijts@mumc.nl EUROTIMES | MARCH 2019

Courtesy of Rudy Nuijts MD, PhD

CSMT (µm)

here is a linear trend between the severity of diabetic retinopathy (DR) and the risk of developing clinically significant macular oedema (CSME) after cataract surgery, Rudy MMA Nuijts MD, PhD, told attending delegates the ESCRS/EURETINA Symposium, during the combined 18th EURETINA and 36th ESCRS Annual Conference in Vienna in September 2018. “Pseudophakic cystoid macular oedema results from a postoperative inflammatory response and develops within 12 weeks after cataract surgery. It results from impaired blood-retina barrier function,” said Dr Nuijts, University Eye Clinic Maastricht UMC+, The Netherlands. “A study showed that the relative risk of developing postoperative CME is 6.23 for patients with any degree of diabetic retinopathy (DR) and is 1.8 even for diabetic patients with no signs of DR,” he said. However, proof of effective prophylaxis had remained elusive. In 2015, the American Academy of Ophthalmology stated that: “There is a lack of Level 1 evidence supporting the long-term visual benefit of NSAID therapy when applied solely or in combination with corticosteroid therapy.” However, a report from the ASCRS Cataract Clinical Committee and the American Glaucoma Society stated: “The efficacy of NSAIDs is compelling, whether used alone, synergistically with steroids or for specific high-risk eyes.” Clearly, there was a need for irrefutable evidence. The ESCRS-sponsored PREvention of Macular EDema after cataract surgery in non-diabetics (PREMED study report #1) introduced Level 1 evidence. This study was the first international, multi-centre, randomised controlled clinical trial directly comparing the efficacy of a topical NSAID, corticosteroid and the combination of both in the prevention of CSME. In the PREMED study for non-diabetics, 914 patients were randomised to one of three treatment groups: topical NSAID (bromfenac), topical steroid (dexamethasone) and a combination of the two. CME was defined as the presence of cystic changes on OCT and an increase of central subfield mean macular thickness (CSMT) of ≥10% as compared to baseline. CSME was defined as the presence of CME and less than 0.2 logMAR improvement in corrected distance visual acuity as compared to baseline. The study showed that mean postoperative


8

SPECIAL FOCUS: RETINA

Managing DME Diabetic macular oedema enters new paradigm of individualised care. Dermot McGrath reports

D

ramatic improvements in the diagnosis and treatment of diabetic macular oedema (DME) have ushered in a new era of patient management, according to Francesco Bandello MD, FEBO. “There have been a number of important breakthroughs in DME over the past few years, with anti-VEGF treatments and multimodal imaging, among others, helping to transform the way we manage our patients. Treatment paradigms, aiming at multiple pathways, are now changing with respect to the past. Individualised therapy, where we choose the right therapy for the right patient, is the most effective approach to maximise results,” Dr Bandello told delegates attending the 18th EURETINA Congress in Vienna. The classification of DME is critical to orient treatment choice, said Dr Bandello. “We need to move away from reliance on the old classification system of identifying clinically significant macular oedema based on topography. This was fine when we had only laser treatments available. However, we can now use a more relevant and useful pathogenetic classification of DME,” he said. Four distinct types of DME can be distinguished using fundus photography and spectral-domain optical coherence tomography (OCT): vasogenic, nonvasogenic, tractional DME and mixed DME, noted Dr Bandello. Vasogenic DME, characterised by retinal thickening with vascular dilations, is the most frequent pattern. The nonvasogenic form involves retinal thickening without vascular dilations, while tractional DME typically involves central retinal thickness (CRT) of at least 400 microns with associated epiretinal traction. Mixed DME combines characteristics of two or more of these specific subtypes, explained Dr Bandello. Fluorescein angiography (FA) should be used to identify microvascular abnormalities responsible for leakage and oedema, and to direct focal laser treatment with greater accuracy. Widefield FA is useful for locating peripheral ischaemia and is performed prior to initiation of therapy, he said. Spectral domain OCT is important to assess the treatment response and to classify different types of oedema, said Dr Bandello. OCT angiography (OCT-A) is increasingly EUROTIMES | MARCH 2019

Francesco Bandello speaking at the 18th EURETINA Congress in Vienna in 2018

being used in a clinical setting and is useful for identifying foveal vascular enlargement, ischaemia, neovascularisation and the different vascular plexuses, he added. “OCT-A enables closer observation of the blood flow of each retinal capillary layer and is the only instrument currently capable of visualising and quantifying what we are seeing in these areas,” said Dr Bandello. Once diagnosis of DME has been confirmed, treatment should be planned according to DME subtype. Anti-VEGF agents are the current first-line therapy for both focal and diffuse DME, noted Dr Bandello, with two-year results from the Protocol T study showing bevacizumab, ranibizumab, and aflibercept all equally effective in restoring visual acuity. Bevacizumab was slightly less effective in patients whose baseline visual acuity was less than 20/350, he added. While laser treatment has been supplanted as standard of care by antiVEGF injections, it may still play a role in treating vasogenic DME, eyes affected by DME with CRT less than 300μm or eyes with persisting vitreomacular adhesion in the absence of response to intravitreal antiVEGF or steroids, said Dr Bandello. Subthreshold grid laser treatment may also be helpful in eyes with higher visual acuity affected by early diffuse DME. Corticosteroids are a good second-

line option for DME patients that do not respond to anti-VEGF therapy, or as a first-choice treatment for those with a history of a major cardiovascular event, or in vitrectomised or pseudophakic eyes. “We must remember that 30-to-40% of our patients are not sensitive to antiVEGF, so there is scope for using this kind of approach. Dexamethasone should be used first, with fluocinolone reserved for chronic macular oedema that is not responsive to other treatments,” he said. Surgery, involving pars plana vitrectomy (PPV) and epiretinal membrane removal, also remains an option in cases of unresponsive tractional DME, noted Dr Bandello. PPV for tangential traction due to epiretinal or hyaloid membrane should be performed only if there is an incomplete response to anti-VEGF or dexamethasone. Dr Bandello also emphasised the importance of a holistic approach to patient care, with close metabolic control of systemic disease. “We need to ensure solid communication between diabetologist and retinologist, to ask for HbA1c levels and systemic blood pressure at baseline and at each follow-up,” he concluded. Francesco Bandello: bandello.francesco@hsr.it


SPECIAL FOCUS: RETINA

Steroids and stress in CSC Research seeks clues that will elucidate disease pathogenesis. Cheryl Guttman Krader reports

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vailable evidence indicates that stress and hypercortisolism are involved in the pathogenesis of central serous chorioretinopathy (CSC), but more research is needed to understand the underlying pathways and the implications for patient management, Elon H C van Dijk MD, PhD, told during a session of the 18th EURETINA Congress in Vienna. He presented findings from a study designed to explore questions related to hypercortisolism and stress in patients with CSC. The study included 88 patients with CSC and 24 controls. It investigated whether patients with CSC might have subclinical hypercortisolism or oligosymptomatic Cushing’s syndrome. In addition, it sought to evaluate psychological stress and coping mechanisms in patients with CSC and identify if they had specific personality traits as previous reports suggested that people with a “type A” personality were at increased risk to develop CSC. Patients included in the study had a diagnosis of CSC established by multimodal imaging within the past two years and no history of corticosteroid use before or after developing CSC. Evaluations included clinical examination, assays of cortisol levels in hair, serum, a 24-hour urine collection, saliva and a dexamethasone suppression test. Results indicated that activity of the hypothalamus-pituitaryadrenal axis was increased in the patients with CSC. None of the patients with CSC had evidence of subclinical Cushing’s syndrome, reported Dr van Dijk, Leiden University Medical Centre, Leiden, the Netherlands. “We previously published that CSC can be the first manifestation of Cushing’s syndrome. Based on our new study, we think that unless patients with CSC have signs or symptoms of Cushing’s syndrome, they do not need to be referred to an endocrinologist as a routine screening measure. The importance of hyperactivity of the hypothalamus-pituitary-adrenal axis in our patients is not known, but warrants further studies.” Stress, coping, and personality traits were evaluated using several validated questionnaires. Analyses showed that the personality profile of the patients with CSC was more similar to that of patients treated for Cushing’s disease than to the general population. No difference in perceived stress was found comparing subgroups of CSC patients who had active and inactive disease, based on either the presence or absence of subretinal fluid on the optical coherence tomography scan. Results regarding stress coping indicated that patients with CSC sought more social support than healthy controls and used more active and passing coping. CSC patients, however, were not found to be abnormal in stress coping. “Based on these findings, we believe there is no clear role for stress reduction in the treatment of CSC,” said Dr van Dijk. Elon H C van Dijk: ehcvandijk@lumc.nl

...unless patients with CSC have signs or symptoms of Cushing’s syndrome, they do not need to be referred to an endocrinologist Elon H C van Dijk MD, PhD

EUROTIMES | MARCH 2019

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SPECIAL FOCUS: RETINA

Transplants and AMD Researchers report promising results with human embryonic stem cell-based tissue transplantation. Cheryl Guttman Krader reports

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ngoing follow-up of patients in a phase I clinical study supports the safety, feasibility, efficiency and stability of a novel tissue transplantation approach as a regenerative therapeutic strategy for age-related macular degeneration (AMD), reported Dr Odysseas Georgiadis, at the 18th EURETINA Congress in Vienna, Austria. Speaking on behalf of The London Project to Cure Blindness team, Dr Georgiadis described the procedure, which involves submacular transplantation of a sheet consisting of a fully differentiated, human embryonic stem cell (hESC)derived retinal pigment epithelium (RPE) monolayer on a coated, synthetic basement membrane. Graft delivery is performed using a purpose-designed surgical tool. He reported encouraging outcomes from follow-up to 18 months in the two patients treated so far. “Late AMD is considered amenable to cell replacement therapy because it manifests with irreversible cell loss. Although previous surgical approaches, such as macular translocation and autologous RPE transplantation, provided proof of principle for cell replacement, their complexity highlighted the need for an easily accessible cell source and a more feasible surgical paradigm,” said Dr Georgiadis, Moorfields Eye Hospital, London, England. “Our ultimate goal is to establish a new therapeutic paradigm, applicable to the large number of patients that suffer from untreatable forms of AMD and a broader spectrum of retinal degenerative diseases.” The two patients enrolled in the study – a 60-year-old woman and an 84-yearold man – had severe neovascular AMD and recent rapid vision decline associated with a submacular haemorrhage and/ or RPE tear. Both had failed anti-VEGF treatment. Dr Georgiadis reported successful delivery and survival of the

Courtesy of Dr Odysseas Georgiadis

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Colour fundus photograph from patient 1. (A) Preoperatively, and (B) at 18 months after the hESC-RPE implantation

graft with resulting regeneration of the RPE-BM structure and rescue and preservation of photoreceptor function. The first patient had a BCVA of 10 ETDRS letters before surgery, reached 39 ETDRS letters at 12 months and maintained this 29-letter gain at month 18. The second patient had eight ETDRS letters BCVA at baseline, gained 21 ETDRS letters at month 12 and maintained a 27-letter BCVA at month 18. Significant improvements were also seen in other functional tests. Reading speed increased from five to 84 words per minute in the first patient and from zero to 49 words per minute in the second patient. Contrast sensitivity also improved. In addition, both patients had a stable on-thegraft fixation during the first year that was maintained through month 18 in the second patient, while the first patient lost some of the stability. Microperimetry testing showed both patients had significant improvement in the light sensitivity of the retinal area treated with the hESC-RPE sheet. A comprehensive battery of imaging tests is being used to evaluate structure. At 18 months, the transplants retained a stable position under the macula and fairly homogenous pigmentation that changed slightly with time, corresponding to functional outcomes. Fundus fluorescein angiography showed the transplants sustained background

Late AMD is considered amenable to cell replacement therapy because it manifests with irreversible cell loss Dr Odysseas Georgiadis

EUROTIMES | MARCH 2019

choroidal perfusion with no signs of disease recurrence in the grafted area. Scanning with SD-OCT showed the transplants gave a stable “double-layer” outer retinal signal and that neurosensory retina segmentation was maintained over the transplant with positive signals of photoreceptor survival. Both transplants emitted autofluorescence and in vivo cellular imaging with adaptive optics technology showed the presence of cones over the transplant. “Consolidating our outcomes, we identified direct associations between improvements in structural and functional assessments,” said Dr Georgiadis. “Loci of good light sensitivity in the microperimetry were found to have preserved and even pigmentation combined with good blood perfusion, autofluorescence and signals of photoreceptor survival in the OCT and adaptive optics imaging.” There were no significant safety concerns. Three serious adverse events – conjunctival dehiscence, retinal detachment and corticosteroid-induced worsening of diabetes – were managed without sequelae. “There were no adverse events related to the transplant, and most importantly, no signs of local or distal uncontrolled proliferation of the implanted cells,” Dr Georgiadis said. Going forward, the researchers are planning to recruit more patients in this study, and in the future to proceed with new studies including patients with dry AMD. The London Project to Cure Blindness is a partnership between Professor Lyndon da Cruz, Moorfields Eye Hospital/University College London, and Professor Pete Coffey, University College London. Odysseas Georgiadis: o.georgiadis@nhs.net


SPECIAL FOCUS: RETINA

Myopic foveoschisis Early intervention correlates with better functional outcome. Cheryl Guttman Krader reports

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reoperative visual acuity is the main factor influencing functional outcomes after vitrectomy for myopic foveoschisis. With this information in mind, retina specialists aiming to improve their results should consider operating sooner rather than later, said Ramin Tadayoni MD, PhD, at the 18th EURETINA Congress in Vienna, Austria. “Of course, we can also do better for our patients by using modern surgical techniques and imaging technologies. But, we will have better results if the indication for surgery is good. If the goal is to achieve BCVA [best-corrected visual acuity] better than 20/40, then surgery should be done when the vision is 20/50 or better. We should not wait for the vision to get worse,” said Dr Tadayoni, Professor of Ophthalmology, Paris 7 University, Lariboisière Hospital & OphtalmoPôle, Paris, France. Dr Tadayoni and colleagues conducted a retrospective study to identify preoperative factors influencing visual recovery after pars plana vitrectomy for myopic foveoschisis. The study, which has been published (Lehmann M, et al. Retina. 2017 Dec 1. Epub ahead of print), included 66 eyes of 65 consecutive highly myopic patients with a mean postoperative follow-up of 14 months. The eyes were stratified into quartiles according to preoperative BCVA (≥20/50, 20/60 to 20/80, 20/100 to 20/125, and ≤20/160) and into three groups based on their preoperative foveal status (simple foveoschisis, foveoschisis with foveal detachment, foveoschisis with macular hole). All four BCVA subgroups benefited with a significant improvement in BCVA, and the worse the baseline vision, the greater the gain. However, mean BCVA for patients in the lower three quartiles did not reach the level achieved by the subgroup with BCVA ≥20/50, and only the highest quartile achieved a mean final BCVA better than 20/40. Predictors for final BCVA were assessed using an analysis of covariance performed with the anatomical status at baseline adjusted for baseline BCVA, spherical equivalent, axial length, central foveal thickness, and age. Of all of the preoperative variables, BCVA was the only factor that correlated with postoperative vision.

Foveal status was associated with vision outcome in univariate analysis, but it was not an independent predictor of final BCVA after adjusting for baseline vision, Dr Tadayoni reported. “The literature suggests that vision gains are better in eyes with foveal detachment than in those with foveoschisis. The explanation is probably that many eyes with foveal detachment present with low vision and therefore have greater gains. But vision in an eye with foveoschisis and low vision evolves exactly like in an eye with a foveal detachment and low vision,” he said. Practically none of the eyes operated on with poorer vision achieved final BCVA of 20/40 or better. Seven (10.6%) eyes lost vision from baseline to last visit because of macular changes. “Interestingly, most of the complications were concentrated in the low vision group. It seems if we wait too long because we are being cautious, we are going to more risky surgery later,” Dr Tadayoni said.

EXTRAPOLATING EVIDENCE TO CLINICAL CARE Dr Tadayoni acknowledged that the findings of this retrospective study do not provide definitive guidance for surgical decisions, but in the absence of evidence from a randomised interventional study comparing early versus late surgery, they provide useful information. “This is a simple piece of information that I think retina specialists can integrate into their practice, but it should not be interpreted as suggesting that all patients should be operated at the stage when vision is better than 20/50,” he said. “In practice, we need to take into account the preoperative status of the eye, whether there is a foveal detachment, if there is a high risk of having a macular hole and also the patient’s preferences and needs. For patients who have 20/50 vision and are happy, we can wait. “These patients, however, need to be informed that if they wait until their vision worsens, they may recover vision, but it may not reach 20/40.”

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EUROTIMES | MARCH 2019

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SPECIAL FOCUS: RETINA

Anti-VEGF and OCT Struggle to keep the more affordable bevacizumab available made nAMD treatment available worldwide. Howard Larkin reports

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n 2003, the convergence of two “heavenly” technologies, optical coherence tomography (OCT) and vascular endothelial growth factor inhibitors (antiVEGF), led to a revolution in treatment of neovascular age-related macular degeneration (nAMD). For the first time, vision loss from nAMD could be reversed and stabilised in many cases, and disease progress could be monitored using OCT to guide additional treatment, said Philip J Rosenfeld MD, PhD, in the Jackson Memorial Lecture at the AAO 2018 Annual Meeting in Chicago. “OCT served as a VEGF meter and we could use it to determine when anti-VEGF therapy was needed. It was remarkable, we could see it work right away,” said Dr Rosenfeld, who participated in many of the early studies of OCT and anti-VEGF at the Bascom Palmer Eye Institute, University of Philip J Rosenfeld MD, PhD Miami Miller School of Medicine, USA. Since then, many studies have demonstrated that OCT-guided anti-VEGF therapy can be just as effective as monthly dosing for treating wet AMD, including an investigator-sponsored trial sponsored by Genentech in 2006 (Fung ae et al. Am J Ophthalmol 2007; 143:566-583. Lalwani GA et al. Am J Ophthalmol 2008; 148:43-58). Beyond reducing patient discomfort and risk, OCT-guided dosing saves big money – from 2008 through 2015 an estimated $16 billion saved for just nAMD treatments in the USA Medicare programme. OCT guidance is now by far the most frequently used dosing strategy throughout the world, according to the American Society of Retina Specialists (ASRS). Even more money – an estimated $24.7 billion – was saved by the use of bevacizumab (Avastin, Genentech) in place of ranibizumab and aflibercept, the same study found. Approved for treating cancer in 2004, bevacizumab is derived from the same mouse monoclonal clones that were used to develop ranibizumab, but the molecule is about three times larger. In part, because it is priced for systemic infusion in cancer patients, bevacizumab is much less expensive when compounded into miniscule doses for intravitreal injection – currently about $50 per dose compared with about $2,150 for ranibizumab in the USA. This dramatically lower cost makes anti-VEGF treatment available to many patients who otherwise could not afford it. However, the struggle to keep it available was long and difficult, Dr Rosenfeld said. The idea to try bevacizumab for AMD came to Dr Rosenfeld in 2003 from his reading of the scientific literature describing its development. Systemic treatment might even have advantages over intravitreal ranibizumab. “At the time, we didn’t expect patients to tolerate monthly injections in the eye. That was the thinking back then.” Genentech would not sponsor a trial with systemic bevacizumab, so Dr Rosenfeld raised $200,000, mostly from patients, for a trial at the Bascom Palmer Eye Institute. After two-to-three systemic infusions of 5.0mg/kg bevacizumab two weeks apart, macular EUROTIMES | MARCH 2019

fluid cleared and vision improved in all 18 patients studied, lasting six months or longer in 12 (Ophthalmol 2005;112(6):1035-1047). Seeking a lower dose and reduced cardiovascular risks for a larger trial, Dr Rosenfeld had another epiphany. A 2004 article by Dennis P Han MD showed that intravitreally injected antibodies penetrated the retina (Trans Am Ophthalmol Soc 2004; 102:305-320), contradicting an earlier Genentech study suggesting they may not (Toxicol Pathol. 1999;27(5):536544). Dr Rosenfeld had pharmacist Serafin Gonzalez PharmD compound bevacizumab for intravitreal injection following strict USP protocols. “His guidelines are adopted by pharmacies all over the world to this day,” Dr Rosenfeld said. By mid-2005, studies clearly established the efficacy of intravitreal bevacizumab for treating nAMD, and it was in use worldwide before ranibizumab was approved by the FDA a year later. Based on his earlier research, Dr Rosenfeld sought FDA approval for a prospective trial of intravitreal bevacizumab – but that endeavour was cut short when he was separately accused of scientific misconduct from an anonymous source. While he was eventually completely vindicated, “my life was turned upside down for 16 months”, Dr Rosenfeld said. In 2007 Genentech tried to remove bevacizumab from the market for ophthalmic compounding after glass particles were found in some batches. After much conflict, the FDA finally ruled the contaminated product was not fit for any human use, and there was no reason to restrict compounding of properly manufactured bevacizumab. A report by Jack Mitchell, a US Senate committee investigator, and related media coverage were pivotal in the victory, Dr Rosenfeld said. Around the same time, ophthalmic speciality societies in the USA and elsewhere led the US National Eye Institute to fund the prospective CATT study, which found no significant difference in outcomes between ranibizumab and bevacizumab for treating nAMD (N Engl J Med 2011; 364:1897-1908). Similarly, a 2008 cost report by Ross J Brechner MD, MS(Stat), MPH, of the agency operating the US Medicare programme, was finally published after much internal resistance (Am J Ophthalmol 2011; 151: 887-895). Extending this research produced the 20082015 estimate of $24 billion-plus savings for AMD in the USA alone (Am J Ophthalmol, July 2018). “That’s a 123,500-fold return on the $200,000 investment from that initial patient clinical trial,” Dr Rosenfeld noted. This creates enormous pressure to keep bevacizumab available. As a result, 70% of USA retina specialists now use bevacizumab for first-line treatment of wet AMD, as do 36% internationally, according to a 2018 ASRS survey (n=1,027). Thanks to several dedicated researchers and the support of ophthalmologists around the world, “we won that war”, Dr Rosenfeld said. Philip J Rosenfeld: prosenfeld@med.miami.edu.


SPECIAL FOCUS: RETINA

SEBASTIAN WOLF Editor of Ophthalmologica

w Ne ded an exp l-RBF Hil

OPHTHALMOLOGICA VOL: 241 ISSUE: 2

GLAUCOMA PATIENTS AT INCREASED RISK FOR RETINAL VEIN OCCLUSION Eyes with pseudoexfoliation (PXF) glaucoma and other types of glaucoma have a two-to-three-fold higher risk of retinal vein occlusions (RVOs), mainly central RVO, compared to the general population, a retrospective cohort study suggests. The authors of the study reviewed the records of 300 PXF glaucoma patients, 300 non-PXF glaucoma patients and 599 non-glaucoma non-PXF patients. Multivariate analysis resulted in a significant probability for RVO in the PXF (p=0.005; OR 2.29) and non-PXF glaucoma groups (p=0.005; OR 3.03) compared to the controls. However, after matching and excluding neovascular glaucoma, PXF was not found to be an independent risk factor for RVO in eyes with glaucoma. G Antman et al, “The Incidence of Retinal Vein Occlusion in Patients with Pseudoexfoliation Glaucoma: A Retrospective Cohort Study”, Ophthalmologica 2019, Volume 241. Issue 2.

RVO AFFECTS 16 MILLION WORLDWIDE Pooled data from population studies from the United States, Europe, Asia and Australia suggests that approximately 16 million people worldwide have retinal vein occlusions. An analyses of 11 studies involving 49,869 patients showed that the prevalence was 5.20 per 1,000 for any RVO, 4.42 per 1,000 for branch RVO and 0.80 per 1,000 for central RVO. Prevalence increased with age and varied by race/ethnicity, but not by gender. The age- and sex-standardised prevalence of any RVO was 3.7 per 1,000 in Caucasians, 3.9 per 1,000 in blacks, 5.7 per 1,000 in Asians and 6.9 per 1,000 in Hispanics. S Rogers et al, “The Prevalence of Retinal Vein Occlusion: Pooled Data from Population Studies from the United States, Europe, Asia, and Australia Ophthalmologica 2019”, Volume 241. Issue 2.

DEXAMETHASONE IMPLANT DECREASES ANTI-VEGF INJECTIONS REQUIRED FOR DME TREATMENT The findings of an observational retrospective study indicate that preceding intravitreal aflibercept with the injection of a dexamethasone implant can reduce the subsequent need for anti-VEGF injections in eyes with diabetic macular oedema (DME). The study involved 30 treatment-naïve DME patients; 15 received five monthly injections of aflibercept, followed by injections every two months. The remaining 15 received a single dexamethasone implant followed by bimonthly aflibercept. The differences between the two groups, in terms of visual gain and decreased macular thickness, were not statistically significant (p>0.05). L Hernández-Bel et al, “Sequential Dexamethasone and Aflibercept Treatment in Patients with Diabetic Macular Edema: Structural and Functional Outcomes at 52 Weeks”, Ophthalmologica 2019, Volume 241, Issue 2.

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EUROTIMES | MARCH 2019

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CATARACT & REFRACTIVE

ERRANT Rhexis There are ways to master the complication of a disobeying rhexis in phacoemulsification. Soosan Jacob MD reports

A

continuous, perfectly circular, sized and centred rhexis is the all-desirable step in phacoemulsification – stretching comfortably for phaco manoeuvres without wrap-arounds and overlapping the IOL optic 360 degrees around, thus preventing posterior capsular opacification, delayed asymmetric capsular shrinkage, pea-podding of haptic, IOL vaulting or decentration, optic edge capture or IOL position/ refraction changes. Increasing surgeon experience, aids such as corneal rhexis markers, millimetre-marked rhexis forceps, imageguided overlay technologies as well as the femtosecond laser or the Zepto capsulotomy systems have further helped increase precision. Many of us, however, still mostly rely on a manual rhexis with either forceps or cystitome, and are sometimes faced with a disobeying rhexis. This article helps deals with this.

The little rhexis trick in four steps. A: Peripheral extension

B: Capsular flap unfolded to lie flat. Holding the flap as close to the root as possible, it is first pulled backwards in a horizontal plane along the circumference of the completed segment of rhexis

C: With flap held stretched, force is directed more centrally to bring the rhexis back in

D: The rhexis is then continued again

or posterior pressure. Alternately, a microrhexis forceps may be used, which, as compared to Utrata forceps, requires only a tiny incision and therefore avoids escape of viscoelastic. Whenever required, viscoelastic should be replenished to maintain a flat anterior capsule. The flap edge is released and regrasped close to the tearing edge for better control.

The initial nick should be just short of the desired radius as it enlarges slightly on turning circularly. The rhexis edge mirrors the curve of the capsular flap edge and maintaining the flap flat and circular against the lens gives a perfect circle. Turning the flap inwards or outwards can make the rhexis smaller or larger respectively. Near the main port, avoid a floating flap from sliding out through the incision,

PEARLS FOR A GOOD RHEXIS A flat anterior lens capsule and low intralenticular pressure help keep the rhexis on track. It is therefore important to have a soft eye, a patient who is not straining and lids that are not squeezing. Beginners may be benefitted by a peribulbar block and a Pinkie ball or Honan balloon application. A selfretaining speculum helps decrease the effect of lid squeezing. Good topical anaesthesia and a dilated pupil make both surgeon and patient more comfortable. Capsular dye (Trypan blue 0.06%) improves visualisation. A partial entry allows better retention of viscoelastic in the anterior chamber (AC) and can be widened later. An oblique bend to the cystitome tip allows it to be visualised as opposed to a right-angled bend. Shaft angulation should avoid incisional distortion secondary to excessive anterior EUROTIMES | MARCH 2019


CATARACT & REFRACTIVE

which can lead to peripheral extension of rhexis. In an average-sized eye, a uniformly dilated pupil may be used as a guide for centration and sizing; however, this would be erroneous in large or small eyes.

FACTORS PREDISPOSING TO AN ERRANT RHEXIS Shallow AC, convex anterior lens capsule, poor visualisation, small pupil, paediatric cataracts, traumatic cataract with anterior capsular tear, white mature or Morgagnian cataract are some of the reasons a rhexis may run out. Young cataracts: Rhexis in a child or young adult has a higher tendency to run out because of an elastic capsule, positive vitreous pressure and low ocular rigidity. The younger the age, the stronger the run-out tendency. Trypan blue can aid visualisation as well as stiffen the capsule. Aiming for a smaller size allows a final rhexis of the desired size as the elastic capsule stretches. The first nick should therefore be made smaller than in an adult cataract. The tear is always directed towards the centre of the lens to avoid a runaway. A high viscosity ophthalmic viscosurgical device (OVD) (Healon5 and Healon GV) may be used to maintain space and flatten the anterior capsule. Various other techniques such as vitrectorhexis, two-incision push-pull technique, Fugo Blade rhexis etc have also been described. Depending on age, a posterior continuous curvilinear capsulorhexis (PCCC) may be required.

White cataracts: The capsule in a mature, white cataract is thin, with higher likelihood of tears and run-outs. Intralenticular pressure in in tumescent white cataract is quite high and the initial nick can extend rapidly to both sides resulting in the “Argentinian flag sign”. Risk factors include diabetes, UV exposure, steroid usage etc. Staining stiffens and makes the capsule brittle and may also be a risk factor. Oblique external illumination with a light pipe can help visualisation. An initial small rhexis can be spiralled around to the right size to prevent a runaway. Morgagnian cataract: These leak and cloud the aqueous. Aspiration with a needle from the centre of the capsule before initiating the rhexis can decrease intra-lenticular pressure and leakage. In case of a turbid AC, it should be washed and high viscosity OVD refilled. Once lens material is released, intralenticular support for needle capsulorhexis may be inadequate and a forceps may be required to continue. Difficult visualisation: Secondary to corneal opacity, mature cataract, a poor red glow because of vitreous haemorrhage/asteroid hyalosis or inadequate co-axial lighting. Visualisation can be enhanced by capsular staining, high magnification, co-axial lighting and oblique illumination with a light pipe.

RUNAWAY RHEXIS Blind pulling is avoided to avoid posterior capsular extension. The little rhexis trick is very useful (see illustration, opposite). The

capsule flap is unfolded to lie flat. While holding it as close to the root of the tear as possible, it is first pulled backwards in a horizontal plane along the circumference of the completed segment of rhexis and then with flap held stretched, directed more centrally to initiate the tear. If the rhexis run-out is irretrievable, it may be attempted to be completed by creating a cut on the flap and continuing forwards or by creating a nick on the opposite side and completing it backwards. Alternatively, can-opener cuts can be done in the incomplete area. For Argentinian flag sign, AC pressure should be immediately increased with cohesive OVD to prevent wraparound tear. A perpendicular relaxing cut on the leaflet is then joined on either side as a partial circular tear. Surgery should be as in torn rhexis.

TORN RHEXIS Only a continuous curvilinear rhexis can stretch. Tensile strength of the capsule is lost in case of any discontinuity, however small. All intra-capsular manoeuvres should therefore be avoided and the nucleus prolapsed out. Very careful, slowmotion phaco is then carried out. In case of doubt or lack of experience, it may be better to convert into an extracapsular cataract extraction. 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

CALL JOHN FOR HENAHAN ENTRIES PRIZE 2019 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/henahanprize

EUROTIMES | MARCH 2019

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CATARACT & REFRACTIVE

Refractive lens exchange Clear lens exchange safe and effective in large five-year real world study. Roibeard Ó hÉineacháin reports

P

resbyopia-correcting intraocular lens surgery can produce visual and refractive outcomes with low complication rates and high patient satisfaction, according to the findings of a large study presented by Andreas Hartwig PhD at the 36th Congress of the ESCRS in Vienna, Austria. “The outcomes are in line with benchmark data. Refractive lens exchange (RLE) is a safe and effective way of providing visual rehabilitation to presbyopes,” said Dr Hartwig, Optegra Eye Sciences, UK. This observational case series review included data from 12,990 RLE procedures performed between January 1, 2011 and June 30, 2017. The implanted IOLs included eight designs comprising extended depth of focus, diffractive trifocal and rotationally asymmetric bifocals. The study showed that postoperative monocular uncorrected distance visual acuity (UDVA) was 20/40 or better in 96.2% of eyes and 20/20 or better in 60.8% of eyes. Monocular uncorrected distance visual Furthermore, binocular UDVA was 20/40 acuity (UDVA) of 20/40 or better was or better in 99.5% of patients and 20/20 or achieved by 99% of high myopic eyes and better in 77.3%. Furthermore, 89.3% of eyes 93% of high hyperopic eyes. 20/20 or better achieved a near visual acuity of N6 or better. UDVA was achieved by 68% of myopic Dr Hartwig noted that the visual eyes and 38% of hyperopic eyes, Dr outcomes achieved with RLE Rehman said. appear to have improved during In addition, 84.5% of high the years studied, which may myopic eyes and 72.5% of high be a result of improvements hyperopic eyes achieved a near in surgical techniques and visual acuity of N6 or better. lens design. However, it Postoperative refraction was also appears that more within ±0.50D of target in recently observed very good 85.6% of myopic eyes and in uncorrected near visual acuity 75.0% of hyperopic eyes. results may have come at a cost of Andreas Hartwig No operative complications uncorrected distance vision. were recorded in 99.6% and Refraction was within 1.0D of target 100.0% of highly myopic and hyperopic in 96.1% of eyes and within ±0.5D of target eyes respectively, whereas postoperative in 80.2% of eyes respectively. There were no complications were observed more intraoperative complications in 99.7% of frequently in the hyperopes. cases and visually significant postoperative “The data indicates better outcomes were complications were also infrequent. achieved for high myopic eyes in comparison RLE also appears to achieve good and to high hyperopic eyes in this cohort for predictable results in eyes with high most metrics assessed,” Dr Rehman added. ametropia, said Dr Hartwig’s associate, For most patients who underwent RLE Shafiq Rehman FRCOphth. He presented in the observational case study, longeran analysis of data from 264 highly myopic term surgery results met or exceeded (-6.0D to -16.5D) and 152 highly hyperopic their expectations, said Clare O’Donnell (+6.0D to +20.0D) eyes included in the total PhD, Head, Optegra Eye Sciences, UK, study group. EUROTIMES | MARCH 2019

in a separate presentation of a subset of the cohort. In response to a questionnaire completed between two and seven years after discharge, 88% of respondents reported their quality of life improved following surgery and 87% of respondents reported the treatment met or exceeded their expectations regarding freedom from spectacles, she noted. In addition, 90% of patients said the treatment met their expectations regarding vision during daytime and in dim light and 73% said the treatment exceeded their expectations. Furthermore, 83% and 73% of respondents, respectively, said the treatment met or exceeded their expectations regarding glare and halos. Some 29% of respondents reported that dry eye sensation was worse than expected after surgery. Nearly 65% of respondents said they experienced dry eye, although this was expected in almost 50% of respondents. Dry eyes are thus potentially a key variable to target to further improve patient experience following surgery. Other vision-related variables are also likely to improve when the tear film is optimised, Dr O’Donnell said. Andreas Hartwig: andreas.hartwig@firma-hartwig.de Clare O’ Donnell: clare.odonnell@optegra.com Shafiq Rehman: Shafiq.rehman@Optegra.com


CATARACT & REFRACTIVE

Rhexis-fixated intraocular lens Capsule-fixated lens achieves stable rotation and centration in international trial. Roibeard Ó hÉineacháin reports

T

he rhexis-fixated FEMTIS (Oculentis) intraocular lens achieved very good visual acuity and excellent centration and rotational stability in an international multi-centre study, reports Gerd Auffarth MD, University Eye Clinic of Heidelberg, Heidelberg, Germany. “Compared to historical data, the FEMTIS IOL was superior to the conventional in-the-bag implanted IOLs,” Dr Auffarth told the 36th Congress of the ESCRS in Vienna, Austria. The study took place in eight clinics in Germany, the UK, Spain and Andorra and involved 360 eyes with cataract and expected postoperative corneal astigmatism of under -1.00D. All underwent implantation of a monofocal FEMTIS IOL following cataract extraction surgery performed with femtosecond laser-assisted capsulotomy. The FEMTIS IOL Foldable one-piece IOL is composed of Hydrosmart, a UV absorbing co-polymer consisting of acrylates with a hydrophobic surface. The lens has a biconvex optic with an aspheric posterior surface. It has a modified plate haptic design with four additional haptics for rhexis-fixation. The mean logMAR best-corrected distance visual acuity improved from 0.25 preoperatively to 0.00 at six-to-eight weeks, 0.00 at six months and -0.04 at 12 months postoperatively. In terms of refractive predictability, Dr Auffarth noted that patients ended up slightly hyperopic on average, with a mean spherical equivalent of +0.35D at 12 months. However, 85% were within 0.75D of emmetropia and 68% were within 0.5D and 41% were within 0.25D. The A constant of the IOL has since been adjusted to improve accuracy. The FEMTIS study group assessed the centration, tilt and rotational stability using images they obtained with microscope, slit lamp and Scheimpflug camera (Pentacam, Oculus). They analysed the data using a dedicated analysis program developed by Heidelberg Institute of Applied Mathematics. Their assessment showed that the average IOL-rotation was 0.78° at 12 months postoperatively, compared to values ranging from 2.7° to 5.3° in historical series. The mean IOL decentration was 0.07mm at 12 months postoperatively, compared to values ranging from 0.19mm to 0.23mm in historical series. In addition, the mean tilt at 12 months was 0.45° compared to tilt of 2.0° to 3.0°. Regarding posterior capsule opacification, the mean PCO grade was 0.7% at six months postoperatively and 1.1% at 12 months postoperatively. “The rhexis-fixated FEMTIS IOL shows very good results regarding the uncorrected and bestcorrected distance visual acuity and excellent rotational as well as centration behaviour,” Dr Auffarth concluded. Gerd Auffarth: Gerd.Auffarth@ med.uni-heidelberg.de

Compared to historical data, the FEMTIS IOL was superior to the conventional in-the-bag implanted IOLs

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Gerd Auffarth MD EUROTIMES | MARCH 2019

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CATARACT & REFRACTIVE

SMILE v femto-LASIK New, less invasive technology faces off against proven results, greater versatility. Howard Larkin reports

W

hen Sri Ganesh, MBBS, BS (Ophth), DNB, received one of the first lasers for small-incision lenticule extraction (SMILE®) corneal refractive surgery in 2012, he was doing about 750 femto-LASIK procedures, annually with good results and happy patients. “So why should I change?” he asked. To answer, Dr Ganesh conducted a prospective, randomised study comparing 50 LASIK with 50 SMILE patients at Nethradhama Super Specialty Eye Hospital, Bangalore, India. “SMILE has since been my preferred corneal refractive procedure,” he told the 36th Congress of the ESCRS in Vienna in a debate session. In that early study, 96% of SMILE patients achieved 20/20 or better uncorrected with 12% at 20/16 or better, compared with 88% and 4% respectively for femto-LASIK three months after surgery, Dr Ganesh reported. Induced higher-order aberrations were nearly double in the femto-LASIK group, leading to less glare, and better night vision in the SMILE group. Tear film break-up time was significantly shorter and tear osmolarity significantly higher in the LASIK group, and patientreported comfort, including post-op pain and dry eye, was better in the SMILE group. All of these differences were statistically significant (Ganesh S, Gupta R. JRS 2013). In the six years since, Dr Ganesh’s SMILE outcomes have only improved.

In more than 7,000 cases, 98.4% have achieved at least 20/20 uncorrected, with 68% better than 20/20. No eye has had complications such as haze, deep lamellar or infectious keratitis, or lost more than two lines of corrected vision. Just 10 eyes have required enhancement. Other studies suggest SMILE is stable long term, regressing less than 0.5 dioptres over five years (Blum M et al. BJO 2016;100(9)). “SMILE has proven popular with patients, who are willing to pay more for it,” Dr Ganesh said. “Minimally invasive surgery is something patients understand and prefer.” With a 2.0mm incision for SMILE vs 20mm for LASIK, SMILE patients have less pain, do not require eye shields at night and there are no restrictions on showering or activities the day after surgery, he noted. SMILE is also a financial winner, Dr Ganesh said. Where 700 or so LASIK procedures generated about €2 million annually before 2012, in 2017 Dr Ganesh’s centre did 2,150 SMILEs, generating more than €15 million. The increased revenue more than offset the higher cost of the laser and consumables, Dr Ganesh said.

LASIK ADVANTAGES Dr Ganesh allowed that SMILE has significant limitations compared with LASIK. There is currently no automatic adjustment for cyclotorsion, which his research suggests could improve outcomes. SMILE has not yet been approved for hyperopic corrections, though Dr Ganesh’s research suggests it will be highly effective

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and believes it will be available soon. Enhancements are also challenging without converting to PRK or LASIK, though SMILE enhancements are possible and becoming more available. Still, SMILE has a long way to go to match the versatility and proven track record of LASIK, said Terry Kim MD, Professor of Ophthalmology, Duke University School of Medicine; Chief, Cornea and External Disease Division and Director, Refractive Surgery Service at Duke University Eye Center in Durham, North Carolina. He cited the work of the LASIK Task Force, a joint effort of the US FDA, AAO, ASCRS and NEI. Their international review found LASIK to be one of the most successful elective surgeries of any kind, with more than 95% satisfaction in 309 published studies (Solomon et al. Ophthalmology. 2009;116(4):691-701.) LASIK also has a much wider treatment range, including hyperopic and mixed astigmatism, and can be customised to enhance prior corneal refractive and cataract surgery. Indeed, femtosecond laser-assisted cataract surgery platforms are now offering LASIK flap capabilities, suggesting the technology is far from played out, Dr Kim said. “LASIK … has a long, proven track record and is one of the most studied procedures in the world. Based on the data we have to date, we can conclude that SMILE may not necessarily be better than LASIK,” Dr Kim said. Sri Ganesh: chairman@nethradhama.org Terry Kim: terry.kim@duke.edu


CATARACT & REFRACTIVE

All-laser versus femto-phaco Study finds nanosecond laser surgery spares corneal endothelium long-term. Howard Larkin reports

R

eplacing torsional phacoemulsification with a nanosecond laser photofragmentation device in femtosecond laser-assisted cataract surgery may reduce long-term corneal endothelial cell loss, suggests a study presented at the 36th Congress of the ESCRS in Vienna. Two years after surgery, 17 eyes in 17 patients undergoing all-laser cataract surgery showed less endothelial cell loss than 18 patients receiving femto-phacoemulsification cataract surgery, said Peter A Mattei MD, PhD. This study showed that reduced endothelial cell loss noted early after surgery in the all-laser group compared with the femto-phaco group persisted for two years. The effect also may be related to increased corneal thickness noted in the femtophaco group in the early post-surgery period. Conducted at Prof Mastropasqua’s Ophthalmology Department at the University “G. d’Annunzio” in ChietiPescara, Italy, the prospective, chronologically randomised trial compared 21 consecutive cataract patients receiving femtosecond laser treatment with a LensAR platform followed by torsional phacoemulsification with an Alcon Constellation system,with 21 consecutive patients treated with the LensAR followed by photofragmentation using the Centus Nano-Laser System (A.R.C. Laser). The nanosecond laser fragments the nucleus using 4-5 nanosecond pulses of 1,064nm near-infrared wavelength with a pulse frequency up to 10Hz. Fragments are aspirated in much the same way as with a coaxial phaco handpiece. Patients ranged in age from 65 to 75 with cataracts up to LOCS grade 3, endothelial cell density greater than 1,200/ mm2 and no other ocular pathologies. Data were collected on all patients out to 730 days after surgery, with four femtonanolaser and three femto-phaco patients lost to follow-up. Early results showed greater corneal thickness in the femtophaco group in both the corneal centre and near the handpiece tunnel, though thickness returned to baseline at 60 days, Dr Mattei reported. There were no statistically significant differences in visual acuity or corneal thickness in the centre or near the tunnel at 60 days, he added. However, endothelial cell losses were significantly greater in the femto-phaco group at 90 days (p=0.004) and 730 days (p<0.001), Dr Mattei said. Prof Mastropasqua’s group concluded: “The long-term results showed that the initial lower corneal tissue trauma and lower endothelial cell loss in the femto-nanolaser group compared with the femto-phaco group yielded a long-term sparing of corneal endothelial cell in all-laser cataract surgery.” Peter A Mattei: pamattei@unich.it

Early results showed greater corneal thickness in the femtophaco group in both the corneal centre and near the handpiece tunnel... Peter A Mattei MD, PhD

EUROTIMES | MARCH 2019

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CATARACT & REFRACTIVE

Watch the lasers Laser use in ophthalmology has seen many great advances over the years. Aidan Hanratty reports

J

ohn Marshall PhD has seen many advances in laser surgery over the years. While he has been wary of some changes, he can admit when things don’t turn out as he expected. Many years ago, he warned about the potential risk posed by LASIK surgery to the biomechanics of the cornea. “Any surgical intervention in the cornea does change the biomechanics, and these weaken the system,” he said in a EuroTimes Eye Contact interview with Paul Rosen MD, PhD. “Do they weaken it sufficiently to cause problems? I don’t think so. Are we going to see continuing problems in later years? Again, I think the evidence now after 20 years of surface surgery is suggesting that we aren’t going to see significant problems generating.” In relation to LASIK itself, Dr Marshall, Frost Professor of Ophthalmology at the Institute of Ophthalmology in association with Moorfield’s Eye Hospital, UCL, London, points out an inbuilt redundancy in the structure of the eye. “If you cut through the fibres all the way around the cornea, as you do in a LASIK flap, you’re cutting around threeand-a-half million collagen fibrils. But I think we’ve been very lucky, there is a huge redundancy in the way in which the cornea is designed.” He finds small-incision lenticule extraction (SMILE®) quite interesting because it is based on a theoretical concept: “That is, if you cut out a lenticule but preserve continuity of the fibres in the strong part of the cornea, the superficial part of the cornea, it should actually be biomechanically less weakening than a LASIK incision. And although we don’t have a lot of detailed biomechanical evidence, the laboratory evidence would suggest that SMILE is going to be less biomechanically invasive.” When he was first introduced to the idea of corneal cross-linking (CXL), Dr Marshall delivered a paper entitled “How would you like to age your cornea 600 years in 600 seconds?” “I thought to prematurely age a system wasn’t really a good idea. However, I was wrong, and I think the whole of crosslinking is really interesting, especially in pathological corneas, like keratoconus,” The procedure can only get better, he believes. “At the moment, we’re probably only getting a dioptre or so of correction, but EUROTIMES | MARCH 2019

Paul Rosen and John Marshall in the Eye Contact studio at the 36th Congress of the ESCRS in Vienna, Austria

that’s not the end of the story. I think there are now beginning to be changes in technology which should give us more, so for very low order corrections, I think cross-linking does have a future in refractive surgery.” Some patients are left dissatisfied following surgery because their brain has become used to the inadequacies of their optical system. The benefit of crosslinking, according to Dr Marshall, lies in its ability to alter specific aspects of the aberrated cornea. While laser surgery will weaken the cornea and cross-linking strengthens it, combining the two procedures works on a complementary basis. Asked about the order in which the procedures should be performed – laser then cross-linking, vice versa or combined, as in LASIK Xtra –

Any surgical intervention in the cornea does change the biomechanics, and these weaken the system John Marshall, PhD

he sees only one potential approach. “If you cross-link a cornea, you slightly change the ablation rate, so you would have to modify the algorithms. I think the easiest way to do this and the quickest way to do this is to do laser and then cross-link before you put the flap back.” Dr Marshall believes in the potential of using femtosecond laser to modify intraocular lenses. “Using two-photon phenomena, you can actually change the refractive index. And certainly, in materials, that is viable.” He doesn’t see the value of attempting to change the refractive index in biological tissue, however. “Who knows what wound healing is going to do? Those changes are so small and so subtle, that I’m pretty sure that wound healing over a period will wipe them out.” With lasers a permanent feature of the ophthalmological landscape, Prof Marshall sees the future going in a different direction. “Personalised medicine and genetics are going to play an incredibly important role. The more we understand of the gene control mechanisms, the more we will have the potential to manipulate them.” He cites technology such as the CRISPR genome-editing system as having a big future. “As a scientist, I love the idea of changing the genes to making the system as it should be.”


CATARACT & REFRACTIVE

JCRS Symposium THOMAS KOHNEN European Editor of JCRS

JCRS HIGHLIGHTS VOL: 45 ISSUE: 1 MONTH: JANUARY 2019

CONVENTIONAL PHACO VS FLACS A large randomised clinical study compared the clinical results of conventional phacoemulsification surgery (CPS) with femtosecond laser-assisted cataract surgery (FLACS) in 400 patients. FLACS procedures utilised the LensX laser system. All operations were performed with a gravity-fluidics torsional phacoemulsification machine (Infiniti). With a four-week follow-up period, the study found no significant differences between two treatment modalities, notwithstanding a significant reduction in posterior capsule ruptures in the FLACS group. The study included measures of post-op visual acuity, corneal thickness and endothelial cell loss. Seven patients (3.5%) in the FLACS group were not able to complete the treatment and received CPS. The rate of posterior capsule rupture was 3% in the phaco group and 0% among FLACS patients (p=0.03). The study showed no statistically significant reduction in phacoemulsification energy between the two groups. HW Roberts, JCRS, “A randomized controlled trial comparing femtosecond laser–assisted cataract surgery versus conventional phacoemulsification surgery”, Vol. 45, No.1, 11-20.

Monday, May 6, 2019

Controversies in Anterior Segment Surgery 1:00 pm–2:30 pm MODERATORS

Nick Mamalis u.s. editor Sathish Srinivasan european associate editor

PHACO, FLACS AND MULTIFOCALS

Proponents of FLACS have suggested that its more accurate centration as well as more precisely sized and shaped capsulotomy should improve refractive stability and predictability by reducing the incidence of IOL movement, tilt, and decentration. Korean researchers compared the outcomes of conventional phaco and FLACS followed by multifocal intraocular lens implantation in a retrospective case series analysis. Seventeen patients (23 eyes) had FLACS, of which 14 eyes also had arcuate keratotomy. Another 22 patients (26 eyes) had conventional phaco. Overall, astigmatic change was more predictable in the FLACS group. Internal aberrations such as total RMS, tilt, and RMS HOAs, were lower in the femtosecond group, and patients in that group were more satisfied. Jin AH Lee, JCRS, “Femtosecond laser-assisted cataract surgery versus conventional phacoemulsification: Refractive and aberrometric outcomes with a diffractive multifocal intraocular lens”, Vol. 45, No.1, 21-27.

FEMTOSECOND LASER FOR RESIDUAL ASTIGMATISM

German researchers evaluated the refractive and visual outcomes of arcuate incisions performed with the femtosecond laser in patients with residual refractive astigmatism after refractive lens exchange (RLE) with trifocal intraocular lenses. The study enrolled 95 eyes of 70 patients, with a mean follow-up of 5.6 months. Patients showed significant improvements in uncorrected vision and in the degree of astigmatism following surgery. No intraoperative or postoperative complications were seen. The investigators conclude that femtosecond laser-assisted corneal arcuate incisions were safe, efficient and feasible to reduce refractive astigmatism after trifocal IOL implantation. I Ludeke et al., JCRS, “Refractive outcomes of femtosecond laser–assisted secondary arcuate incisions in patients with residual refractive astigmatism after trifocal intraocular lens implantations”, Vol. 45, No.1, 28-34.

1:00 pm IOL Power Calculations Nicole Fram usa Intraoperative Aberrometry Is Here to Stay Douglas Koch usa Modern IOL Formulas Have Superseded Intraoperative Aberrometry

1:30 pm Femtosecond Laser–assisted Cataract Surgery Richard Davidson usa FLACS Is the Best and Safest Surgery for White Cataracts Soon-Phaik Chee singapore Manual Phacoemulsification Surgery Is Still Good and Safe Enough for White Cataracts

2:00 pm Managing Vitreous Loss During Cataract Surgery by the Cataract Surgeon Abhay Vasavada india Pars Plana Anterior Vitrectomy Is the Best Kevin Miller usa Traditional Anterior Vitrectomy Is Good Enough

ASCRS•ASOA ANNUAL MEETING May 3–7, 2019 | San Diego, California, USA

EUROTIMES | MARCH 2019

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MEETING REPORT

23rd ESCRS Winter Meeting

ath ens

Strengthening ties Winter Meeting in conjunction with Hellenic Society of Intraocular Implant and Refractive Surgery was a major success with more than 1,870 delegates

T

he 23rd ESCRS Winter Meeting in Athens, Greece, which convened from Friday February 15 to Sunday February 17, was a major success with more than 1,870 delegates in attendance. “We are delighted to be returning here after very successful meetings in 1999, 2007 and 2016, and to be joined once again by our colleagues from the Hellenic Society of Intraocular Implant and Refractive Surgery,” said Professor Béatrice Cochener-Lamard, President, ESCRS. “The HSIOIRS has made a significant contribution to the scientific programme and I would like to thank Dr Konstantina Koufala, HSIOIRS President, and everyone involved for all their time and support,” said Professor Cochener-Lamard. Dr Koufala said that from the very beginning, HSIOIRS enriched the programme of its scientific events with the participation of internationally distinguished ophthalmologists and has pursued collaborations with other established European and International ophthalmological societies. “We especially need to mention that our Society has maintained strong ties with the European Society of Cataract and Refractive Surgeons (ESCRS) for many years,” said Dr Koufala. The Cornea Day in conjunction with EuCornea on Friday was well-attended, and the Young Ophthalmologists Programme, ‘Learning from the Learners’, was also a popular attraction, as was the Basic Optics Course. Instructional courses on Friday included ‘Intraocular Lenses in the Absence of Capsular Support’, ‘Complex Cataract Surgery’ and ‘Spectacle Independence After Cataract Surgery’. Another highlight of Friday’s programme was the HSIOIRS Kelman lecture on ‘Life Behind the Lens’, delivered by ESCRS PastPresident Professor David Spalton. EUROTIMES | MARCH 2019

HSIOIRS President Dr Konstantina Koufala with ESCRS President Professor Béatrice Cochener-Lamard at the 23rd ESCRS Winter Meeting in Athens, Greece

In his lecture,delivered during the Welcome Ceremony, President Spalton discussed the unsolved problem of longterm posterior capsule opacification (PCO) prevention. The Meeting continued on Saturday with Cornea, Cataract Surgery and Refractive Surgery Didactic Courses, the European Society of Ophthalmic Nurses and Technicians Didactic Day, a Moderated Poster Session and Symposia on ‘Trends in Refractive Surgery’ and ‘When the Unexpected Happens’. The HSIOIRS also organised a Near Live Surgery session.

POSTER PRIZES A prize of €1,000 was awarded to the Meeting’s best Cataract and Refractive ePoster presentations. The prize in the Refractive category went to Florian Schraml, Germany, for

‘Predictability of intraocular lens power calculation after SMILE for myopia’. The prize in the Cataract category went to Ioannis Tzamichas, Greece, for ‘Scleral fixation of dislocated 1-piece IOL without IOL explantation or intrascleral sutureless 3-piece IOL fixation: making the right surgical decision’. The Meeting concluded on Sunday with a symposium organised by the YO Committee on ‘Pearls for the Young Cataract Surgeon’ and a HSIOIRS symposium on ‘Advanced Technology: Better Results?’ “With so much on offer, it is impossible to attend every session. However, if you log on to the Education Portal on the ESCRS website, you can access the sessions on ESCRS On Demand and the didactic courses on ESCRS iLearn,” said Prof Cochener-Lamard.


MEETING REPORT

EUROTIMES | MARCH 2019

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CORNEA

Intraoperative OCT for keratoplasty Role of the imaging technology lies in the eye of the beholder. Cheryl Guttman Krader reports

D

oes intraoperative anterior segment optical coherence tomography (iOCT) bring value to surgeons performing keratoplasty or just added cost?

Nino Hirnschall MD, PhD, and Massimo Busin MD presented their opposing views on this question in the Journal of Cataract & Refractive Surgery Symposium during the 36th Congress of the ESCRS in Vienna, Austria. Dr Hirnschall, Hanusch Hospital Vienna, Austria, admitted that the technology has some limitations. Because a shadow is created behind metal instruments, transparent tools need to be developed for surgeons to take advantage of the full potential of OCT-guided imaging. In addition, with current technology, the iOCT scans are only two-dimensional. Nevertheless, there are benefits and evidence to support iOCT use during EK surgery, according to Dr Hirnschall. “Intraoperative OCT may lead to safer surgery, and the only question is, if we need now, or in the future. But we definitely need it,” he said. Discussing the advantages of iOCT, Dr Hirnschall said that because of the visualisation it provides, iOCT can allow DMEK in eyes with a cloudy cornea, where otherwise DSAEK would be needed by default. Because it clearly identifies Descemet remnants, iOCT also assures complete Descemet removal in DMEK and DSAEK. “This is important because we know from several studies that the detachment rate is higher if the graft is placed on top of remnants of Descemet’s membrane,” Dr Hirnschall explained. Evidence from published papers shows that by improving visualisation, iOCT in DMEK surgery can also be associated with shorter graft manipulation time that would be expected to translate into less endothelial cell loss. Furthermore, iOCT is useful in DMEK for confirming correct graft orientation. “With iOCT, surgeons will never have an upside-down DMEK graft,” Dr Hirnschall said. During both DMEK and DSAEK, iOCT enables identification of fluid in the donor-graft interface and of graft adherence. For deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty procedures, iOCT gives surgeons exact information about trephination depth and during DALK, it can guide cannula depth when creating the big bubble. Prof Busin noted that results from the PIONEER

Intraoperative OCT may lead to safer surgery, and the only question is, if we need now, or in the future. But we definitely need it Nino Hirnschall MD, PhD EUROTIMES | MARCH 2019

and DISCOVER studies, in which surgeons indicated that iOCT affected decision-making in nearly one-half of cases, might be cited as evidence to support use of this technology. He pointed out, however, that the research has limitations. “PIONEER and DISCOVER were not masked or randomised studies, and most importantly, they did not assess whether iOCT impacted actual clinical outcomes,” he said. “The question we need to ask is whether the changed decision was relevant for the clinical outcome. We need more studies to demonstrate the true value of iOCT by showing that the clinical outcomes are better using the intraoperative imaging, rather than focusing on OCT-based outcomes, which may not be clinically relevant” said Prof Busin, Head, Department of Ophthalmology, Villa Igea Hospital, Forlì, Italy. Prof Busin discussed a variety of techniques that can be used instead of iOCT to improve success rates in corneal lamellar transplant surgery. Although he said there is no evidence proving that residual Descemet’s membrane interferes with graft attachment, Prof Busin suggested that surgeons can visualise Descemet remnants by performing descemetorhexis under air. He noted that surgeons can determine DMEK graft orientation by looking through the microscope. If they are unsure, there are a variety of effective, welldescribed strategies that Massimo Busin MD are more practical and less expensive than iOCT, including a handheld slit beam, an S or F stamp, the Moutsouris sign or endoillumination. Prof Busin also described surgical techniques he uses that obviate any need for iOCT for assessing interface fluid or cannula depth when injecting air for the big bubble. To evacuate interface fluid in DSAEK cases, Prof Busin said he combines high-pressure tamponade with venting incisions. To achieve pneumatic dissection of the Descemet’s membrane in DALK, he precalibrates the trephine so that the blade advancement stops within 100 microns from the thinnest pachymetric value and the air cannula is inserted at the base of this trephination. In this technique, the depth of the cannula is based on predetermined quantitiative inputs and does require intraoperative clarification of depth from any source, including iOCT. Furthermore, in any case the cannulas currently available are metallic and therefore block the iOCT image in the most critical area; that is the residual stromal depth below the cannula.

The question we need to ask is whether the changed decision was relevant for the clinical outcome

Massimo Busin: massimo.busin@unife.it


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CORNEA

Treatment of dry eye disease Several agents can treat dry eye by breaking the cycle of chronic inflammation. Howard Larkin reports

10th EuCornea Congress

13 – 14 September 2019 Paris Expo Porte de Versailles Abstract Submission Deadline: 15 March 2019

S

everal treatments are available and in development that modulate ocular surface immune responses and help break the cycle of chronic inflammation that perpetuates severe dry eye without shutting down beneficial immune function, Stefano Barabino MD, PhD, of the University of Milan, Italy, told the 2018 Cornea Subspecialty Day at the 36th Congress of the ESCRS in Vienna. “We don’t want to eradicate inflammation, we want to control inflammation. A medium level of inflammation can have a positive effect. If the inflammation becomes chronic then we have problems,” said Dr Barabino, delivering his own paper and one on behalf of Elisabeth Messmer MD of the University of Munich. The immune cascade driving dry eye disease is complex and can be interrupted at several points, Dr Barabino noted. Corticosteroids, including loteprednol etabonate, rimexolone and hydrocortisone, interrupt the inflammatory cycle by directly regulating gene expression of inflammatory factors and inhibiting many inflammatory pathways. Steroids inhibit cytokine and chemokine production, decrease expression of cell adhesion molecules, and decrease synthesis of matrix metalloproteinases (MMP) and lipid inflammation mediators such as prostaglandins. Corticosteroids also stimulate lymphocyte apoptosis. Dr Barabino recommended preservative-free preparations delivered in a tapering or pulsed regimen to disrupt but not eradicate immune responses, and to minimise sideeffects including cataracts, ocular hypertension, glaucoma and infections.

RELIEVES SYMPTOMS

www.eucornea.org

Cyclosporine A inhibits T cell activation and decreases IL-6 and HLA-DR, which cause ocular surface cells to recruit more immune cells and increases goblet cells. It improves dry eye signs and relieves symptoms, but takes eight-to-12 weeks to work. It also causes irritation on installation for 8-to-10% of patients, Dr Barabino noted. Topical cyclosporine A is available in 0.05% preparations in the USA and 0.1% in Europe. Lifitegrast inhibits T cell-mediated inflammation by blocking the binding of lymphocyte function-associated antigen 1 (LFA-1) and intracellular adhesion molecule 1 (ICAM-1), Dr Barabino said. It significantly improves dry eye disease signs and symptoms in about two weeks. However, lifitegrast also may burn on installation and is not yet available in Europe. Tetracycline derivatives reduce MMP activity and synthesis and reduce collagenases and B cell activity. They have a positive effect on ocular surface inflammation associated with rosacea, Dr Barabino said. Future immunomodulator candidates include compounds that block CD-4, VLA-4, chemokine receptor 2, DA-6034, IL-17 and VEGF-C. “What we really want is a treatment that can break the inflammatory cascade without side-effects,” Dr Barabino said. Stefano Barabino: stebarabi@gmail.com

EUROTIMES | MARCH 2019


GLAUCOMA

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IOP and the distal drainage tract New discovery regarding outflow resistance in the aqueous drainage tract has significant treatment implications. Leigh Spielberg MD reports

Courtesy of James Tan MD, PhD

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utflow resistance in the aqueous drainage tract distal to trabecular meshwork is potentially an important determinant of intraocular pressure and success of trabecular bypass glaucoma surgeries, reported James Tan MD, PhD from the Doheny Eye Institute and UCLA in Los Angeles, USA. Dr Tan addressed delegates during the ESCRS Main Symposium, “Glaucoma for the Cataract Surgeon”, at the 36th annual ESCRS Congress in Vienna. He shared the results of cutting-edge research entitled “Imaging Distal Aqueous Outflow: Mouse Lessons Relevant to Trabecular Bypass Surgery”. “The distal aqueous drainage tract is denser and much more complex than previously thought. However, we don’t yet have a deep understanding of how this region affects intraocular pressure,” he said. Conventional wisdom states that the intrascleral outflow tract distal of the trabecular meshwork is low-resistance, allowing nearly unrestricted outflow to the episcleral veins. This would imply that trabecular bypass surgery, such as ab interno trabeculotomy or microstenting procedures, are sufficient to eliminate resistance to outflow. However, the results of Dr Tan’s imaging research suggest otherwise. “Significant resistance seems to reside in the distal outflow tract beyond the trabecular meshwork,” he said. “This is important for two reasons. First, it might affect intraocular pressure in glaucoma patients. Second, it might affect the results of glaucoma bypass surgery. Understanding this system might allow us to target it pharmacologically.” The functional organisation and regulation of this tract was previously unknown, and it remains unclear whether disease might affect this system to affect intraocular pressure. “The complexity of the distal drainage tract had earlier been suggested using OCT virtual casting, and aqueous angiography had shown that the distal outflow pattern is regional and that it varies with time,” said Dr Tan. Further, phase-sensitive OCT had shown that the outflow is pulsatile with the meshwork showing cyclical expansion & contraction in sync with cardiac output. Dr Tan’s research adds significantly to our knowledge of the tract. In transgenic mice that were engineered to produce fluorescent endothelial proteins, high-resolution two-photon deep tissue optical sectioning showed that the distal tract resembles a vascular system with some features of lymphatic vessels. The mouse aqueous outflow system is known to highly resemble humans’, only smaller. One of the mysteries that Dr Tan sought to unravel was whether the distal tract was a type of vascular system. The first question was: is the distal tract lined with endothelium, and, if so, what type? “The intrascleral plexus can be shown to be lined by cells, and those in Schlemm’s canal are Prox1-positive, like cells of the lymphatic endothelium,” said Dr Tan. “But Schlemm’s canal endothelium also expresses CD31 and other proteins found in blood vessel endothelium.” This suggests that the endothelium of the aqueous outflow tract carries features of both lymphatic and blood vessel endothelial cells.

Two-photon image of the collector channel. A significant proportion of the channel crosssectional area comprises wall cells with filamentous actin (red). This leaves a lumen (black oval) that is smaller than might be expected relative to the opening in sclera (cyan)

On the other hand: “Distal tract walls showed prominent filamentous actin labelling, reflecting cells in a contracted state. Smooth muscle markers were seen in these contractile wall regions, which may have the capacity to affect lumen size,” said Dr Tan. The distal tract’s wall organisation resembles that of blood vessels, and contraction might cause a narrow-calibre, high-resistance system that could significantly decrease outflow. “In summary, the distal outflow tract has vascular properties with several differences as compared to vessels that carry lymph and blood,” he said. “That it has its own type of endothelium is not surprising because it carries a different type of fluid, aqueous humour.” Dr Tan believes that the distal outflow tract is not just an inert system of openings. Instead, it is a dynamic system with auto-regulatory properties, which might offer low resistance when relaxed and higher resistance when contracted to a narrow-calibre state. “Although it is unclear how distal resistance is modulated, this auto-regulation might be a target for IOP-lowering treatment,” he concluded. Dr Tan also suggested that the distal tract might adapt after a micro-incisional glaucoma procedure, affecting the outcome of surgery. EUROTIMES | MARCH 2019


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PAEDIATRIC OPHTHALMOLOGY

WCPOS V | 2020 5th World Congress of Paediatric Ophthalmology and Strabismus

2–4 October 2020 RAI Amsterdam, The Netherlands www.wspos.org

Infant aphakia Secondary IOL implantation in infant aphakia: when and how. Cheryl Guttman Krader reports

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he Infant Aphakia Treatment Study found that when performing cataract surgery in infants up to six months of age, it is appropriate to leave most children aphakic. Therefore, for many children the question becomes when to perform secondary IOL implantation and how to do the surgery. Addressing these issues at the World Society of Paediatric Ophthalmology and Strabismus subspecialty day preceding the 36th Congress of the ESCRS in Vienna, Daniel J. Salchow MD noted that there is no one-size-fits-all answer. As a guideline, he recommended that secondary IOL implantation should be done as late as possible, but the timing will depend on many factors. “These procedures are not free of complications. I believe, however, that we are lucky to be practising at a time where we are able to help almost every aphakic child because we have different options.” Waiting to implant a secondary IOL is advisable because it will have better refractive predictability, but earlier implantation may be necessary if the child is at risk for amblyopia because of difficulties with contact lens or spectacle wear. Although there are various formulas for predicting myopic shift over time, there is a lot of individual variability. “The younger the child, the less precise the IOL is that you can put in,” Dr Salchow said. The adequacy of capsular support is one factor influencing IOL selection. When in-the-bag implantation is not an option, sulcus placement can be done. Then, a three-piece design is generally advised as it is more stable than a single-piece lens. When there are intact anterior and posterior capsulotomies and the two leaflets are fused, implantation of the bag-in-the-lens may be considered. However, preparation is time-consuming as it requires separating the capsule leaflets and aspirating existing lens material and it does not always work. If in this case sulcus placement is selected, it is important to remove lens material between the capsule leaflets in order to avoid secondary-angle closure through anterior displacement of the IOL. A recent study comparing in-the-bag and sulcus secondary IOL implantation found no difference in prediction error between the two, but the sulcus lenses tended to cause more corneal oedema and early postoperative inflammation. The rate of glaucoma was also higher in the sulcus group, although Dr Salchow suggested that this might have been the consequence of differences between the eyes rather than of the site of IOL placement because the anterior chamber angle maintains normal configuration with sulcus placement. A study including 174 eyes with secondary IOL implantation showed good visual results, but also showed the potential for complications such as membrane formation in about 10% of eyes, optic capture, hypotony, IOL decentration, and glaucoma. In eyes with a subluxated lens associated with Marfan syndrome or homocystinuria where placement of a capsular tension ring is not possible, Dr Salchow said he has abandoned suturing the IOL to the iris after he had two patients develop iris cysts. Since then, he and colleagues have been using the iris clip lens. A retrospective review including seven eyes of four patients, showed that the children had good visual outcomes with an acceptable endothelial cell loss rate, and no child developed glaucoma or other complications. “This is a nice technique because it is something that can work when there is no capsular support and you want to avoid suturing an IOL,” he noted. Daniel Salchow: daniel.salchow@charite.de

EUROTIMES | MARCH 2019


PAEDIATRIC OPHTHALMOLOGY

Jack Kanski (1939–2019)

Jack Kanski contributed enormously to the ocular care of children writes Ken Nischal, founding co-chair of WSPOS

Jack Kanski, MD, MS, FRCS, FRCOphth (August 5 1939 – January 5 2019)

J

ack J. Kanski was born Jacek Jerzy Kanski on August 5, 1939, in Warsaw, Poland. He was the son of Jerzy Jordan Kanski and Adela Jozefa (Wroblewska) Kanski. His father was a senior member on the staff of Marshal Edward  Migy-Rydz, the commander-inchief of Polish forces at the start of World War II. The family escaped from Poland in 1946 and settled in Great Britain. Jack qualified at The London Hospital Medical College in 1963, and after spending time at the London, the Western Ophthalmic and Westminster hospitals, he became a resident at Moorfields Eye Hospital, High Holborn. In 1973, he was appointed as consultant surgeon at the Prince Charles Eye Unit in Windsor. As a resident, he had started to collect a series of interesting cases with clinical photos, which were the inspiration for his books  in fact,  with help from his wife, Valerie, he created audio cassettes with slides, which became the basis for his first book, Clinical Ophthalmology, in 1984. This was followed over the next 25 years by more than 30 books covering all aspects of ophthalmology. During this period,  Clinical Ophthalmology  was being updated with new editions and became the bestselling ophthalmology textbook ever. Jack Kanski gave the first ever Keynote Lecture at the World Congress of Paediatric Ophthalmology and Strabismus (WCPOS) in Barcelona in 2009. In 2013, WSPOS established the Kanski Medal, which is awarded at every WCPOS to an outstanding contributor to the care of children with ocular disease but who was not a paediatric ophthalmologist by training. This was based on the fact that Jack Kanski contributed enormously to the ocular care of children with idiopathic juvenile arthritis but was not a paediatric ophthalmologist by training. Jack died on January 5, 2019, with his wife, Valerie, at his side. He will be sorely missed by his friends and colleagues. His dedication and work in teaching and training generations of ophthalmologists world-wide epitomises the essence of a true professor and will echo in eternity.

WSPOS World Society of Paediatric Ophthalmology & Strabismus

S UB S P E C IA LT Y DAY Friday 13th September 2019 Preceding the 37th Congress of the ESCRS, 14 – 18 September 2019

Abstract Submission Open Online

www.wspos.org EUROTIMES | MARCH 2019

29


See into the future of eye surgery and patient care.

www.escrs.org

Belong to something inspiring. Join us.


ESCRS NEWS

23rd ESCRS Winter Meeting

ath ens

ESCRS

NEWS

Odile O’Sullivan from Alcon (left) and ESCRS President Professor Béatrice Cochener-Lamard presenting the ESCRS/Alcon Fellowship to Dr Bogdan Spiru

ESCRS/Alcon Fellowship 2019 The European Society of Cataract and Refractive Surgeons (ESCRS) has announced the recipient of the ESCRS/Alcon Fellowship 2019. Bogdan Spiru, of the University Hospital of Marburg, Germany, has been awarded the Fellowship, a grant funded by Alcon, for a European ophthalmologist in training. The Fellowship was announced in Vienna at the 36th Congress of the ESCRS and awarded at the 23rd ESCRS Winter Meeting in Athens. Doctor Spiru will use the €50,000 grant to fund a oneyear fellowship at the Instituto de Microcirugía Ocular (IMO) in Barcelona, Spain in order to gain clinical experience in the field of cataract and refractive surgery. He has been accepted to work under Professor José L. Güell at the IMO. Working as a resident in Marburg, Dr Spiru has had as a mentor Professor Walter Sekundo. He also undertook a five-week surgical fellowship in Bangalore alongside Prof Sri Ganesh in 2018. “I am very grateful and honoured to receive this award from ESCRS and look forward to working with the distinguished team of specialists at IMO Barcelona, it will be an honour to start new research projects with the team of Prof Güell,” said Dr Spiru. “This important grant complements the existing ESCRS young ophthalmologists’ programmes and initiatives designed to provide further education and training in the specialist field of cataract and refractive surgery.” said Professor Béatrice Cochener-Lamard, President of the ESCRS. “This is a unique lifetime opportunity to learn from peers and have an enriching experience in a different clinical environment.” “Alcon is committed to supporting ophthalmologists throughout their training. This one-time grant is meant to encourage the new generation to observe practice, gain clinical experience and international exposure,” said Ian Bell, Alcon EMEA region President.

EUROTIMES | MARCH 2019

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CME Educational Symposium

San Diego 2019

Save the date Friday, May 3 – Monday, May 6, 2019

Make the most of your time at the ASCRS•ASOA Annual Meeting and attend our EyeWorld multi-supported CME and Corporate Events. They are a great opportunity to network with your colleagues while learning tips and techniques from the experts.

Registration is now open!

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

Corporate Education

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

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

meetings.eyeworld.org Topics are subject to change.


INDUSTRY NEWS

INDUSTRY

NEWS

Rainer Kirchhübel (left) receiving a certificate in honour of his 40th work anniversary from Andreas Tielmann, Managing Director of the Chamber of Industry and Commerce in Lahn-Dill

2019

40 years of service

“You have dedicated your entire working life to OCULUS,” said Co-Director Christian Kirchhübel, at a special ceremony to mark his father’s Rainer Kirchhübel 40th work anniversary. Rainer Kirchhübel said: “For 38 of my 40 years at OCULUS, I’ve been the Director. These years saw many great challenges, but I always enjoyed it.” A spokeswoman for Oculus said that from his start at the firm in 1979, engineer Rainer Kirchhübel led the company success as a worldwide high-tech company, and she also pointed out that OCULUS is still a family company. Sons Christian and Matthias are executives at the company, and Rainer’s wife Rita Kirchhübel has been Director of Marketing for over 25 years. www.oculus.de

NEXT-GENERATION MONOFOCAL IOL Johnson & Johnson Vision has announced the launch of its TECNIS Eyhance IOL for the treatment of cataracts in Europe. “This next-generation monofocal intraocular lens allows patients to experience high-quality vision at both intermediate and far distances. This is an important first for the monofocal IOL category, as most lenses in this category only correct vision to help patients with cataracts see things at a distance, and thus do not improve intermediate vision required for many daily tasks,” said a company spokeswoman. “We are proud to deliver another meaningful solution for patients with cataracts,” said Tom Frinzi, Worldwide President, Surgical, Johnson & Johnson Vision. https://www.jjvision.com/

CE MARKING Heidelberg Engineering has announced the CE marking of the SPECTRALIS® High Magnification Module. “With the addition of a highly innovative lens and software upgrade, this enables visualisation of the ocular fundus at a microscopic level,” said a company spokeswoman. “The SPECTRALIS High Magnification Module makes optimal use of the confocal scanning laser ophthalmoscopy (cSLO) technology of SPECTRALIS to resolve retinal microstructures by diminishing stray light from outside the focal plane. It combines the selectivity of laser light with confocal scanning to provide infrared fundus images with a level of detail and clarity not available from fundus photography,” she said. https://www. heidelbergengineering.co.uk/

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: l l

l

l

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

Closing date for applications is 1 May 2019 Applications and queries should be sent to Danielle Maher at danielle.maher@escrs.org

EUROTIMES | MARCH 2019

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OUTLOOK ON INDUSTRY

ZEISS efficiency Digital technology and collaboration focus physicians on greatest patient need. Howard Larkin reports

A

s Carl Zeiss Meditec’s James V. (Jim) Mazzo sees it, ophthalmic practitioners must assess each patient’s unique condition and diagnose based on the patient’s greatest needs, which generally fall into three categories. “Some patients are of stable health while others have conditions that need a referral, perhaps to a retina specialist. Then there are patients who have complex issues needing further diagnosis and understanding. Doctors usually look at diagnostic images with patients and educate them to better understand their specific needs and options for care,” says Mazzo, global president of ZEISS’s ophthalmic devices business unit. “The challenge is, doctors end up spending sufficient time with all types of patients when limited clinic hours would be better suited if time was spent focusing on the patients they can help the most,” Mazzo adds. He believes technology can help identify the needs of patients prior to meeting with the doctor – which is critical for increasing efficiency and meeting rising patient need. Over the past few years, ZEISS has developed a wide range of technologies that help make the daily ophthalmic practice more efficient by producing, capturing, displaying and, increasingly, organising and analysing data. These include cutting-edge diagnostics, such as the new Swept-Source OCT IOLMaster 700 that measures both anterior and posterior corneal curvature, and the PLEX Elite 9000, which provides a new level of detail of retinal blood vessels. The ZEISS FORUM workflow software pulls together data from many kinds of devices and EMRs into organised presentations on work stations optimised for glaucoma and retina, and for large and small practices. “Our job is to make sure the physician can arrive at the correct diagnosis using all available data,” Mazzo says. On the treatment side, FORUM is enabled to forward data to surgical planning modules, such as Veracity for cataract surgery planning and to engage in data transfer with treatment devices, including the OPMI Lumera cataract microscope and the Callisto toric IOL alignment system, and the MEL80 LASIK and VisuMax SMILE® refractive lasers. To better utilise the data collected by these devices, ZEISS sponsors the Advanced Retina Imaging (A R I) Network, allowing PLEX Elite users to share data and collaborate on new algorithms for interpreting and displaying data. This data has greatly enhanced retinal EUROTIMES | MARCH 2019

Courtesy of Carl Zeiss Meditec

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A R I Network from ZEISS brings researchers together from across the globe in pursuit of discovering innovation that will better support vision care around the world

waiting room if a home network can scan specialists’ ability to customise how they images. The patient can stay at home and the use the data to identify, assess and treat doctor can receive these images remotely and progression of diseases, such as age-related analyse the images,” Mazzo said. macular degeneration, as the physician Artificial intelligence-aided analysis can use the shared information to aid is another new technology that in identifying neovascularisation could greatly improve practice before it advances to the performance. Data from exudative stage, resulting in thousands of images from closer follow-up and better hundreds of patients with vision outcomes. similar conditions may help The A R I Network also identify new patterns and helps ZEISS engineers associations that can generate accelerate development predictive algorithms. These of imaging technology. A may help identify patients similar collaboration for who are at risk and when they glaucoma, the Advanced Nerve should be called in for additional and Glaucoma Imaging (A N G I) James V. (Jim) Mazzo examination and treatment. Network, was launched at the 2018 Chaired by Philip Rosenfeld MD, PhD, AAO Annual Meeting. the A R I Network has developed more than “What does this mean in day-to-day 10 algorithms and currently supports 150 practice? It means ophthalmologists have a research collaborations across 120 research much better idea of a patient’s need before sites. “The A R I Network has already they enter the examining room, enabling advanced the understanding of retinal more efficient handling of cases,” Mazzo disease progression and changed the way says. And when they get to surgery, they retina specialists follow and treat patients, and can be more confident that their data and design clinical studies,” Dr Rosenfeld says. calculations are correct, leading to higher “Another critical concern is protecting efficiency and better outcomes. clinicians and ensuring they are not Images can help patients see how their overwhelmed by the sheer mass of new data,” disease is progressing so they can better Mazzo notes. Organising images and facts, understand and care for their conditions. such as correlating OCT retinal findings “ZEISS is the leader in capturing data and with ongoing treatment, gives clinicians providing machines that inform the doctor new insight into long-term patterns of and that helps patients every step of the way. progression, helping separate the effects of That’s our focus,” Mazzo says natural history from treatment effects over “ZEISS is leveraging data to improve years of treatment. ophthalmic practice efficiency and “Such systems will augment, rather than effectiveness, but much more can be done,” replace, physician judgement,” Mazzo says. Mazzo says. “Home monitoring of patients “Our job is not to tell the doctor what to do. is one path ZEISS is developing,” he adds. Our job is to give the doctor the data and the “We want to eliminate unnecessary visits. context to make a better decision, helping Patients no longer need to get in their car, patients every step of the way.” drive to the doctor’s office and sit in the


RANDOM THOUGHTS

Driving and the elderly What is the ophthalmologist’s role in certifying older patients for driving? Aidan Hanratty reports

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n January 17, 2019, Prince Philip, Duke of Edinburgh, was involved in a road traffic accident near Queen Elizabeth II’s private home, the Sandringham estate in Norfolk, England. According to a report from the BBC, the 97-year-old lost control of his vehicle and made contact with another car carrying two women and a baby. The adult passenger broke her wrist in the accident. A bystander reported hearing that the Duke told police he had been dazzled by the sun. While most of the headlines focused on the fact of Prince Philip’s position and the well-being of the injured woman, the incident also opened up a conversation about driving and the elderly. What is the protocol for older drivers? In both the United Kingdom and Ireland, drivers older than 70 are required to renew their licence every one-to-three years. In the UK, drivers must meet minimum eyesight requirements, including being able to read a car number plate made after 1 September 2001 from 20 metres and having a visual acuity (VA) of at least 6/12. In Ireland, however, drivers older than 70 require a certification of fitness to drive by their doctor. “This includes a cardiac and neurological and cognitive

assessment as well as vision and hearing,” says Dr Tony Cox, Medical Director of the Irish College of General Practitioners. “Assessment of their mobility and independence is also undertaken. It’s a thorough enough assessment.” As in the UK, drivers must have VA of at least 6/12. Arthur Cummings MD says: “The second requirement is doing a binocular visual field test to ensure that the visual field is wide enough and the current requirement is 150°.” Ultimately, the directions are clear. However, the remaining unknown is the quality of the relationship between the patient and GP, which can be built up over many years and can be shattered in moments. With patients referred to him by GPs, the issue can go one of two ways, says Mr Cummings: “Many times the issue is due to a cataract and we can resolve it with surgery and sometimes unfortunately it is due to something like advanced glaucoma, or age-related macular degeneration and then the news is less good.” It may also fall to the patient’s family to step in. The ability to drive can be someone’s lifeline, a symbol and manifestation of their independence. This will not be given up lightly. Patient safety, however, and that of other road users, is paramount.

23 - 25 JUNE 2019 PARIS, FRANCE REGISTER NOW AT

www.maculart-meeting.com FACULTY LIST Francesco Bandello • Caroline Baumal • Mohamed Bennani • Bahram Bodaghi • Alexander Brucker • Neil Bressler Susan Bressler • Usha Chakravarthy • Gemmy Cheung Chui Ming • Itay Chowers • Salomon Yves Cohen Catherine Creuzot Garcher • Karl Csaky • Emmett Cunningham • Diana Do • Pravin Dugel • Michael Elman Amani Fawzi • Bailey Freund • Alain Gaudric • Mark Gilles • Agnes Glacet Bernard • Frank Holz • Lee Merrill Jampol Laurent Kodjikian • Alfredo Garcia Layana • Nicolas Leveziel • Anat Loewenstein Bruno Lumbroso William F. Mieler • Joseph Moisseiev • Jordi Mones • Quan Dong Nguyen • Kyoko Ohno-Matsui • Giuseppe Querques Sam Razavi • Elias Reichel • Kourous Rezaei • Daniel Roth • Srinivas Sadda • Jose Sahel • David Sarraf Ursula Schmidt-Erfurth • Johanna Seddon • Oudy Semoun • Michael Singer • Lawrence Singerman • Jason Slakter Theodore Smith • Eric Souied • Richard Spaide Mayer Srour • Giovanni Staurenghi • Adnan Tufail • Nadia Waheed Lawrence Yannuzzi • Marco Zarbin • Sandrine Zweifel EUROTIMES | MARCH 2019

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EXPLORING PARIS

The Beaugrenelle shopping mall is housed in three buildings along the Seine

PARIS

3

TO KNOW ...

SEE LADY LIBERTY AT HER HOMES AWAY FROM HOME Visitors to Beaugrenelle will find Lady Liberty seeming to lift her lamp beside the door of the shopping mall. Actually, she’s in the Seine on the Île aux Cygnes and the mall is located steps away. This quarter-sized replica was a gift from the American community in Paris on the occasion of the centennial of the French Revolution. From the Grenelle bridge, descend the ramp to reach Madame Liberté. She’s one of five replicas of Bertholdi’s statue in Paris; there’s one in the Luxembourg Garden, another in the Musée d'Orsay, one outside the Musée des Arts et Métiers and one inside. That last one is the 2.86-metre tall original plaster maquette finished in 1878 by Auguste Bartholdi from which the statue in New York was made.

BOOK YOUR PLACE AT THIS HISTORIC MARKET Every Saturday and Sunday, from 9.00 to 18.00, a book market opens up in Parc Georges-Brassens in the 15th arrondissement. Booksellers, some of them prestigious Parisian houses, set up stalls in the Marché du Livre, a well-attended event since its inception 1987. More than 50 booksellers show their wares here, sheltered in a pavilion designed by the architect Ernest Moreau and built near the park’s entrance on Rue Brancion in 1897. Search for old French film posters or fall for an elegantly illustrated Japanese children’s book. Afterwards, explore the park. Highlights include: A Garden of Scents with 80 kinds of aromatic plants, spice and medicinal plants, identified in Braille; a bee-hive where children come to learn about bees and pollination; and a terraced vineyard where volunteers harvest the pinot noir grapes which produce about 200 bottles of ‘Clos des Morillons’ each year.

TEACH YOURSELF TO COOK LIKE THE BEST Does, the name ‘Julia Child’ ring a dinner bell with you? It will if you know her cookbook or have seen Julie and Julia, in which the soon-to-be famous chef, played by Meryl Streep, hones her culinary skills at the Cordon Bleu cooking school. Since 2016, this renowned establishment has enjoyed an extensive campus in the 15th arrondissement: 1315 Quai André Citroën. Dip your own spoon into French cooking during your Paris stay by reserving a place at one of the Cordon Bleu’s range of workshops. In two-to-four hours you could learn to pair food and wine, or make eclairs, or find your way around vegetarian cooking. The school’s boutique is worth checking for the perfect tea towel, a cookbook or a gift-worthy box of Breton short breads. Details of the workshops and the boutique ’s offerings are at www.cordonbleu.edu

Shop till you drop The 15th arrondissement offers hundreds of shops and boutiques to suit all tastes. Maryalicia Post reports. Beaugrenelle Paris is a large shopping centre at 12 Rue Linois in the 15th arrondissement. Along with 110 retail shops, 16 restaurants and a 10-salle cinema it offers a sense of space and comfort. Not surprisingly, it won the accolade of ‘Best European Shopping Mall’ in 2015. The Beaugrenelle is housed in three buildings along the Seine: the Magnetic, Panoramic and City. The Magnetic and Panoramic buildings are linked by a covered pedestrian bridge and their atria are illuminated by skylights that fill the shopping mall’s six floors with natural daylight – a spectacular setting for the blue glass ‘Grand Mobile’. It is 15 metres high and was designed by French artist Xavier Veilhan. Special services at Beaugrenelle include a personal shopper who will, for a fee, fill in the gaps in your wardrobe or produce a ‘new you’. The entire centre offers free wifi; you can charge your device in a comfortable seat while enjoying a smoothie or a coffee. ID but no device? Beaugrenelle with lend you an iPad for your visit. And on the roof, there’s a community garden and beehives which produce tons of honey every year. Shops are open Monday to Saturday from 10:00 to 20:30 and from 11:00 to 19:00 on Sunday. Restaurants are open until midnight daily and options range from bistro style to McDonald’s and include vegetarian. Tickets for the cinema, with its cosy upholstered seats, may be purchased online at www.cinemaspathegaumont.com. (Cinema closes at 0.30 daily) Beaugrenelle’s website is: www.beaugrenelle-paris.com If old-fashioned store-to-store shopping is more your thing, head for Rue du Commerce. Both sides of this attractive street are lined with interesting boutiques and branches of famous stores like

Monoprix and Sephora. The street is not pedestrianised, but slow-moving one-way traffic gives you the chance to thread your way from side to side as the fancy strikes. Jules, at 26-28 rue du Commerce, is an address cherished by young and trendy French men, while at 93 Rue du Commerce, you’ll find the flagship store of the Somewhere brand. Now international, Somewhere was created in Paris in 1993 to provide eco-aware clients, male and female, with garments in natural fibres (organic cotton, linen, silk, wool, cashmere, yak …) all sourced from responsibly managed suppliers. If your plan calls for lunch or dinner in the area, the Cafe du Commerce has been a welcoming presence at number 51 since 1921. Tables on three floors, lots of greenery. For something smaller but still traditional, try La Tour Eiffel located at 96 Rue du Commerce.

Lady Liberty in the Seine on the Île aux Cygnes, one of five replicas of the statue in Paris

EUROTIMES | MARCH 2019

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SOCIETY NEWS

Advancing knowledge

T

Konstantina Koufala, HSIOIRS President, reflects on the society’s distinguished history

he Hellenic Society of Intraocular Implant and Refractive Surgery (HSIOIRS) was founded in 1984. At that time, the revolution in cataract and refractive surgery had already begun. The new method of phacoemulsification, as well as the use of intraocular lenses to restore vision after cataract surgery, was not easily accepted by the academic community. So, the necessity for something new and progressive in the field of ophthalmology was addressed by pioneering colleagues with the initiative of Spyros Georgaras and a small group of ophthalmologists, who founded HSIOIRS. Our Society has always operated with the main goal of education and training of Greek ophthalmologists in cataract surgery, refractive surgery and ophthalmic microsurgery. In all our annual conferences and other scientific events, we try to offer ophthalmologists the most advanced knowledge in the above fields, in an effort to contribute to their continuous education, which should not stop after the completion of the residency. We must emphasise that even in the years of the economic crisis in our country we have managed to keep the quality of our conferences and other events at a very high level, scientifically and organisationally. From the beginning, HSIOIRS enriched the programme of its scientific events with the participation of internationally distinguished ophthalmologists and has pursued collaborations with other established European and International

Prof David Spalton receiving the Kelman Medal from Dr Miltiadis BalidisHSIOIRS President Elect, and current President Dr Konstantina Koufala

ophthalmological societies. We especially need to mention that our Society has maintained strong ties with the European Society of Cataract and Refractive Surgeons (ESCRS) for many years, leading up to the 23rd ESCRS Winter Meeting this year. We were very pleased to present the Kelman award to Professor David Spalton. The title of his lecture, which was delivered during the Meeting’s Welcome Ceremony, was ‘Life Behind the Lens’.

DISTINGUISHED COLLEAGUES Stressing that the level of ophthalmology and ophthalmic surgery in Greece has always been extremely high, we are proud that many of our Greek colleagues have

distinguished themselves internationally. We need to especially mention Professor Ioannis Pallikaris, the “father” of LASIK, who has helped develop refractive surgery worldwide. On the Board of Directors of the ESCRS, Greece is currently represented by our prominent colleague Vikentia Katsanevaki. Our cooperation with ESCRS in co-organising its Winter Meetings started in 1999 and continued in 2007 and 2016. The success of these three previous conferences gave us the assurance that the 23rd ESCRS Winter Meeting in conjunction with the 33rd International HSIOIRS Meeting in Athens would also be a great success, with a large number of participants from Greece and abroad.

Grow Your Practice Through Innovation Win a €1,500 Bursary ESCRS Practice Management and Development Innovation Award Submission Deadline Monday 29 July 2019

For further details visit: www.escrs.org

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CALENDAR

LAST CALL

MARCH 2019 9th EURETINA Winter Meeting 1–2 March Prague, Czech Republic www.euretina.org

Retina World Congress

8th World Glaucoma Congress 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

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

The 2019 ASCRS•ASOA Symposium and Congress will take place in San Diego, USA

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

46th EFCLIN Congress Exhibition 25–27 April Brussels, Belgium www.efclin.com

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

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

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

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

The 17th SOI International Congress will take place in Rome, Italy

EUROTIMES | MARCH 2019

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CALENDAR

JUNE

The World Ophthalmology Congress (WOC) will take place in Cape Town, South Africa in 2020

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

NEW MaculArt 2019

June 23–25, Paris, France www.maculart-meeting.com

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

2020 MAY

37th Congress of the ESCRS

ASCRS•ASOA Symposium and Congress

14–18 September Paris, France www.escrs.org

15–19 May Boston, USA www.ascrs.org

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

20th EURETINA Congress

38th Congress of the ESCRS

1– 4 October Amsterdam, The Netherlands www.euretina.org 2–3 October Amsterdam, The Netherlands www.eucornea.org

World Ophthalmology Congress (WOC)

Ophthalmic Imaging: from Theory to Current Practice

OCTOBER

11th EuCornea Congress

JUNE

AAO Annual Meeting

OCTOBER

26–29 June Cape Town, South Africa http://woc2020.icoph.org

WCPOS V 5th World Congress of Paediatric Ophthalmology and Strabismus

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

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

2– 4 October Amsterdam, The Netherlands www.wspos.org

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

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