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SPECIAL FOCUS CATARACT & REFRACTIVE

May 2019 | Vol 24 Issue 5

ACCOUNTABILITY

BENCHMARK ALGORITHM

PATIENT CARE OUTCOMES & RISKS

Registries in Ophthalmology CORNEA | RETINA PAEDIATRIC OPHTHALMOLOGY | GLAUCOMA


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

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

www.eurotimes.org

SPECIAL FOCUS

RETINA

REGULARS

CATARACT & REFRACTIVE

26 Using intravitreal injections

38 Outlook on industry 40 Travel 41 Industry news 43 ESCRS News 45 Random thoughts 46 Practice management 47 Calendar

4 European registries are helping shape practice and guide research

to reduce endophthalmitis

27 The latest in choroidal neovascularisation imaging

8 Pearls for the young

29 Ophthalmologica update 30 Fundus autofluorescence

10 Differentiating

31 Does laser therapy still

12 A report from Prof David

PAEDIATRIC OPHTHALMOLOGY

cataract surgeon

between bullous and rhegmatogenous types of Descemet’s detachment Spalton’s HSIOIRS Kelman Award Lecture

16 Poster winners show new insights

18 Outcomes in cataract surgery following vitrectomy

19 Can a bifocal implant provide spectacle independence?

20 JCRS highlights

CORNEA 21 New topical drug

promotes corneal healing in dry eye cases

explained

have a role to play in PDR?

33 The latest strategies

for preventing myopia progression

34 When is SMILE

appropriate in the younger population?

GLAUCOMA 36 Identifying glaucoma

patients at higher risk of progression

P.4

22 EU funding promotes international collaboration

24 Improving outcomes in 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.

Supplement May 2019

infectious keratitis

Included with this issue... Elevating Surgical Outcomes and Satisfaction With Advanced OSD Diagnostics and Therapeutics

ESCRS/EuCornea Education Forum Supplement

EUROTIMES | MAY 2019


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EDITORIAL A WORD FROM MOR DICKMAN MD, PhD

The value of registries

GUEST EDITORIAL

Mor Dickman

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

INTERNATIONAL EDITORIAL BOARD Noel Alpins (Australia), Bekir Aslan (Turkey), Roberto Bellucci (Italy), Hiroko Bissen-Miyajima (Japan), John Chang (China), Béatrice Cochener-Lamard (France), Oliver Findl (Austria), Nino Hirnschall (Austria), Soosan Jacob (India), Vikentia Katsanevaki (Greece), Daniel Kook (Germany), Boris Malyugin (Russia), Marguerite McDonald (USA), Cyres Mehta (India), Sorcha Ní Dhubhghaill (Ireland) Rudy Nuijts (The Netherlands), Leigh Spielberg (The Netherlands), Sathish Srinivasan (UK), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Marie-José Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy)

I

The future of registries holds much promise

n recent years, there is growing recognition that registries are a valuable tool to improve healthcare outcomes and contain rising healthcare spending. Data from registries is increasingly being used for research and to inform guidelines, especially to fill in gaps of evidence that cannot be provided by randomised controlled trials. Registries also play an important role in monitoring the safety of medicines and implants and are a valuable source of post-authorisation realworld data for regulatory decision-making. Implementing patientreported outcome measures (PROMs) in registries captures the missing link in defining a good outcome: quality of life issues that are the very reasons that most patients seek care. Registries also face a myriad of challenges related to the burden of data collection, technical issues, regulations – managing ethical, privacy and legal considerations, quality management, data utilisation and publications. Isaac Newton said: “If I have seen further, it is by standing on the shoulders of giants.” In the field of clinical registries in ophthalmology, Professor Mats Lundström is the Professor Mats undisputed giant on whose shoulders we stand. Lundström is the He established the undisputed giant Swedish National Cataract on whose shoulders Registry and the European Registry of Quality we stand Outcomes for Cataract and Refractive Surgery (EUREQUO), and is clinical director of the European Cornea and Cell Transplantation Registry (ECCTR) and the European Registry of Childhood Cataract Surgery (EuReCCa). He developed the Catquest-9SF patient outcomes questionnaire, introduced evidence-based guidelines in cataract surgery, and initiated seminal studies on the use of prophylactic antibiotics, immediate sequential bilateral cataract surgery (ISBCS) and femtosecond laser-assisted cataract surgery (FLACS). Building on his vast experience, Dr Lundström remains a pioneer with an eye for innovation who inspires the next generation of ophthalmologists with his endless energy, optimism and scientific integrity. The future of registries holds much promise. The randomised registry study represents a disruptive technology that has the potential to resolve the recognised limitations of current clinical trial design, using bigger data and smaller budgets. Machine learning algorithms may provide means to navigate big data available to registries and help recognise parameters, a combination resulting in optimal outcomes. As clinical registries cover progressively more of the healthcare landscape and are supplemented by additional data from electronic healthcare records, they will provide insights into real-word practice, ultimately improving healthcare delivery and patient outcomes in the era of value-based healthcare.

Mor Dickman, University Eye Clinic Maastricht University Medical Center EUROTIMES | MAY 2019


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REGISTRIES IN OPHTHALMOLOGY

A treasure trove of invaluable data

ESCRS-backed European registries are helping shape clinical practice and guide future research. Dermot McGrath reports

I

n an era of advanced computing power and digital technology, it is no surprise that registries comprising medical data play an increasingly important role in healthcare and research. Clinical data registries are organised systems that collect data on patients diagnosed with a disease or condition or who undergo a certain procedure. Although clinical data registries have been around since at least 1856, when Norway established the National Leprosy Registry, the world’s first national patient register for any disease , it is only in recent decades that large populationbased health administrative databases and clinical registries have come to the fore as a vital resource for clinical benchmarking and health research. Several factors lie behind the robust growth of registries in recent years including advances in information technology, increasing use of electronic health records and growing demand for accountability in quality of care. The United Kingdom currently has 50-plus clinical audit programmes, the United States has more than 110 federally qualified registries and Sweden, an acknowledged pioneer in the domain, has more than 100 registries, covering a broad spectrum of medical conditions and procedures from birth to old age. Although priority conditions such as cancer and cardiovascular disease have traditionally led the pack in registries development, ophthalmology has also played its part in advancing the cause of clinical registries to improve quality and cost-efficiency in medical care. Registry-based studies have been used EUROTIMES | MAY 2019

to study real-world clinical outcomes and shape the development of new guidelines and standards in areas such as cataract surgery, corneal transplantation, glaucoma and macular degeneration. A recent meta-analysis of the PUBMED database listed at least 97 clinical eye registries worldwide, with significant growth noted in the past four decades. Most of those registries originate in the European region, North America and Australia, and nine of them have multinational coverage. The American Academy of Ophthalmology’s IRIS Registry, with data on more than 225 million patient visits, claims to be the largest clinical data registry in the world for any specialty. It enables clinicians to look at large patient populations, rare diseases, prevalence data and differences in practice patterns geographically or disparities in practice among certain patient populations. In Europe, the ESCRS actively supports three major pan-national registers: the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO), the European Cornea and Cell Transplantation Registry (ECCTR) and the European Registry for Childhood Cataract Surgery (EuReCCA).

TREASURE TROVE OF VALUABLE DATA The oldest of these registers, EUREQUO, started in 2008 as a European Unionfunded project and now has almost 3 million cataract extraction surgeries in its database. This treasure trove of surgical data has already yielded tangible results in terms of improving cataract outcomes,

providing evidencebased practice guidelines and generating research. Studies based on EUREQUO have helped to shape clinical practice through a wide range of recommendations on second-eye surgery, outpatient procedures, preand postoperative visual tests, refractive outcomes, managing co-morbidities and complex cases, anaesthesia, IOL lens type and materials and other key aspects of surgical technique. The database also supported the largest study to date comparing visual, refractive and safety outcomes of patients undergoing femtosecond laser cataract surgery (FLACS) versus conventional phaco cataract surgery. Mats Lundström MD, PhD, the pioneer and driving force behind the Swedish National Cataract Registry and EUREQUO, notes that registries for diseases and/or interventions serve two main goals. “The first purpose is to offer comparison and benchmarking to initiate clinical improvement work for clinics and surgeons. The second purpose is scientific, which means to improve knowledge of real-world outcomes and stimulate analyses and studies,” he told EuroTimes.

VALUE-BASED CARE Even though the principal purpose of EUREQUO is to offer benchmarking and serve as the basis of clinical improvement work, the utility of such a registry is


REGISTRIES IN OPHTHALMOLOGY

CORNEAL TRANSPLANTATION DATA

still underestimated by many surgeons, regrets Dr Lundström. “I think the purpose of registries is often poorly understood by our colleagues. For the clinician, EUREQUO gives them knowledge of their own results, what needs to be improved for better outcomes as well as expected outcomes given the patient’s characteristics. For the patient, it provides information about expected outcomes and risks, helps them to set realistic expectations and gives them confidence in a provider that prioritises quality control,” he said. With national health authorities, payers and other stakeholders placing ever-greater emphasis on quality control and valuebased healthcare, ophthalmologists can no longer afford to ignore the relentless drive

towards evidencebased medicine. “I really feel our profession is not as focused on the benefit of registries as it should be,” said Mor Dickman MD, PhD, who is steering group member of the Dutch National Organ Transplantation Registration (NOTR), EUREQUO, ECCTR and EuReCCa. There is increasing demand in healthcare from all stakeholders for robust performance measures, noted Dr Dickman. “In that context, it is imperative for every practitioner to know what his or her results are and to communicate that also to the patient. When I ask many top surgeons what their outcomes in terms of how predictable their refractive results are, their rates of posterior capsular rupture, the performance of their residents and so forth they simply do not know the answer because they do not look at it. Registries allow us to benchmark our performance starting at the single surgeon level and working up to clinic, national and European levels and are an invaluable resource for any medical practitioner,” he said.

The capacity of registries to inform and guide current clinical practice is also manifest in the field of corneal transplantation, points out Rudy Nuijts MD, PhD, one of the key figures in ECCTR, a three-year registry programme co-funded by the EU and the ESCRS to assess the safety, quality and efficacy of ophthalmic donor tissue transplantations and cell-based therapies. “Registries are very important in terms of evidence-based medicine and are an important complement to randomised clinical trials in measuring the effect of specific interventions and raising standards of patient care. We saw this first-hand with our national transplant registry in the Netherlands, which showed that many factors influence outcomes such as surgical learning curve in Descemet’s Stripping Endothelial Keratoplasy (DMEK) and also indications for transplantation, where we see differences in graft survival,” he said. With more than 4,000 surgeries in its database, and more expected as the project nears completion in 2019, the ECCTR web-based registry is expected to provide a wealth of useful information concerning corneal transplantation for academics, health professionals and health authorities. Expected outcomes of the project include the development of key objective performance indicators to increase the quality of corneal transplant surgeries, validation of patient-related outcome measures (PROMs), development of evidence-based guidelines for good clinical practice and innovative benchmarks that will enable healthcare practitioners to better inform patients about expected outcomes. Based on the Dutch experience, the expectation is that a European registry will also help to illuminate some fundamental questions relating to corneal transplantation as techniques continue to evolve, said Dr Dickman. “We need to develop and evolve with the times. A few years ago we had only penetrating keratoplasty (PK) and now we have Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK), DMEK and limbal stem cell transplantation. The landscape of corneal transplant surgery has transformed dramatically, and will continue to develop as more advanced therapy medicinal products (ATMPs) become available. We need to ask ourselves if we want the data about these treatments guided by companies, or do we want to collect this data ourselves and have a real picture of how these perform in the real world on a wide variety of patients and in the long term?” he said. EUROTIMES | MAY 2019

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REGISTRIES IN OPHTHALMOLOGY

Although the recent trend in registries is towards analysing ever-larger data sets, there is also value to be found in focusing on specific questions relating to less common diseases, points out MarieJosé Tassignon MD, PhD, FEBO, who is spearheading the European Registry for Childhood Cataract Surgery (EuReCCa). “Because paediatric cataract is a rare disease, it makes administration of the database and transcription and validation of patient data much easier. We hope through the registry to obtain a better understanding of the mechanism of emmetropisation in infants and children. We also have some sub questions that will be addressed as well, such as the target of the IOL lens power implanted depending on the underlying cause of the cataract and the age of the patient,” she said. EuReCCa is currently in the early stage of development, but has benefited greatly from the experience of Dr Lundström and EUREQUO in getting the registry up and running, said Dr Tassignon. This included navigating the complexity of the new European General Data Protection Regulation (GDPR), which came into effect in 2018 and which has wide-reaching implications for any clinical data registry dealing with European citizens. In essence, the new rules require all registries to ensure that patient consents are aligned with the GDPR as well as with national requirements that allow sharing of aggregated and anonymised patient-level data for research or regulatory purposes. As Dr Nuijts sees it, this is one of the most critical issues facing clinical data registries today. “We need to be able to assure doctors and patients that their data is handled according to the legal requirements. To increase the potential of registries it would be worthwhile to include the retrospective data of existing registries, as was done with the ECCTR, but this needs adjustment to the current GDPR legislation,” he said. Although the complexity of such regulatory legislation is daunting, Dr Tassignon said that everything is currently on track with EuReCCa. “We have had a lot of interest from parties interested in contributing. It is quite challenging to bring all the various components together, to harmonise electronic health records (ERH) from different countries and respect all the various regulatory requirements, especially bearing in mind the new EU rules concerning GDPR. We are fortunate EUROTIMES | MAY 2019

We need to be able to assure doctors and patients that their data is handled according to the legal requirements Rudy Nuijts, MD, PHD

to be able to draw on Dr Lundström’s expertise to help meet all these challenges,” she said.

FUTURE DEVELOPMENTS Going forward, there is scope in the future to harness artificial intelligence applications and deep learning algorithms to delve deeper into the massive clinical datasets now available. There is also the challenge of continually refining the data collection to reflect evolving practice and ensure the relevance of the information contained therein. Dr Lundström also sees potential to use large databases to describe risk factors for rare events. “This means describing risk factors for rare complications and also outcomes when rare baseline characteristics are present. For instance, we can use the database to describe risk factors for a poor refractive outcome. The probable outcome for combinations of preoperative characteristics such as age, gender, preoperative visual acuity and ocular comorbidities can also be described,” he said. The current EUREQUO forms can also be used as Case Report Forms that could be utilised in future clinical studies, added Dr Lundström. “If needed, new parameters can be included that suit the research question being posed. To set up such a system from scratch is expensive and the EUREQUO system can be used by ESCRS scientists for free. The system is also updated to make it easier for clinics and surgeons to transfer data without double entry. I want to acknowledge the board of the ESCRS for its foresight in support of registries,” he said. Ophthalmology could also take inspiration from cardiology and oncology in using low-cost registrybased randomised

trials to guide clinical practice, suggests Dr Dickman. He cited the example of the Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia (TASTE) trial, in which investigators designed a large-scale trial to answer an important clinical question and carried it out at remarkably low cost by building on the platform of an already-existing highquality observational registry. “There is no reason why we cannot do the same for ophthalmology, whether in cataract, corneal surgery or paediatric cataract, to make better use of these wonderful data platforms that already exist and capture information about surgical techniques or innovative therapies,” Dr Lundström concluded. Mats Lundström: mats.lundstrom@ karlskrona.mail.telia.com Rudy Nuijts: rudy.nuijts@mumc.nl Marie-José Tassignon: Marie-Jose.Tassignon@uza.be Mor Dickman: mor.dickman@mumc.nl To join EUREQUO contact: lucia.brocato@escrs.org


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SPECIAL FOCUS: CATARACT & REFRACTIVE

Pearls

for the young cataract surgeon Challenging cases were presented and discussed at the 23rd Winter Meeting of the ESCRS in Athens, Greece. Aidan Hanratty reports

A

panel of experienced surgeons offered words of wisdom at ‘Pearls for the Young Cataract Surgeon’, a symposium organised by the Young Ophthalmologists Committee during the 23rd Winter Meeting of the ESCRS in Athens, Greece. First to speak was Basak Bostanci Ceran MD, Okan University Hospital, Istanbul, Turkey, who discussed her first rhexis and hydrodissection attempts. In the words of her mentors, if you don’t have a perfect rhexis, “you will be doomed in the following steps”. Dr Bostanci Ceran showed a video of one of her earliest rhexis attempts, with poor visibility, poor centration and little control. In subsequent cases she learned about the many variables at play in each patient. These included pupil size, globe exposure, red reflex and capsular texture and eye movements, which are almost impossible to replicate in a simulation environment. One of her key points of advice was that good visualisation is a must: “Before doing anything, learn how to use your microscope.” The ideal rhexis is something that ophthalmic pioneer Professor Thomas Neuhann, Germany, is still striving for. It is not a technique that requires certain movements; rather it is a principle that must be understood, he believes. “Once you understand it, then you make it work for your hand.” The ideal rhexis should be able to do three things: reliably encase or support an IOL implant; contribute to maintaining the diaphragm function between the anterior EUROTIMES | MAY 2019

and posterior segments; and it should be maximally resistant to mechanical stress or distension intraoperatively. To achieve these things, it must be continuous. Quoting his co-inventor of the capsulorhexis Howard Gimbel MD, he asserted that “it’s not about circularity, it’s about continuity”, reminding the audience that a perfect circle is not essential – as long as it covers the IOL margin 360°. It should also be centred. Not on the pupil or the limbus, but on the IOL, although he acknowledged that this is easier said than done. Vincent Qin MD, CHU UCL Namur,

Belgium, showed a series of video cases where complications occurred and how they were overcome. These included posterior capsular rupture, dropped nucleus and rhexis running out. His

Before doing anything, learn how to use your microscope Basak Bostanci Ceran MD

Basak Bostanci Ceran MD


SPECIAL FOCUS: CATARACT & REFRACTIVE

It is important to have a clear plan of action for each of the successive steps in the surgery so that they are repeatable and consistent Richard Packard MD, FRCS, FRCOphth advice was to plan ahead, taking time even the day before surgery to anticipate the various complications that may occur. In case they do present themselves, stay calm, add some viscoelastic and then think about what you’re going to do. Richard Packard MD, FRCS, FRCOphth, Director, Arnott Eye Associates, London, UK, described the dream phaco – many factors must align for this to take place, from patient selection, draping and microscope preparation, to perfect incisions, minimal ultrasound use and so forth. Machine settings must be optimal, the patient must be calm and the surgeon must be comfortable: “At the end of the day you won’t have a sore back, because you’ve got a long career ahead of you.” Speaking to EuroTimes after the event, Dr Packard added: “It is important to have a clear plan of action for each of the successive steps in the surgery so that they are repeatable and consistent. By this means the dream phaco will encompass more complex cases.”

CONSCIOUS INCOMPETENCE Recalling his own mistakes, Vasilios Diakonis MD, PhD, The Eye Institute of West Florida, USA, advised that surgeons avoid challenging cases until after they had performed at least 50 surgeries. It's important to be comfortable with everything in the operating room, from pedal to tip. Like Dr Qin, he also suggested that “you cannot save on viscoelastics” – use as much as is necessary. He then described the difference between conscious incompetence and unconscious incompetence in young surgeons, warning against the danger of the latter condition. If a young ophthalmologist understands their limitations, they should step back and allow their mentor to take on more challenging cases. When searching for such a mentor, it’s important to find one with conscious competence, as the unconsciously competent cannot explain how they do what they do. Ultimately, he advised doctors to learn from their mistakes and not to repeat them.

Prof Thomas Neuhann (top) and Boris Malyugin MD

Closing the session, Boris Malyugin MD, Fyodorov Eye Microsurgery Federal State Institution, Russia, showed his mastery of challenging cases with videos of his more difficult procedures. Most intriguing was “FLACS upside down”, where the main incision and paracentesis incisions were made at the wrong sides as the technician had put the right eye settings on the left eye. After asking his expert colleagues what they would do in this situation – Dr Packard said he would make some incisions with a knife and “get on with it” – Dr Malyugin, “not looking for the easy way”, decided to opt for a temporal approach. The situation got worse when a posterior capsular rupture occurred. The

key here was converting the flap into a posterior capsulorhexis. Dr Malyugin also showed a difficult case with an extremely floppy iris, and how it was dealt with including use of the Malyugin pupil expansion ring. His take-home message was the importance of knowledge of the basics, tips and tricks in surgery, mastery of cases, attendance at meetings such as the ESCRS Meetings and most important of all, building up of experience. Ultimately, one must be prepared for complications. How the surgeon deals with them is what is most important. “The definition of a good surgeon is not the one who never gets complications, but the one who can get out of his complications without any complications,” he concluded. EUROTIMES | MAY 2019

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SPECIAL FOCUS: CATARACT & REFRACTIVE

Descemet’s

detachment Differentiating between bullous and rhegmatogenous types of Descemet’s detachment after cataract surgery. Soosan Jacob MD reports

D

escemet’s detachment (DD) after cataract surgery is a relatively frequent complication. It may also be seen after other surgeries or trauma. The author has classified Descemet’s detachments into rhegmatogenous, tractional, bullous and complex detachments based on pathophysiology, clinical, ASOCT findings and treatment required. The most common type of DD seen is the variety with a tear in the Descemet’s membrane (DM), generally seen as a free-floating undulating membrane in the anterior chamber (AC). The tear is generally, though not necessarily located at an incision and may be due to a blunt instrument, the phaco probe or the IOL injector pushing against the DM. This is the classical rhegmatogenous DD and treatment for this variety is simple – injection of air or long-acting gas from the opposite quadrant (pneumodescemetopexy) to drain supraDescemetic fluid and appose the detached DM against overlying stroma followed by postoperative head positioning to keep the air/gas bubble over the area of detachment. However, rarely a postoperative Descemet’s detachment does not resolve despite this commonly followed management and it is important to rule out a bullous variety of Descemet’s detachment in such cases. In addition, learning to identify a bullous DD at the time of primary surgery can save considerable heartburn later on. This article will discuss Bullous DD and its identification, management, prevention and treatment.

Post stromal hydration Bullous Descemet detachment: A: A bullous DD is seen (white arrows) originating from a paracentesis (black arrow). Air from a previous unsuccessful pneumodescemetopexy is seen. Trapped fluid and blood are present within the bullous DD. Blood gravitates down forming a fluid level (yellow arrow); B: A Relaxing Descemetotomy cut is made through the Descemet’s membrane (DM) to provide an egress route for the trapped fluid; C: Pneumodescemetopexy from the opposite quadrant is combined with steam rolling of the cornea; D: An attached DM and a clear cornea is seen on first postoperative day

BULLOUS DESCEMET’S DETACHMENT This is generally seen at the end of surgery while performing stromal hydration for the incision. If the cannula is held too posterior (close to the DM), the injected fluid may cause a hydroseparation of the DM from the overlying stroma. This is seen as a fluid wave moving forwards from the incision. The injected fluid creates a bullous detachment with fluid trapped under DM. Since there is no tear or cut in the DM, a plain pneumodescemetopexy does not work as there is no egress route for the trapped fluid to drain out through. Bullous DD is seen intraoperatively as a fluid wave and may sometimes be overlooked. The classical free-floating detached DM is not seen. Postoperatively, it is seen as a well-defined area of detachment with no tear/flap and a planar or convex separation of the DM from overlying stroma. A fluid level may EUROTIMES | MAY 2019

be seen if mixed with blood. ASOCT may be required for densely oedematous corneas and shows the classical configuration with absence of a tear. The undulating membrane with tear seen in rhegmatogenous DD is not seen here.

MANAGEMENT

Relaxing Descemetotomy: Though small and peripheral bullous DD may resolve spontaneously, larger ones may require surgical management, especially if crossing the visual axis, if rapid visual rehabilitation is required or if the patient develops pain/bullae. Surgical principles are simple. A cut is created on the detached DM in order to make an exit route for the trapped fluid. This may be done by creating a keratome incision in to


SPECIAL FOCUS: CATARACT & REFRACTIVE the AC through the paracentesis, thus creating a cut on the DM through which trapped fluid escapes. This cut on the DM has been described by the author as a Relaxing Descemetotomy cut. For a centrally located bullous DD, the relaxing Descemetotomy may be performed ab-interno by passing a bent 26-gauge needle into the AC and carefully making small relaxing canopener cuts on the DM in the periphery under pressurised air infusion. Soosan Jacob MD Steam rolling of the overlying cornea together with pressurised air infusion through an air pump helps in draining the supraDescemetic fluid completely and hastening DM reattachment. For bullous DD extending to the inferior limbus, a keratome entry is made at the inferior limbus to cut through the detached DM to allow gravitational drainage of fluid. All techniques also require pneumodescemetopexy and postoperative head positioning. The Nd:YAG laser may also be used to drain a centrally located BDD internally. Venting incisions that are sometimes used as an adjunct with pneumodescemtopexy for rhegmatogenous DD may not work effectively for bullous DD. This is because in the absence of a tear, venting incisions in isolation may not be able to evacuate the fluid sufficiently. For a large bullous DD, two limbal-relaxing Descmetotomy incisions can be made perpendicular to each other (thereby negating any astigmatism as well). In contrast, venting incisions are small, are

The most common type of DD seen is the variety with a tear in the Descemet’s membrane (DM)

made in the mid-peripheral cornea as opposed to the limbal location of the relaxing Descemetotomy and therefore have limited effect on drainage of fluid. Large venting incisions carry the risk of scarring, irregular astigmatism, epithelial ingrowth, infective keratitis etc.

PREVENTION Care should always be taken to insert the needle or the cannula completely through the incision before injecting. During stromal hydration at the end of surgery, the cannula should not be placed too posterior against the stroma. It is important to recognise the absence of a tear and treat the bullous DD appropriately during primary surgery itself.

OTHER CAUSES FOR BULLOUS DD Fluid, blood, viscoelastic or air may cause a bullous DD. A bullous detachment can also occur while injecting Trypan blue for staining the capsule if the needle has not been fully inserted through the wound. This blue staining of the cornea does eventually resolve but may take time. Accidental injection of viscoelastic into the cornea during cataract surgery causing a bullous DD, if not identified, has been reported to have been mistaken for the lens capsule and Descemetorhexis performed on the detached DM instead of capsulorhexis. Viscoelastic may also find its way into the cornea and detach the DM during viscocanalostomy. Air injected purposely during Anwar’s big bubble deep anterior lamellar keratoplasty (DALK) creates a central bullous detachment that also includes the pre-Descemet’s layer when a Type 1 bubble forms. Sometimes, a Type 2 bubble forms while attempting the big bubble in DALK and this is a true bullous DD. 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

EU-CC-NP-0014

EUROTIMES | MAY 2019

11


12

SPECIAL FOCUS: CATARACT & REFRACTIVE

Life behind the lens Research honing in on PCO prevention through new surgical techniques and innovative lens design. Roibeard Ó hÉineacháin reports

N

ew IOL designs and surgical techniques suggest that there is the prospect of longer-lasting prevention of posterior capsule opacification (PCO) and include platforms that are likely to be amenable to the restoration of accommodation, said David Spalton MD, FRCS, in his HSIOIRS Kelman Award Lecture, which he delivered at the 23rd ESCRS Winter Meeting in Athens, Greece. “I think we are going to see new intraocular lens designs which will modulate and control PCO. The open-bag concept has the possibility to leave us with a flexible bag in which we can place an accommodative lens,” said Prof Spalton, St Thomas’ Hospital, London, UK. Prof Spalton noted that much of his clinical research has concerned the study of PCO. In the early 1990s, he and his associates developed a system at St Thomas’ Hospital for detecting and quantifying PCO. The project involved designing a special, state-ofthe-art retroillumination camera and developing a software program based on texture analysis, which initially had been developed for military imaging analysis to quantify the area of PCO behind the IOL optic. In 1994, Ekehard Mehdorn MD, Germany, reported his observation that eyes with Acrysof IOLs had a very low incidence of PCO. A subsequent study carried out by Prof Spalton and his team using their PCO analysis system confirmed Dr Mehdorn’s observation, showing that there was less PCO with the Acrysof lens compared to a similar silicone or PMMA lens. The reason for this was unknown until later research by Okihiro Nishi MD, Japan, demonstrated that it was the IOL’s square-edge that reduced PCO rather than the lens material. However, with time and longer follow-up it has become apparent that square-edged lenses delay but don’t prevent, PCO. There are now a range of approaches currently under investigation for preventing PCO in a more long-lasting manner, which include new surgical techniques and IOL designs. Most have their caveats and all will inevitably require long follow-up. EUROTIMES | MAY 2019

David Spalton delivering his HSIOIRS Kelman Award Lecture at the 23rd ESCRS Winter Meeting in Athens, Greece

POSTERIOR CAPSULOTOMY

OPEN-BAG CONCEPT

Rupert Menapace MD, PhD, Austria, has proposed “button-holing” the IOL optic behind a posterior capsulotomy. Although this is very effective in preventing PCO, many cataract surgeons are reluctant to open the posterior capsule, Prof Spalton said. Meanwhile, Burkhard Dick MD has proposed using the femtosecond laser to perform a posterior capsulorhexis at the end of a cataract procedure. Prof Spalton noted initial results are encouraging but pointed out that Albert Galand MD, Belgium, had used a posterior rhexis in the 1990s with ECCE to prevent PCO, but found that over time lens epithelial cells migrated over the surface of the anterior hyaloid and abandoned the technique.

The newest approach includes techniques that aim to prevent PCO by maintaining a separation between the anterior and posterior capsules, Prof Spalton said, originating from the fortuitous observation that eyes with the Synchrony accommodative lens remained remarkably free of PCO. The likely explanation for the PCO-preventive effect of this lens is that by preventing the anterior and posterior capsular leaves from sealing together, aqueous can irrigate through the capsular bag and wash out growth factors and cytokines, he noted. Several new IOL designs aiming to exploit this principle are now under investigation. They include systems where the IOL is implanted within an endocapsular ring that maintains capsular separation. There is also a lens from AnewOptic Inc, which has a circular disc haptic designed to separate the anterior and posterior capsule, which is now entering clinical trials. The open-bag concept has particular appeal in that it may provide a capsular bag free of PCO that maintains its flexibility for the newer types of lens that achieve accommodation through change of curvature. Examples of such lenses now in clinical trials include Powervision’s Fluidvision IOL and Lensgen’s Juvenal IOL.

SANDWICH THEORY Another approach is to prevent epithelial cells from proliferating by sandwiching the posterior capsule to the posterior lens surface – the ‘no space no cells’ concept. In their Vivinex IOLs, Hoya seek to achieve this through an ozone treatment of the posterior surface of the optic, rendering it more adhesive to lens epithelial cells. Animal studies look good, but clinical studies with the lens have so far not demonstrated any superiority over the Acrysof lens in terms of PCO prevention. Prof Spalton said longer-term follow-up is needed to see whether clinical results can confirm the animal work.

Prof Spalton is a stockholder in AnewOptic Inc. David Spalton: profspalton@gmail.com


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B i n kh o rst M e d al Lectu re E h u d A ss i a I S RA E L Th i n k i n g O u t s i d e t h e B ox

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P A R I S


P A R I S

3 7 TH C O N G R E S S O F T H E E S C R S 14 – 18 SEPTEMBER 2019

Saturday 14 September

Saturday 14 September

Saturday 14 September

Lunchtime Symposia

Lunchtime Symposia

Evening Symposium

Boxed Lunch Included

Boxed Lunch Included

18.15 – 19.45

13.00 – 14.00

13.00 – 14.00

MST Satellite Meeting Sponsored by

FEMTIS - Turn your Automated Capsulotomies into Great Vision Sponsored by

Ziemer Satellite Meeting

New Developments using Scheimpflug Technology in Cataract and Refractive Surgery

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Moderators: C. Roberts USA, M. Belin USA Sponsored by

Heidelberg Engineering Satellite Meeting Sponsored by

Sunday 15 September Lunchtime Symposia Boxed Lunch Included

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Quantel Medical Satellite Meeting

Glaukos Satellite Meeting

13.00 – 14.00 PhysIOL Satellite Meeting Sponsored by

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Bausch + Lomb Satellite Meeting

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Sunday 15 September

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Monday 16 September

Lunchtime Symposia

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18.15 – 19.45

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13.00 – 14.00 NIDEK Satellite Meeting Sponsored by

Targeting Refractive Outcomes Precision: Beyond the Innovations

INFOCUS: 2 Minutes to Enhanced OR Experience and Patient Selection! Debating the Topics Most Important to your Practice Moderator: A. Brezin FRANCE Sponsored by

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Presbyopia Correcting IOLs: Learning from Clinical Evidence Sponsored by

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Rayner Satellite Meeting Sponsored by

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13.00 – 14.00 NTC/Santen Satellite Meeting Sponsored by

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16

SPECIAL FOCUS: CATARACT & REFRACTIVE

Poster Prizes Winners in 23rd ESCRS Winter Meeting competition provide new insights in secondary cataract and refractive procedures. Roibeard Ó hÉineacháin reports

Above left: Ioannis Tzamichas accepting the award for Best Cataract Poster from Vikentia Katsanevaki and Thomas Kohnen. Above right: Apostolos Lazaridis, on behalf of Florian Schraml, accepting the award for Best Refractive Poster from Dr Katsanevaki and Prof Kohnen

S

tudies on intraocular lens power calculation and scleral IOL fixation won the poster awards at the 23rd ESCRS Winter Meeting in Athens, Greece. The prize in the Refractive category went to Florian Schraml, Philipps University of Marburg, Germany, for “Predictability of intraocular lens power calculation after SMILE for myopia”. The poster describes a study that included 204 eyes of 105 patients, who underwent IOL implantation following small-incision lenticule extraction (SMILE®) procedures. All eyes underwent preoperative evaluation with the IOLMaster® 500 (Carl Zeiss Meditec) and corneal tomography using Pentacam HR (Oculus). At three months’ follow-up Dr Schraml and his associates compared the difference between the predicted preoperative and postoperative IOL power – as predicted by ray tracing using Oculogix software, and third- and fourth-generation IOL calculation formulas – and the change of sphere as determined by manifest refraction. They found that the IOL power difference as predicted with ray tracing and the fourth-generation Haigis L formula showed no significant differences compared to the change of sphere. In contrast, the IOL power difference as predicted with all other formulas showed significant difference compared to the sphere difference. Moreover, the prediction error was significantly smaller with ray tracing compared to the third- and fourthgeneration formulas. “Ray tracing takes into consideration the true shape of the cornea after refractive surgery Ioannis Tzamichas by using both the

Our proposed surgical methods depend on patients’ phakic status, and are safe and have favourable visual outcomes

EUROTIMES | MAY 2019

anterior and posterior central curvature radii and the asphericity of the surfaces. Moreover, it uses the central IOL, thickness, the index of refraction and the true geometrical position, as defined by the anterior chamber depth, to describe the IOL and calculate its power more accurately,” Dr Schraml concluded. The prize in the cataract category went to Ioannis Tzamichas, Ippokrateio General Hospital of Thessaloniki, Greece, for “Scleral fixation of dislocated 1-piece IOL without IOL explantation or intrascleral sutureless 3-piece IOL fixation: Florian Schraml making the right surgical decision”. The poster describes a retrospective consecutive case series of 22 patients who underwent scleral IOL fixation following complicated cataract surgery owing to insufficient zonular/capsular support. The study included seven aphakic patients who underwent transconjuctival intrascleral 25g-trocar-based sutureless fixation of a three-piece IOL. There were also 17 pseudophakic patients who underwent transscleral 9-0 polypropylene fixation of the dislocated one-piece IOL without IOL explantation. At a mean follow-up of approximately one year, mean visual acuity improved from hand movements to 0.8 among the seven aphakic patients, and from 0.05 to 0.63 among 17 pseudophakes with dislocated IOLs. There were no major ocular complications in either group. “Our proposed surgical methods depend on patients’ phakic status, and are safe and have favourable visual outcomes. Both procedures are time- and cost-efficient, a non-negligible factor taking into account the financial crisis in Greece that has dramatically affected public healthcare services,” Dr Tzamichas concluded.

Ray tracing takes into consideration the true shape of the cornea after refractive surgery


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18

SPECIAL FOCUS: CATARACT & REFRACTIVE

Cataract surgery and vitrectomy Cataract surgery safe and effective in vitrectomised eyes but complications more common. Roibeard Ó hÉineacháin reports

W

ith appropriate surgical technique, cataract surgery following vitrectomy can be safe and effective with refractive outcomes similar to those achieved in non-vitrectomised eyes, although the underlying retinal pathology may limit visual acuity and increase the risk of complications, Dimitrios Chiras MD, PhD, FEBO, Moorfields Eye Hospital, London, UK, told the 23rd ESCRS Winter Meeting in Athens Greece. In a retrospective study, Dr Chiras and associates analysed data from consecutive patients undergoing cataract surgery between January 2015 and August 2017. Patients without postoperative visual acuity data were excluded. The study included 149 vitrectomised eyes and 608 non-vitrectomised eyes (reference group) in whom they compared bestcorrected visual acuity, refractive outcomes and intraoperative and postoperative complications The indications for pars plana vitrectomy were retinal detachment in 111 (74%) eyes, macular hole in 18 (12%) eyes, epiretinal membrane in 13 (9%) eyes, vitreomacular traction in three (2%) eyes, diabetic retinopathy in two eyes (1%), floaters in one (0.7%) eye and injury in one eye (0.7%). Consultants performed the cataract surgery in 73% of the vitrectomised eyes and in 48% of the non-vitrectomised eyes. Fellows performed the remaining surgeries.

SIMILAR REFRACTION BUT LOWER VISUAL ACUITY IN POST-VITRECTOMY EYES Dr Chiras and his associates observed no significant difference between the refractive outcomes of the two groups. Three weeks after surgery, refraction was within 1.0D of target in 88.6% of the prior vitrectomy group and 89.8% of the reference group. Refraction was within 0.5D in 65.8 % of the prior vitrectomy group and in 63% of the reference group. EUROTIMES | MAY 2019

However, vitrectomised eyes had significantly worse preoperative and postoperative visual acuity than the nonvitrectomised eyes, which was related to the pre-existing retinal pathology requiring vitrectomy, Dr Chiras said. The preoperative logMAR visual acuity in eyes that had undergone previous vitrectomy was 0.7 compared to 0.4 in the reference group (p<0.0001) and the postoperative visual acuity was 0.15 vs 0.09 (p=0.014). On the other hand, postoperative visual acuity was 6/12 or better in 79.9% of the prior vitrectomy group and 89.3% in a reference group. Furthermore, postoperative visual acuity was improved compared to preoperative values in 96.6% of the prior vitrectomy group and 91.4% of the controls.

MORE CME AND PCO IN VITRECTOMISED EYES Regarding intraoperative complications, there were two (1.3%) cases of zonular dialysis in the prior vitrectomy group, seven (1.1%) cases of anterior capsule tear and six (1%) cases of capsule rupture in the nonvitrectomy group. During follow-up there was a higher incidence of postoperative cystoid macular oedema (4% vs 1.5%, p=0.046) in the vitrectomised eyes. The rate of posterior capsule opacification was significantly higher in vitrectomised eyes (6% vs 0.7%, p<0.0001). The vitrectomised eyes also had a higher incidence of postoperative ocular hypertension (1.3% vs 0.2%) and retinal detachment (1.3% vs 0%), but a lower incidence of anterior uveitis. “A close postoperative follow-up is recommended for vitrectomised eyes, considering the higher incidence of cystoid macular oedema and posterior capsule opacification. Prospective studies including randomised controlled trials could help to analyse the relationship between previous vitrectomy and the development of cystoid macular oedema after cataract surgery and identify possible prophylactic options to reduce this risk,” Dr Chiras said.

A close postoperative follow-up is recommended for vitrectomised eyes, considering the higher incidence of cystoid macular oedema and posterior capsule opacification Dimitrios Chiras MD, PhD, FEBO Dr Chiras noted that cataract surgery in post-vitrectomised eyes has become more common in recent years. However, it is challenging and the percentage of eyes achieving postoperative vision greater than 6/12 has varied in previous studies. There are also contradictory reports regarding the safety of phacoemulsification in vitrectomised eyes.

LIMITATIONS OF THE STUDY Limitations of the present study were that it was retrospective, used Snellen visual acuities to calculate logMAR visual acuity and had different durations of follow-up, Dr Chiras said. “Based on our results, we can say that although cataract surgery is challenging, with careful consideration of multiple factors before, during and after surgery, an experienced cataract surgeon can adapt their technique to avoid complications and ensure the safest outcomes. However, the underlying pathology and other factors may compromise visual outcomes,” he concluded. Dimitrios Chiras: d.chiras@nhs.net


SPECIAL FOCUS: CATARACT & REFRACTIVE

Implant offers improved UNVA Bifocal intracorneal implant offers ‘mostly’ spectacle-free everyday life. Roibeard Ó hÉineacháin reports

SPARKtacular features in one device New OCULUS Smartfield

T

he monocular implantation of the Presbia Flexivue Microlens bifocal intracorneal inlay can provide presbyopes with a significant improvement in uncorrected near vision (UNVA), at the expense of some loss of monocular uncorrected UDVA and contrast vision, according to the results of prospective, controlled, clinical trial, presented by Thomas Kohnen MD, PhD, at the 23rd ESCRS Winter Meeting in Athens, Greece. “Patients report a mostly spectacle-free everyday life because of unchanged binocular UDVA,” said Prof Kohnen, Goethe-University, Frankfurt, Germany. In the study, 25 emmetropic patients with presbyopia requiring a 1.5D to +3.0% D add for near vision underwent placement of the corneal inlay in the nondominant eye. Their preoperative uncorrected UDVA was logMAR -0.08 in the study eye. The inlays were inserted into a pocket in the corneal stroma created with a femtosecond laser. The implant has a central zone free of refractive power for distance vision and a peripheral zone with a standard positive refractive power to provide corneal multifocality. Throughout the six months of followup, the eyes with the intracorneal implant had significantly better uncorrected near visual acuity (UNVA) than their fellow eyes. That is, in eyes with the implant, mean UNVA was logMAR 0.21 at one week, 0.16 at one month and three months and 0.13 at six months. The UDVA Thomas Kohnen MD, PhD remained unchanged in the eye without the implant. However, UDVA eyes with the implant were statistically significantly worse, which was logMAR 0.22±0.15 at one month and 0.19 at three months, 0.24±0.17, compared to around logMAR -0.1 throughout follow-up in eyes without the implant. The eyes with the implant also had poorer contrast sensitivity than their fellow eyes. On the other hand, uncorrected binocular distance visual acuity remained stable throughout follow-up.

GOOD CORNEAL CLARITY Prof Kohnen cautioned that two patients had their implants taken out. Following explantation of the IOL, there was a light stromal haze with reduced visual acuity. However, the haze cleared up over time and the patients now have good corneal clarity, Prof Kohnen said. He suggested that an ideal candidate for this implant would be would be a presbyopic patient, 45-to-55 years old with a clear crystalline lens in whom it could afford a good 10-to-20 years of spectacle independence, after which they may consider using a lenticular approach to multifocality. “At the moment we have no poor outcomes, we have 23 patients who still have this lens and are happy with this lens,” Prof Kohnen said.

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Thomas Kohnen: kohnen@em.uni-frankfurt.de EUROTIMES | MAY 2019

19


20

SPECIAL FOCUS: CATARACT & REFRACTIVE

JCRS Symposium 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

THOMAS KOHNEN European Editor of JCRS

JCRS HIGHLIGHTS VOL: 45 ISSUE: 3 MONTH: MARCH 2019

CATARACT SURGERY POST-VITRECTOMY Prediction of refractive outcomes after cataract surgery in patients who have undergone vitrectomy is challenging. US researchers evaluated outcomes in a retrospective case series review involving 61 eyes of 57 patients with a mean age of 60 years. Indications for vitrectomy included macular hole, macular pucker, vitreous haemorrhage, retinal detachment, proliferative diabetic retinopathy with vitreomacular traction and visually significant vitreous debris with bleb-associated endophthalmitis after treatment with intravitreal antibiotics. Statistically significant differences between the predicted and actual refractive outcomes were found with all of the formulas used, except the WKA Holladay and WKA SRK/T. The Holladay 2 had the highest percentage of outcomes within 0.5D of predicted, at 60.42%. Given the variability in predicting refractive outcomes, patients should be counselled accordingly, the researchers conclude. T Lamson et al., “Refractive outcomes of phacoemulsification after pars plana vitrectomy using traditional and new intraocular lens calculation formulas”, Volume 45, Issue 3, 293-297.

CAPSULORHEXIS COMPARISON IN WHITE CATARACTS 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

Femtosecond laser-assisted cataract surgery (FLACS) may be the best option in white cataract cases, a prospective study suggests. The study compared conventional phaco surgery and FLACS in 132 eyes of 132 patients (66 in each group). Anterior capsule tears were significantly more common in the conventional group than the FLACS group (12.1% versus 0%). Six FLACS cases developed incomplete capsulotomies. Capsulotomy produced better circularity index and diameter stability than capsulorhexis. IOLs were better centred in the FLACS group than the conventional group. The mean ultrasound power, absolute phaco time, effective phaco time and postoperative visual acuities were similar in both groups. Y Zhu et al., “Lens capsulerelated complications of femtosecond laser-assisted capsulotomy versus manual capsulorhexis for white cataracts”, Volume 45, Issue 3, 337-342.

MICROSTENT AND CATARACT SURGERY Implantation of a trabecular micro bypass stent in glaucoma patients undergoing cataract surgery provides substantial, durable and safe IOP reductions, a five-year prospective study concludes. The study included 65 eyes of 43 patients with open-angle glaucoma or ocular hypertension. Among eyes without additional glaucoma surgery, the mean year-five IOP decreased by 38% to 14.7mmHg ± 3.0. Some 92% of eyes had a mean year-five IOP of 18mmHg or lower and 65% had an IOP of 15mmHg or lower. Medications were reduced by 75% to 0.5 ± 0.9 medications versus 2.0 ± 1.0 preoperatively, with only 4% of eyes on three-to-four medications versus 28% preoperatively. More than twothirds of cases were medication-free versus 5% preoperatively. Safety was favourable throughout the follow-up. T Neuhann et al., “Long-term effectiveness and safety of trabecular micro bypass stent implantation with cataract surgery in patients with glaucoma or ocular hypertension: Five-year outcomes”, Volume 45, Issue 3, pages 312–320.

May 3–7, 2019 | San Diego, California, USA JCRS is the official journal of ESCRS and ASCRS

EUROTIMES | MAY 2019


CORNEA

21

Drug helps relieve DRY EYE New drug promotes corneal healing, reduced symptoms in phase II study. Howard Larkin reports

IMPROVED SIGNS AND SYMPTOMS The four-week phase II study compared 76 ITT patients treated TID daily with BRM421 drops to 75 receiving a treatment vehicle placebo after a washout period to eliminate the placebo effect. BRM421 was safe and well-tolerated, with adverse ocular and non-ocular adverse events similar in the treatment and placebo groups, and no serious adverse events or adverse event-related withdrawals were reported, Dr Prabhakar said. After four weeks, the differences between the two groups failed to reach statistical significance for the two primary endpoints of corneal repair as measured by fluorescein staining

Courtesy of Uma Prabhakar PhD

A

first-in-class topical drug that promotes corneal healing significantly reduced clinical signs and symptoms of dry eye, particularly in patients with moderateto-severe disease, in a phase II clinical trial, Uma Prabhakar PhD told the 2018 American Academy of Ophthalmology Annual Meeting in Chicago, USA. A 29-amino acid synthetic peptide derived from pigment epitheliumderived factor (PEDF), BRM421 (BRIM Biotechnology, Taipei, Taiwan) is biologically active in many parts of the body, and promotes tissue regeneration at the ocular surface, Dr Prabhakar said. It has been shown to promote growth and expansion of limbal epithelial stem cells after wounding in both mice and rabbits, and suppresses desiccationinduced inflammation, reducing inflammatory factors, including interleukin, tumour necrosis factor and MCP-1 protein, on the ocular surface in a mouse model. It may also reduce the effects of damage-associated molecular pattern proteins (DAMP) displayed by damaged corneal cells that stimulate non-infectious inflammation that drives and worsens dry eye disease, she added.

The vicious cycle of corneal damage in dry eye disease

...BRM421 interrupts the dry eye vicious cycle and has the potential to control inflammation induced by DAMP, reducing subsequent tissue oedema and damage Uma Prabhakar PhD

score and ocular discomfort score, Dr Prabhakar reported. However, BRM421 showed significant improvement in several secondary efficacy measures. These included prolonging tear film break-up times (p=0.0339), relief of burning after one week of treatment (p=0.0411) and improvement in visual function for reading (p=0.0312) and working with a computer or ATM (p=0.0124). In a subgroup comparison of 22 treated and 22 placebo patients with moderateto-severe dry eye, the primary endpoint of repair of corneal damage as measured by fluorescein corneal staining was

reached after 14 days of treatment (p=0.0248), and dryness scores were significantly improved (p=0.0085), Dr Prabhakar noted. By promoting corneal healing, BRM421 interrupts the dry eye vicious cycle and has the potential to control inflammation induced by DAMP, reducing subsequent tissue oedema and damage, Dr Prabhakar said. Clinical data so far suggest it may be especially useful for treating moderateto-severe dry eye syndrome. Further trials are planned. Uma Prabhakar: umaprabhakar1@gmail.com EUROTIMES | MAY 2019


CORNEA

Cornea research advancing thanks to EU funding Collaboration can generate tangible results. Cheryl Guttman Krader reports

T

he Network of Excellence in Corneal Regeneration (NExCR) managed by the COST (European Cooperation in Science and Technology) Action BM1302 “Joining Forces in Corneal Regeneration Research” officially ended in 2017. However, by serving as the foundation for developing a new generation of cornea specialists interested in regenerative medicine, fostering growth in knowledge and being the impetus for additional research initiatives, its impact endures. The idea to seek COST funding to link researchers and accelerate progress in the field of corneal regeneration originated with Claus Cursiefen MD, PhD, Cologne, Germany, Martine Jager MD, Leiden, the Netherlands, and Nadia Zakaria PhD, Antwerp, Belgium. Ultimately, groups from 21 countries participated in NExCR, and the four-year project is being deemed highly successful because of the opportunities it provided for training young scientists and for promoting scientific information exchange. Beyond those achievements, however, NExCR became the springboard for new

NExCR brought together scientists who were working in isolation and allowed us to skill-share at a level that was not possible before Sorcha Ní Dhubhghaill MD, PhD EUROTIMES | MAY 2019

Courtesy of Neil Lagali PhD

22

The ARREST BLINDNESS project consortium at the 4th Annual Project Meeting in Rome in February 2019

ideas and success in securing additional funding, including for two important new projects — ARREST (Advanced Regenerative and REStorative Therapies to combat corneal) BLINDNESS, which is supported by a grant of nearly €6 million from the HORIZON 2020 programme of the European Commission; and Aniridia: networking to address an unmet medical, scientific, and societal challenge (ANIRIDIA-NET), a four-year EU COST Action that is just getting under way. “NExCR brought together scientists who were working in isolation and

allowed us to skill-share at a level that was not possible before. But while there is certainly value in being able to network with colleagues, it is more important for the collaboration to generate tangible results,” said Sorcha Ní Dhubhghaill MD, PhD, University of Antwerp, Antwerp, Belgium. “With limited resources available to fund healthcare research, it can be difficult to attract research money for cornea disease that unlike some other problems is not a matter of life or death. But vision impairment and loss have devastating consequences on quality of life, and by bringing together the expertise of


CORNEA

multiple players through NExCR, we have been able to successfully push for corneal blindness to get the attention it deserves.”

ARREST BLINDNESS Led by Neil Lagali PhD, Linköping University, Linköping, Sweden, ARREST BLINDNESS is a four-year research consortium of 12 partners in eight EU countries. It is a multifaceted programme that has as its main goal the development and validation in preclinical and first clinical studies advanced regenerative and restorative therapies to treat the loss of corneal transparency so that it does not result in blindness. More specifically, ARREST BLINDNESS is aiming to validate tissue-engineered GMP-compliant scaffolds based on natural materials; validate and optimise

new GMP-compliant cell-based therapies; and validate new molecular agents and drug-delivery approaches for restoring the neural and immune environment in order to prevent graft rejection. “The project includes four clinical studies applying new materials, imaging and cell therapies in the cornea. It is the first and largest HORIZON 2020-funded project in cornea research,” said Dr Lagali. “Cornea grafting is the oldest form of tissue transplantation and it has a lower rate of rejection than any other tissue or organ transplant surgery. Rejection still happens, however, and because people are living longer now than before, ideally we would like to see that a corneal graft can be viable for a person’s lifetime,” said Dr Ní Dhubhghaill.

ANIRIDIA-NET Under the leadership of Dr Lagali, seven partners from COST NExCR/ARREST BLINDNESS put together the proposal for COST Action ANIRIDIA-NET. The network, which is funded for 2019 to 2023, is open to European researchers to join. Now, it consists of 69 members in 24 European countries. Its goal is to promote scientific exchanges, collaborative research, harmonised protocols and pooling of samples and models to advance aniridia

Cornea grafting is the oldest form of tissue transplantation and it has a lower rate of rejection than any other tissue or organ transplant surgery Sorcha Ní Dhubhghaill MD, PhD

research and clinical practice. “Aniridia is a devastating congenital eye disease affecting the entire eye, leading to cataract, glaucoma, nystagmus and a progressive corneal stem cell deficiency,” said Dr Lagali. “A key focus of ANIRIDIA-NET is to develop novel diagnostics and treatments based on the latest developments in genomics, regenerative medicine, stem cells, investigational drugs, gene therapy, tissue engineering and transplantation.” “As NExCR was winding down, we reflected on its success in generating research articles, drawing attention to the field, and making inroads into corneal blindness. Wanting to not lose the momentum, several partners came together to identify a develop a plan to address another unmet need,” said Dr Ní Dhubhghaill. “Aniridia is a challenging disease for which there are few good treatments. Because it is a relatively rare condition, however, individual clinicians or single centres see only a small number of affected patients. The collaboration, networking and sharing opportunities afforded by the COST action should enable research progress that will result in benefits for aniridia patients.” Dr Lagali concluded: “In funding ARREST BLINDNESS and ANIRIDIANET, the European Commission has committed significant investments in promoting transnational collaboration in the area of cornea research. This research is making its way into the clinic to provide tangible benefits to patients.” Sorcha Ní Dhubhghaill: nidhubhs@gmail.com Neil Lagali: neil.lagali@liu.se

We‘ve made it! «After 4.5 years of development and countless hours of joy and hard work we can now spread the word that we have received the CE Certificate for our Sophi.» Sophi’s proud R&D team

www.sophi.info EUROTIMES | MAY 2019

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CORNEA

Infectious keratitis treatment New treatment protocols set to improve outlook in Russian infectious keratitis patients. Roibeard Ó hÉineacháin reports

A

failure to correctly diagnose the cause of infectious keratitis and the uncontrolled use of obsolete and ineffective treatments frequently results in eyes developing more severe disease in the Russian population, but authorities are taking steps to correct these problems, said Dmitry Yurevich Maychuk MD, PhD, DMSc, Svyatoslav N. Fyodorov State Institution Eye Microsurgery Complex, Moscow, Russian Federation. Speaking at a Cornea Day Ulcer caused by Pseudomonas aeruginosa, three days after onset. Untreated condition (Top Left). Severe fibrosis after adenoviral conjunctivitis (Top right). session of the 23rd ESCRS Meeting, Removal of pseudomembrane from the upper eyelid in case of acute in Athens Greece, he noted as an adenoviral conjunctivitis (Above) example that acanthamoeba keratitis has such a low incidence in Russia that when it does occur physicians often fail to Another problem for patients with recognise its early symptoms. As a result, contact lenses is the low usage of modern patients referred to hospitals are often at a antibiotics in cases of acute bacterial more advanced stage of their disease. ulcers caused by pseudomonas aeruginosa. Again, physicians fail to recognise the condition and treat it with older agents like CONTACT LENSES chloramphenicol or ofloxacin, which does The condition is virtually always associated not stop the corneal melt. However, updated with extended-wear contact lenses, he said. national guidelines now recommend an Common treatments for acanthamoeba are aggressive treatment programme with the agents like voriconazole and fluconazole, use of newer antibiotics, particularly thirdbut they are not very effective. Dr Maychuk and fourth-generation fluoroquinolones. said he and his colleagues are trying to Another update in the national teach physicians to treat the condition guidelines has to do with the treatment more aggressively from the outset with of pseudomembranes, which occur in phototherapeutic keratectomy. EUROTIMES | MAY 2019

Courtesy of Dmitry Yurevich Maychuk MD, PhD, DMSc

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one-in-30 cases of adenoviral keratoconjunctivitis. Many ophthalmologists are afraid to remove them or think that they will resolve spontaneously once the infection is eliminated. However, severe fibrosis occurs in 2.1% of pseudomembranes. Therefore, removal of pseudomembranes is now included in the national treatment protocol for adenoviral keratoconjunctivitis. Paediatric ulcerative keratitis resulting from chronic blepharitis and allergic conjunctivitis is another condition that is often treated incorrectly in Russia, allowing the disease to advance to a more advanced stage. Parents often treat their children with the condition using over-thecounter antibiotics and antihistamines. By the time an ophthalmologist sees them they will have had the condition for 19 months, Dr Maychuk said. He noted that in a study of 148 children aged four-to-12 years with ulcers primarily of bacterial origin, 78% were positive with PCR smear for CMV and 42% were positive for HSV. He and his associates have a new treatment protocol that is a viral systemic therapy involving topical steroids and topical cyclosporine that has had good results so far, without any signs of recurrences. Dmitry Yurevich Maychuk: maychuk@mail.ru


10th EuCornea Congress

13 – 14 September 2019 | Paris Expo Porte de Versailles

2 Days 7 Courses 8 Focus Sessions 4 Free Paper Sessions EuCornea Medal Lecture Friday 13 September | 10.30 – 11.30 (At the Opening Ceremony)

“Clinical Corneal Research: Why it is Important to get Involved” Sadeer Hannush USA

Scientific Programme, Registration & Hotel Bookings www.eucornea.org


RETINA

Anti-VEGF therapy Reducing endophthalmitis risk with intravitreal injections. Dermot McGrath reports

EUROTIMES | MAY 2019

400 350 300 250 200 150 100 50 0

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Year Bevacizumab

Ranibizumab

Aflibercept

Source: Parikh, et al. “Trends of anti-vascular endothelial growth factor use in ophthalmology among privately insured and medicare advantage patients.” Ophthalmology 2017

“In fact, this is the only intervention that has been demonstrated by a randomised controlled trial to reduce the risk of postoperative endophthalmitis,” noted Dr Grzybowski. Chlorhexidine may also be used for patients that are sensitive to PVI, although it is known that chlorhexidine is a much weaker antiseptic agent, and it should be remembered that true PVI allergy is unique and commonly overestimated. By contrast, perioperative antibiotics are not recommended as part of the guidelines, with pooled estimates of the risk of endophthalmitis after IVI found to be three times higher when they were used. “There is no evidence that topical antibiotics lower endophthalmitis rates after intravitreal injection. And as we are all aware, frequent use of topical antibiotics promotes increasing antibiotic resistance and growth of pan-drug-resistant bacteria, which might lead to more severe cases,” said Dr Grzybowski. Use of an eye speculum is also recommended during the procedure. “Any effective way to avoid lid closure during the procedure is justified, and ideally we should use a sterile speculum. It has also been reported that the instillation of additional povidone-iodine antisepsis after placement of the lid speculum decreases the incidence of endophthalmitis compared with other tested protocols,” he added. With most patients preferring sameday bilateral injections and an estimated 46% of ophthalmologists in a recent US study performing bilateral IVI, appropriate

measures should be taken to minimise the risk of endophthalmitis, said Dr Grzybowski. “It is important to remember to treat each injection as a separate procedure and not to reuse any equipment,” he said. A recent study published in the American Journal of Ophthalmology found a 0.027% rate of endophthalmitis in 102,932 injections with no increased risk of infection from bilateral injections, added Dr Grzybowski. While there is no significant evidence that the use of sterile gloves or drapes reduces endophthalmitis rates or adverse events, the use of gloves, either sterile or non-sterile, is consistent with modern practice combined with hand washing before and after patient contact, he said. The use of face masks is highly recommended, however, with a zerotalking, sneezing and coughing policy also advisable, said Dr Grzybowski. It was recently shown that the use of lidocaine jelly or Tetravisc might increase the endophthalmitis rate in IVI. There is increasing accumulation of evidence that low concentrations of PVI, between 0.25-1.25%, are as effective as 5%. PVI, however, must be used more often. Lower concentrations are much better tolerated, and rarely irritate the ocular surface. However, the precise procedure of low-concentration PVI use, including contact time, number of repetitions, etc, still needs to be established. Andrzej Grzybowski: ae.grzybowski@gmail.com

Courtesy of Andrzej Grzybowski MD, PhD

W

ith intravitreal injections now one of the most commonly used ophthalmic procedures, there are certain straightforward measures that can be taken to reduce the risk of post-intravitreal injection-related endophthalmitis, Andrzej Grzybowski MD, PhD, told delegates attending the 9th EURETINA Winter Meeting in Prague. Recent years have seen an enormous increase in the number of intravitreal injections as anti-VEGF agents such as ranibizumab, bevacizumab, and aflibercept have become standard-of-care treatment for AMD and other retinal diseases. The reported cumulative endophthalmitis incidence related to intravitreal injections (IVI) is around 0.048% based on different studies carried out between 2011 and 2018, although there is disparity between different studies, noted Dr Grzybowski, Professor of Ophthalmology, Chair of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland, and Head of the Institute for Research in Ophthalmology, Poznan, Poland. “One study from Denmark shows a zero endophthalmitis rate, although that was based on a case series with quite low numbers of intravitreal injections of around 20,000. Two other studies, by Casparis et al. in 2014 and Freiberg et al. in 2017, both reported rates of endophthalmitis of 0.0075% and 0.0074% that were six or seven times lower than the other studies,” he said. There seems to be no increased risk based on the choice of agent, said Dr Grzybowski. This was shown in a study by Rayess et al. in 2016, which concluded that endophthalmitis following intravitreal bevacizumab, ranibizumab and aflibercept injection appears to occur at similar rates and have comparable visual outcomes. Dr Grzybowski and colleagues recently published expert consensus recommendations to guide members in their use of IVIs. In terms of the ideal clinical setting, operating theatre, adequate room or in-office settings are all recommended. “There has been a bit of controversy about the ideal setting for administering injections. However, recent literature confirms that office-based and in particular OR-based injections have very low endophthalmitis incidence,” he said. It is also advised to administer 5% povidone-iodine antisepsis for a minimum of 30 seconds.

Rate per 1,000 patients

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RETINA

Evolution of CNV imaging OCT invaluable in tracking choroidal neovascularisation. Dermot McGrath reports

O

ptical coherence tomography is an extremely valuable imaging modality that complements traditional fluorescein angiography (FA) in the diagnosis and management of choroidal neovascularisation (CNV) in age-related macular degeneration (AMD), according to Karen B. Schaal MD, FEBO. “Spectral domain OCT (SD-OCT) and OCT angiography can help us to make the right diagnosis at an early stage in the disease process and to be able to identify the tell-tale signs of CNV activity as well as differentiate different lesion types, which will help determine the most appropriate course of treatment,” she said speaking at the 9th EURETINA Winter Meeting in Prague. Dr Schaal, University Hospital of Bern and Vista Diagnostics Zürich, said that OCT greatly facilitates understanding of the differences between classic and occult lesion types, retinal angiomatous proliferation (RAP) and disciform scars in the natural course of the disease and to gauge the response to antivascular endothelial growth factor (VEGF) drugs. SD-OCT is also very useful to help differentiate outer retinal tubulation (ORT), intraretinal fluid (IRF) or so-called (pseudo)cysts, said Dr Schaal. “It is important to be able to tell the difference as ORT features are not a sign of exudation and do not require anti-VEGF treatment. A (pseudo)cyst does not have an external limiting membrane (ELM) and it is usually located above the outer nuclear layer, whereas ORT always has an ELM, is located in the outer nuclear layer and has a distinctive hyper-reflective band,” she said. The importance of identifying different lesion types has become more apparent in recent years, noted Dr Schaal. “In the early days of anti-VEGF treatment this didn’t matter so much. We usually just looked for signs of lesion activity and treated the patient on that basis. Now, with years of experience of anti-VEGF therapies we know that different lesion types behave differently and require different treatment strategies,” she said. Recent studies have shown that combined FA/OCT grading is capable of identifying a higher frequency of type 3 RAP lesions and a lower incidence of type 2 classic lesions than found previously in the scientific literature. This is significant because type 3 lesions typically follow a more severe disease course compared to type 1 and 2 lesions, she explained. “We can usually expect a good response of type 3 lesions to antiVEGF treatment if diagnosed early with a good visual prognosis. The patients in general are older than the average AMD age and they carry a high risk for atrophy, almost always associated with subretinal drusenoid deposits. It is a bilateral disease and it also carries a higher risk for cardiovascular events,” she concluded. Karen B. Schaal: Karen.schaal@vista.com

In the early days... we usually just looked for signs of lesion activity and treated the patient on that basis Karen B. Schaal MD, FEBO

EUROTIMES | MAY 2019

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5-8 September 2019 Le Palais des Congrès Paris, France 15 Euretina Sessions 20 Free Paper Sessions 30 International Society Symposia 50 Surgical & Instructional Courses + Industry Sponsored Symposia Keynote Lectures Euretina Lecture

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Saturday 22 September

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RETINA

SEBASTIAN WOLF Editor of Ophthalmologica

A bright vision on illumination

OPHTHALMOLOGICA VOLUME 241 ISSUE 3

HIGHER INCIDENCE OF RVO IN GLAUCOMATOUS EYES In a retrospective cohort study, a multivariate analysis of the records of 300 pseudoexfoliative (PXF) glaucoma patients and 300 non-PXF glaucoma patients yielded a significantly higher probability for retinal vein occlusion (RVO) when compared with 599 non-glaucoma non-PXF patients, with odds ratios of 2.29 and 3.03, respectively, and a p value of 0.005. The odds ratio for central RVO was especially elevated in the PXF and non-PXF glaucomatous groups, at 3.64 and 3.78, respectively (p=0.013). However, there was no significant difference between the PXF and non-PXF glaucoma groups regarding RVO (p=0.541), CRVO (p=0.092) or branch RVO (p=0.774). G Antman et al, “The Incidence of Retinal Vein Occlusion in Patients with Pseudoexfoliation Glaucoma: A Retrospective Cohort Study”, Ophthalmologica 2019, volume 241, Issue 3.

DURATION NOT AMOUNT OF ANTI-VEGF TREATMENT A PRIMARY RISK FACTOR FOR RPE ATROPHY The post-hoc analysis of 52 neovascular age-related macular degeneration (AMD) patients without baseline retinal pigment epithelium (RPE) atrophy, who were treated with nine or more anti-vascular endothelial growth factor (VEGF) injections for three or more years, showed that the onset of concomitant RPE atrophy was significantly associated with the duration of nAMD treatment (mean 5.34 years; odds ratio = 1.83, p=0.012) but not the number of injections of anti-VEGF, delay to the first treatment or baseline intraocular VEGF. V Sitnilska et al, “Onset of Retinal Pigment Epithelium Atrophy Subsequent to Anti-VEGF Therapy in Patients with Neovascular Age-Related Macular Degeneration”, Ophthalmologica 2019, volume 241, Issue 3.

GENDER DIFFERENCES FOUND IN CHORIORETINAL MICROVASCULATURE OF CHILDREN Both diabetic and non-diabetic male and female children have significant differences in their foveal avascular zone (FAZ) and retinal thickness, according to a new study. Optical coherence angiography (OCT-A) and structural OCT examination in 233 diabetic children and 62 healthy children showed that the deep capillary plexus FAZ area in boys was significantly smaller than in girls both in diabetics (p=0.0010) and healthy children (p=0.0302). The superficial capillary plexus FAZ area was significantly smaller in boys with diabetes compared to girls with the condition (p=0.0006), and compared to controls (p=0.0870). Central retinal thickness was significantly greater in diabetic boys than in diabetic girls (p=0.0001) and controls (p=0.1008). Niestrata-Ortiz M, “Sex-Related Variations of Retinal and Choroidal Thickness and Foveal Avascular Zone in Healthy and Diabetic Children Assessed by Optical Coherence Tomography Imaging”, Ophthalmologica 2019, volume 241, Issue 3.

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RETINA

Fundus autofluorescence Imaging helps to evaluate AMD, macular dystrophies, retinitis pigmentosa and other retinal disorders. Dermot McGrath reports

F

undus autofluorescence (FAF) imaging continues to offer a safe, non-invasive, easy-to-perform and reproducible diagnostic method that delivers useful information about retinal health and metabolism, according to Thomas Ach MD, FEBO. “FAF images are technically easy to acquire, take just a few seconds and are repeatable. They enable us to track patients over a long period and monitor disease progression and are still used as an endpoint in clinical trials,” he told delegates attending the 9th EURETINA Winter Meeting in Prague. Dr Ach explained that FAF uses the autofluorescent properties of tissues, in particular the retinal pigment epithelium (RPE) and its fluorophores. It can be used to evaluate diseases such as age-related macular degeneration (AMD), macular dystrophies, retinitis pigmentosa and various other retinal disorders. “It gives us a good indication of outer retinal health, with the loss of autofluorescence usually signalling a point of no return for retinal pigment epithelial (RPE) cells,” said Dr Ach, University Hospital of Würzburg, Germany. Lipofuscin, the term given to fine granules composed of lipid-containing residues of lysosomal digestion (though exact composition is still unknown), is one of the main sources of RPE autofluorescence, said Dr Ach. “Each RPE cell has hundreds of autofluorescent granules and they show a very characteristic retinal distribution in normal ageing. The exact mechanisms behind the accumulation of lipofuscin are still unclear and there is a lot of debate as to whether it is just a natural marker of age or an actual disease trigger in pathologies such as AMD,” he said. FAF allows visualisation of different stages of RPE transition in various diseases, from healthy to atrophic in histological slides, said Dr Ach. “We can clearly identify this transition zone, which can be referred to as ‘between heaven and hell’. Once an RPE cell is in

Courtesy of Thomas Ach MD, FEBO

30

Quantitative autofluorescence measurements allow comparison of AF values among subjects. AF increases with age. Warmer colours indicate higher AF

this transition zone and starts losing autofluorescent granules, as in AMD, it seems to go into atrophy and the RPE changes subsequently its phenotype,” he said. Another recent evolution of these imaging techniques, known as quantitative AF, has opened the door to measuring these degenerative changes in the retinal cells over time, said Dr Ach. “It allows us to compare autofluorescence intensities among subjects and at different time points in specific areas of the retina. We can use images from age-matched healthy controls that show that the qAF value increases with age based on the accumulation of lipofuscin. In diseases such as AMD the qAF values decrease due to intracellular granule re-organisation and loss of lipofuscin,” he explained. Another exciting area of research lies in analysis of AF emission tissue spectra of RPE, drusen and sub-RPE deposits, said Dr Ach. “On histology we see specific emission signals for sub-RPE deposits including drusen, which might be used as a possible marker for early AMD. Our current goal is to adapt this ex vivo technique into in vivo clinical imaging,” he reported. Thomas Ach: ach_t@ukw.de

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RETINA

Anti-VEGF vs PRP Which is best? Laser therapy still has its place in proliferative diabetic retinopathy treatment. Dermot McGrath reports

P

anretinal photocoagulation (PRP) remains the gold standard of initial therapy for proliferative diabetic retinopathy (PDR) and its neovascular complications despite a recent trend towards front-line use of anti-VEGF agents, according to Nigel Davies PhD, FRCOphth. “There is no medical need to replace PRP with anti-VEGF treatment alone. We need to remember that PDR is a severe and progressive disease. It is important to treat aggressively and to do the PRP properly,” he told delegates attending the 9th EURETINA Winter Meeting in Prague. Left untreated, PDR is a leading cause of blindness, with more than 50% of eyes with high-risk PDR experiencing severe vision loss within five years. Dr Davies, Consultant Ophthalmologist at Guy’s and St Thomas’ NHS Trust, London, United Kingdom, said that anti-VEGF agents should not be seen as a panacea for patients with diabetic retinopathy and PDR. “Anti-VEGF agents definitely have a role to play, but the future should involve personalised care for each patient. Ideally, we need further studies to help us understand which treatments or combinations work best at different stages of PDR in order to preserve the vision of our patients,” he said. A review of the scientific literature over the past decade underscores the utility of using combination PRP and anti-VEGF agents to limit the visual and anatomical damage from PRP, said Dr Davies. “What emerges is that the patients that had combination treatments with bevacizumab or ranibizumab did better than those that had PRP alone in terms of visual outcomes and control of their neovascularisation,” he said. The PROTEUS Study, which compared the efficacy of ranibizumab plus PRP versus PRP alone in patients with high-risk proliferative diabetic retinopathy over a 12-month period, found that combination treatment delivered better visual acuity and anatomical outcomes, said Dr Davies. Another important trial to note was

...we need further studies to help us understand which treatments or combinations work best at different stages of PDR in order to preserve the vision of our patients Nigel Davies PhD, FRCOphth

the DRCR.net Protocol S study, which evaluated the efficacy and safety of ranibizumab versus PRP over five years for PDR, said Dr Davies. “The findings were very interesting. Visual acuity outcomes were clearly better at two years and throughout the whole study period for the patients who had ranibizumab alone, and this was better for the patients who had diabetic macular oedema than for those who did not. The PRP group also seemed to do much worse in terms of their visual field outcomes. The anatomical results were about the same, with approximately 30% of patients without active or regressive new vessels at the end of the study period,” he said. Similar findings also emerged from the UK-based CLARITY trial in which patients with PDR who were treated with intravitreal aflibercept had an improved outcome at one year compared with those treated with PRP standard care. While the evidence from such trials may seem to undermine the rationale for PRP treatment in favour of anti-VEGF agents, Dr Davies said it was important not to rush to hasty conclusions. He cited a recent paper by Susan Bressler MD that looked at factors that led to worsening of diabetic retinopathy in Protocol S patients. “Some factors were ones we might have expected, with patients at high-risk of PDR doing worse than moderate-risk patients. In the PRP group, eyes that received pattern scan PRP were more likely to have PDRworsening events compared with eyes treated with conventional single-spot PRP,” he said. Possible explanations for the difference in efficacy include the type and number

of burns or total area of retinal ablation created by the laser, added Dr Davies. “With conventional laser, it's a longer pulse duration, the burn expands over a larger area and it is a denser burn, which makes the treatment more effective. With the pattern laser, the burn tends to contract, with a smaller treated area and a lighter burn and less effective treatment. On the whole you need between 50% and 75% more burns with pattern laser than conventional laser to get the disease under control,” he said. Dr Davies noted that the five-year drop-out rate of 34% overall for the Protocol S study was also relatively high. “Of those lost to follow-up, half had anti-VEGF injections and half had PRP. While we don’t actually know what happened to those lost to follow up, there is a recent paper from Obeid et al. at Wills Eye Hospital (Ophthalmology 2018 Sep;125(9):1386-1392) that might give some indication of what to expect if our patients return after more than six months without any treatment,” he said. The study found that eyes with PDR that received only intravitreal antiVEGF demonstrated worse anatomic and functional outcomes after being lost to follow-up compared with eyes that received PRP. “If a treated patient is lost for about a year despite previous treatment they will probably come back and their vision and anatomy will be worse. The Wills Eye Hospital evidence also indicates that patients treated with antiVEGF alone may do worse than those treated with PRP,” he concluded. EUROTIMES | MAY 2019

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WSPOS World Society of Paediatric Ophthalmology & Strabismus

SU B SP EC I A LT Y DAY Friday 13th September 2019 Preceding the 37th Congress of the ESCRS, 14 â&#x20AC;&#x201C; 18 September 2019

Registration & Scientific Programme Available www.wspos.org/subspecialty-day-paris-2019/


PAEDIATRIC OPHTHALMOLOGY

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Slowing myopia progression Strategies target different steps along the continuum to pathologic disease. Cheryl Guttman Krader reports

A

s the world faces an epidemic of high myopia and an increase in the number of people at risk for the blinding sequelae of pathologic myopia, research continues to focus on identifying strategies for preventing myopia and its evolution. Speaking at the 18th EURETINA Congress in Vienna, Gemmy Cheung MD provided an update on this topic. The first target for intervention would be to prevent a nonmyopic child from developing myopia, and there is definitely evidence to support recommending increased outdoor time for children, she said. Dr Cheung cited a study from Taiwan that demonstrated a reduction in the incidence of myopia after children were made to go outside the classroom during break time. In addition to increasing time spent outdoors, available evidence supports the safety and efficacy of both topical “ultra” low-dose atropine and orthokeratology. Dr Cheung said while atropine treatment was first demonstrated effective in the 1980s, it was not adopted because the 1% concentration that was being used caused photophobia and blurred near vision, leading to poor compliance. Now there is evidence from studies with up to five years of follow-up that 0.01% atropine is also effective, as well as safer and better tolerated than the 1% concentration. Based on this research, ultra low-dose atropine is being used in a lot of clinics and particularly in Asia to prevent myopia progression in children, she said. Nevertheless, there are some logistical challenges that are limiting its use. One obstacle is the absence of a commercially available licensed preparation. There are also questions to be answered about who should be treated, when to start and for how long treatment should continue. “We still are not sure of what is the perfect way to treat with atropine, and there is still a proportion of children who are poor responders and continue to progress despite atropine treatment,” Dr Cheung said. Discussing orthokeratology, she said that while it was originally thought that this approach involving overnight wear of a reverse geometric designed rigid gas permeable contact lens only provided temporary improvement in unaided vision, recent evidence and the findings of a metaanalysis suggest orthokeratology has long-term effects on refractive error and axial elongation. “The mechanism by which orthokeratology might work is not clear, but it has been suggested that the reshaping of the cornea reduces peripheral defocus leading to a lack of a stimulus for the eye to continue to elongate,” Dr Cheung said. She noted some interesting survey data showing that knowledge and uptake of orthokeratology is much higher among optometrists compared with ophthalmologists. Aiming to reduce peripheral defocus, strategies using a conventional contact lens or spectacle lens have also been investigated for their potential to prevent myopia progression. Such studies of these modalities are limited in terms of sample size and follow-up duration. Research to identify effective strategies for preventing progression from high myopia to pathologic myopia is also limited. So far, there is some evidence showing that in patients with myopic choroidal neovascularisation, treatment with anti-VEGF therapy reduces the development of macular atrophy.

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PAEDIATRIC OPHTHALMOLOGY

Preventing amblyopia SMILE is as effective as LASIK, easier for anisometropic children. Howard Larkin reports

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educed pain and dry eye after surgery make small-incision lenticule extraction (SMILE®) an attractive alternative to femto-LASIK for preventing amblyopia in anisometropic children who cannot tolerate patches or contact lenses, Mohamed MK Diab MD told the 2018 World Society of Paediatric Ophthalmology and Strabismus Subspecialty Day in Vienna. At first glance, performing corneal refractive surgery on very young patients seems like a mistake destined to cause problems as the children grow and their refractions change, Dr Diab noted. However, for severely anisometropic children, correcting the refractive imbalance early can prevent a far worse fate – amblyopia. For young children who cannot tolerate eye patches or contact lenses, refractive surgery may be the best available option, he added. Due to its refractive efficacy and painlessness relative to surface ablation, femto-LASIK has been the corneal procedure of choice for treating young children. However, the less-invasive SMILE procedure offers several potential advantages over LASIK including less pain, dry eye and injury risk due to flap dislocation after surgery. But is SMILE as effective and stable as LASIK over the long-term? To find out, Dr Diab and colleagues at Magrabi Eye Hospital in the Asser region of Saudi Arabia conducted a prospective study to evaluate how SMILE visual outcomes compare with

femto-LASIK six years after surgery. The study compared 105 eyes undergoing SMILE with 98 eyes undergoing femto-LASIK. SMILE procedures utilised a 6.5mm diameter lenticule with a 7.5mm cap and minimum thickness of 15 microns. All eyes were tested in follow-up for refractive efficacy, dry eye, optical aberrations and corneal biomechanics. Patient questionnaires evaluated dry eye symptoms, comfort and recovery time.

POSITIVE SMILE RESULTS Concerning safety, refractive predictability and efficacy, there was no statistically significant difference between the two groups, Dr Diab reported. One year after surgery, mean uncorrected visual acuity was -0.01±0.11 logMAR in the SMILE group and 0.02±0.12 in the femto-LASIK group. Both means remained stable at five years with -0.01±0.12 logMAR in the SMILE group and 0.05±0.13 in the femtoLASIK group. However, SMILE performed better in several other areas, Dr Diab noted. For one, wavefront aberrometry using the Topcon KR-1W showed significantly lower total higher-order aberrations induced in the SMILE group than in the LASIK group. This finding is consistent with other SMILE-LASIK comparisons, which have found a wider proportion of the optical zone in SMILE v LASIK, at about 80 and 69% respectively.

For another, minimal pain and postoperative discomfort resulted in higher patient satisfaction in the SMILE group. The smaller incision and lack of a flap that must be carefully cared for after surgery may help explain these findings. SMILE showed a clear advantage over femto-LASIK in dry eye. Schirmer’s test, tear film break-up time, corneal sensitivity and corneal regeneration all favoured SMILE, Dr Diab said. These results may be explained by the fact that the smaller SMILE lenticule cut of 2.0mm-to-3.0mm may leave more corneal surface nerves intact than a 20mm or so LASIK flap. However, Dr Diab noted both procedures prevent deep stromal nerves from reaching the surface. Since Bowman’s layer and the anterior lamellae remain intact after SMILE, the procedure may preserve corneal biomechanical strength better than LASIK, which is especially important for younger patients, Dr Diab said. However, the literature on this effect includes conflicting reports and is not conclusive. No significant changes were noted in endothelial cell density in the SMILE group, Dr Diab reported. “Five years after surgery, ReLEx® SMILE and femto-LASIK show equally good results in terms of safety, predictability and efficacy. However, no dry eyes were observed in the SMILE group compared to the femto-LASIK group. “Therefore, we clearly favour the ReLEx SMILE technique in patients who ask for painless refractive correction,” Dr Diab concluded.

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The patient-reported outcome is linked to clinical data in EUREQUO. This enables better knowledge of indications for surgery and offers a tool for clinical improvement work based on the patients’ outcome.

EUREQUO is free of charge for all ESCRS members


WCPOS V | 2020 5th World Congress of Paediatric Ophthalmology and Strabismus 2–4 October 2020 RAI Amsterdam, The Netherlands

Keynotes Friday 2 October 2020 David Mackey

AUSTRALIA

Non-Strabismus Keynote Lecture Genes and Environment: Towards Personalised Prevention of Myopia in Children

Saturday 3 October 2020 Burton Kushner

USA

Strabismus Keynote Lecture Forty-Five Years of Studying Intermittent Exotropia — What Have I Learned

Sunday 4 October 2020 Marie-José Tassignon

BELGIUM

Kanski Medal Lecture A Thing of Beauty is a Joy Forever

Nicoline Schalij MD Local Host President

www.wspos.org


36

GLAUCOMA

Predicting progression Contact lens sensor data may help, but prospective studies needed to clarify use. Howard Larkin reports

ESCRS

Glaucoma Day 2019 Friday 13 September Pavilion 7, Paris Expo, Porte de Versailles

E

merging evidence suggests that measuring circadian intraocular pressure (IOP) patterns with a contact lens sensor (CLS) could help identify glaucoma patients at higher risk of progression. But more work is needed to make it clinically useful, Arthur J Sit SM, MD told the Glaucoma Subspecialty Day at the 2018 American Academy of Ophthalmology Annual Meeting in Chicago, USA. In a recent multi-centre retrospective study involving 445 patients, a model based on 24-hour CLS IOP patterns correlated more closely with actual progression than did Goldmann tonometry readings obtained in clinic in the same patient population (De Moraes CG et al. JAMA Ophthalmol 2018; 136(7):779085). The CLS model was based on 55 variables in IOP patters as measured by a Triggerfish CLS over a 24-hour period, said Dr Sit, of the Mayo Clinic, Rochester, Minnesota, USA. The resulting CLS model correlated with fast progression rates, defined as visual field mean deviation slopes >1 dB/year, at R2=30.1%. By comparison, Goldman mean IOP measured directly during office hours correlated at R2=27.8%. Other retrospective studies have linked greater variation in CLS-measured Arthur J Sit SM, MD circadian IOP with faster progression in patients with closed-angle glaucoma (Tan et al. IOVS 2015) and normal tension glaucoma (Tojo N et al. J Glaucoma 2017; 26(3): 195–200). However, Dr Sit urged caution interpreting CLS-generated IOP data.

CLS measurements do not directly correlate to IOP measured by Goldmann applanation tonometry

A full day programme for cataract and refractive surgeons, on the latest developments and techniques in glaucoma.

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CLS DOES NOT MEASURE IOP While specific 24-hour CLS patterns are associated with progression, reproducibility of such CLS patterns varies widely, reducing the predictive power of the model overall. One study comparing two sets of 24-hour CLS readings from the same patients on different days found overall reproducibility of R=0.59, ranging from 0.80 to 0.20 for individual patients (Mansour K et al. Arch Ophthalmol 2012 Aug 13: 1-6). Moreover, CLS measurements do not directly correlate to IOP measured by Goldmann applanation tonometry, Dr Sit said. That’s because CLS does not measure IOP, but rather changes in corneal curvature resulting from corneal distension related to IOP changes. Nonetheless, studies show the pattern of IOP and CLS measurement and the timing of peaks correlate strongly (Mansouri K et al. PLoS One 2015;10(5): e0125530). However, the amplitude of the two measures do not (Liu et al. PLoS One 2015 June 15;10(6): e0129529). While this suggests CLS and IOP patterns are not equivalent, CLS may yet prove useful, Dr Sit said. “To really understand where [CLS data] fits into our clinical armamentarium, we are probably going to need prospective data.” Arthur Sit: sit.arthur@mayo.edu

EUROTIMES | MAY 2019


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38

OUTLOOK ON INDUSTRY

Expanding trifocal

technology

New sulcus-fixated trifocal IOL provides easy and reversible option for cataract patients and pseudophakes seeking spectacle independence. Roibeard Ó hÉineacháin reports

A

t a surgical skills programme held by Rayner at Ophthalmic Consultants of London, UK, leading ophthalmologists introduced the new Sulcoflex trifocal lens. Designed with the same diffractive optics as the RayOne trifocal, the Sulcoflex Trifocal is the successor of the Sulcoflex refractive multifocal. Like the other additive lenses of the Sulcoflex platform, the lens can be implanted at the time of cataract surgery in a duet procedure or at later time. And unlike capsule-fixated multifocal IOLs, the sulcus-fixated Sulcoflex lens can also be easily removed if necessary. “This lens is an additive lens, which means it is put into the eye in a pseudophakic situation. So, if you have a patient with some biometric surprise or something you can easily correct the refraction with sulcus-fixated add-on lens. That was the original idea of this lens platform, which is now more than 10 years old,” said Michael Amon MD, PhD, Head of the Academic Teaching Hospital of St John, and Chair of Ophthalmology at Sigmund Freud University, Vienna, Austria.

SIX-MONTH RESULTS Dr Amon has carried out a single-surgeon initial trial in which he performed duet implantation of a capsule-fixated IOLs and Sulcoflex trifocals in 40 eyes of 20 patients. The study showed that at a follow-up of six-months, patients had a mean Snellen decimal uncorrected visual acuity of 1.2 for distance vision, 1.05 for intermediate vision and 1.45 for near vision. He is also carrying out a trial involving the additive implantation of the Sulcoflex Trifocal lens in 40 pseudophakic eyes of 20 patients. As yet, the trial has not been completed, but as an example of the kind of results achieved so far, he presented the case of a 72-year-old pseudophakic woman who underwent bilateral implantation of the additive trifocal lens in September 2018. He noted that at the most recent follow-up visit the patient has a distance visual acuity and near visual acuity of 0.7 and J1, respectively, in her right eye, and 1.0 and J1 in her left eye. He added that the results in the right eye were less than optimal because of secondary cataract and he will soon be performing a YAG laser capsulotomy. EUROTIMES | MAY 2019

Mr Mark Hulbert (The St Albans Eye Care and Vision Centre) with Warwick Strand, Vice President Marketing at Rayner

SULCOFLEX PLATFORM Like the older Sulcoflex additive IOLs, the Sulcoflex trifocal is composed of Hydrophilic Rayacryl: HEMA-MMA copolymer, chosen for its high uveal and capsular biocompatibility. Moreover, optical bench studies show that the lens does not reduce the optical quality of the primary lens in the capsular bag, Dr Amon said. Sulcoflex lenses have a 14mm diameter with undulating


OUTLOOK ON INDUSTRY

Professor David Gartry (Moorfields Eye Hospital)

round-edged haptics and a 10-degree angulation that reduces the risk of contact with the posterior iris and pigmented epithelium. They have a round-edged 6.5mm optic to prevent optic-iris capture and reduce the likelihood of edge glare and dysphotopsias. In addition, the optic has a concave posterior surface to prevent contact between the IOL in the capsular bag and the Sulcoflex lens. Dr Amon noted that in a 12-year follow-up study of 200 eyes implanted with various types of IOLs in the Sulcoflex platform there were no cases of iris trauma, pigment dispersion, interlenticular opacification, pupil ovalisation or optic capture. In addition, in all eyes there was positive distance between the Sulcoflex lens and the iris and the optic of the IOL in the capsular bag. “The Sulcoflex Trifocal provides excellent visual acuity results across all distances, there were no intraoperative or postoperative complications and preliminary data from a large EU study support our data,” Dr Amon added.

rings within a 4.5mm diffractive zone, beyond which is a monofocal zone for distance vision. The lens has been developetd to be less dependent on pupil size or lighting conditions than older multifocal designs. With a 3.0mm pupil, it transmits 89% of light to the retina, allocating 52% of the light to the distance focus, 22% intermediate and 26% Brian Little MD to the near focus. “With its comfortable transition from near to distance activities the RayOne Trifocal improves intermediate visual acuity enabling patients to feel more comfortable transition from near to distances activities.”

...the clinician should engage the patient in clear, open and honest communication

RAYNER TRIFOCAL TECHNOLOGY

PATIENT SELECTION IS KEY

Patients implanted with the RayOne Trifocal IOL – which has the same diffractive profile as the Sulcoflex lens – can also achieve a high level of spectacle independence, said Allon Barsam MA (Cantab), MBBS, FRCOphth, who is a Director and Partner at Ophthalmic Consultants of London, UK. In a study in which Dr Barsam implanted RayOne Trifocal IOLs in 36 eyes of 18 patients, the average uncorrected binocular logMAR visual acuity was -0.07 for distance and 0.16 logMAR for near one month following surgery. In addition, 93% of patients achieved an intermediate visual acuity of N5 or better. Although all patients experienced mild night-time halos, none were disabling and all patients were happy with the lens. The RayOne trifocal lens has a 12.5mm overall haptic length and a 6.0mm diameter optic with an Amon-Apple enhanced squareedge for minimal PCO. In addition, its aberrationneutral aspheric trifocal optic has 16 diffractive

Appropriate patient selection is critical for success with multifocal IOLs. Therefore, the clinician should engage the patient in clear, open and honest communication and discuss the advantages and disadvantages of multifocality, explaining the need for a period of neuroadaptation, and the likelihood of some dysphotopsias, particularly in the early postoperative weeks, said Brian Little MD, London, UK. “Patients should be made aware of the multifocal IOLs option, but it is wise to undersell it and let the patient persuade you. Motivation for spectacle independence is paramount. If patients are happy with their reading glasses, they should stick with them,” Dr Little said When one is beginning with multifocal IOLs it is best to start with those patients who are most likely to have satisfactory visual outcomes, namely, presbyopic hyperopes. It is best to avoid the more complex case like low myopes’ eyes with high cylinder and extreme eyes. In addition, it is generally best to avoid patients with any serious ocular morbidities. “Know your patient’s needs and expectations, know your patient’s eye, know your favoured IOL and get comfortable doing the easy cases,” he summarised.

Know your patient’s needs and expectations, know your patient’s eye, know your favoured IOL and get comfortable doing the easy cases

Michael Amon: Michael.Amon@bbwien.at Allon Barsam: https://www.oclondon.com/contact-us/ Brian Little: eye.surgeon@me.com

Michael Amon MD, PhD EUROTIMES | MAY 2019

39


40

EXPLORING PARIS

Neuilly’s outdoor market

PARIS

3

TO HEAR ...

OPERA AND FINE DINING, IN PERFECT HARMONY For music with your meal consider Neuilly’s Bel Canto restaurant, where the waiters are students from the Paris Conservatoire. Several times each evening the waiters and waitresses break into song performing popular arias by Puccini, Verdi and Mozart. The restaurant is installed in a former mansion and designed as an intimate theatre with a grand piano under a crystal chandelier and with tables on two levels. The three-course menu offers a choice of starter, main course, cheese or dessert at a fixed price; €87, which includes the performance and service but not wine. Dishes can be adapted to dietary restrictions. It’s at 6, rue du Commandant Pilot, closed Sunday and Monday. www.lebelcanto.com

RECREATE THE BUZZ OF A PARISIAN CAFE IN THE COMFORT OF YOUR OWN HOME The French cafe as a home-from-home for the Parisian intellectual is part of the legend of the city. Hemingway and James Joyce, F. Scott Fitzgerald, Simone de Beauvoir, Jean-Paul Sartre – they all famously talked, argued and wrote in a cafe. Some might say it was because cafes were warm in winter and offered breezy terraces in summer. Others would say it was for the buzz. Though you may be miles away from Les Deux Magots, La Coupole or the Café de Flore, you can still enjoy the buzz. Brew yourself a very strong cup of coffee, settle comfortably at a table and open a notebook (even a digital one). The final touch? The ambient background sounds of a Paris cafe. For that simply click on http://bit.ly/ ET-ParisCafe. Or, if you’d prefer a table on the terrace, put on your headphones and enjoy these atmospheric binaural sounds: http://bit.ly/ET-ParisCafeTerrace

ENJOY THE SONG OF THE SPARROWS They may have been poor little sparrows at the beginning of their careers, but when they flew to the heights of fame and fortune both the ‘Little Sparrow’ Edith Piaf and the later ‘Sparrow of Avignon’, Mireille Mathieu, made their nests in Neuilly-sur-Seine. Listen to Mireille singing at http://bit.ly/ET-Mireille. For Edith Piaf’s greatest hits: http://bit.ly/ET-Edith. Over in the 15th arrondissement, the music to tune into would be the songs of Brassens, who lived in the neighbourhood all his life and whose memory lives on in the garden named after him: the Parc Brassens. Hear George Brassens on Spotify http://bit.ly/ET-Brassens

EUROTIMES | MAY 2019

Enjoy the far side Neuilly-sur-Seine proudly goes its own way, with restaurants new and old, writes Maryalicia Post The Palais des Congrès in Paris, which hosts this year’s EURETINA Congress, is a conference centre, a performance venue and a shopping mall. Opened in 1974 (and expanded in 1999) it attracts top entertainers, selective shoppers and some of the most well-attended conventions and meetings in the city. Part of its appeal to delegates is the centre’s easy access to the heart of Paris. The Champs Elysées, the Louvre, the Marais, are all just a few stops away on a direct Métro line or within minutes by taxi. A bonus is the neighbouring town of Neuilly-sur-Seine, only a 10-minute walk away on the far side of the Périphérique. One of the most upmarket suburbs of Paris, Neuilly enjoys a direct sight line down its main thoroughfare – Avenue Charles de Gaulle – from the Arc de Triomphe in the east, to the Grande Arche in the west. Tucked away from the weight of history at one end and the cutting edge of architecture at the other, bourgeois Neuilly proudly goes its own way, Like every small town in France, Neuilly has its outdoor market. The stalls are set up Wednesday, Friday and Sunday (07.30 to 13.30) on the Place de Marché. However, what will probably bring you to the area – unless you are a photographer, of course – is not the picturesque open market but the choice of restaurants. Neuilly residents don’t mind spending money on a meal but they do expect value in return. That’s why a restaurant like Le Sébillon has prospered in Neuilly since 1914. Oysters in season are the typical starter here, followed by the signature dish, roast lamb (all you can eat) served with creamy haricot beans. A decorous setting with white tablecloths and attentive waiters, Sébillon offers a set menu of three

courses for €45. Book online for lunch or dinner. www.sebillon.com Another good choice for a memorable meal is ‘Neuilly’s’, especially recommended if you enjoy seafood. This restaurant, his ‘life-long dream’, was established in 2015 by Didier Mader and his two sons Adrien and Antoine. The care with which food is selected, prepared and presented reflects their passion. There’s an outstanding wine cellar. The bistro is at 14 rue de Longchamp. Open for lunch and dinner Monday through Friday and Saturday evening. Closed Sunday. www.neuillys.fr For something casual, call in to the Café du Marché facing the market at 10 Place du Marché. Good food, pleasant service and a friendly atmosphere. Two courses here cost about €25. A glass of red wine is under €5. If there’s a football match, chances are it will be on the TV. Open daily from 06.00 to 24.00.

Le Sébillon, a Neuilly institution


INDUSTRY NEWS

FREE TO USERS OF RAYNER IOLS INDUSTRY

NEWS

Intelligent Refractor

NIDEK has announced the launch of the RT-6100 Intelligent Refractor. “The RT-6100 is a breakthrough refractor from NIDEK that enhances refraction workflow,” said a company spokesperson. “This refractor is designed to increase efficiency without compromising patient comfort. With a complete set of refraction functions, the RT-6100 provides the versatility for performing a quick refraction check to a comprehensive subjective refraction.” According to NIDEK, the combination of a streamlined refractor head and user-friendly control console allows exceptionally precise and quick examinations. NIDEK has also introduced two new system table models, the ST-6100 and ST-600. “The combination of these tables with the RT-6100 provides the COS-6100 and COS-610 Refraction Workstations for efficient workflow with seamless device connection,” said the NIDEK spokesperson. www.nidek.com

NEW INDICATION

FDA APPROVAL

ILUVIEN® has been approved for use in UK patients for the prevention of relapse in recurrent noninfectious uveitis affecting the posterior segment of the eye (NIU-PS). “This indication for ILUVIEN was based on data from two threeyear, double-masked, prospective shamcontrolled studies, PSVFAI-001 and PSV-FAI-005, in 282 patients with NIU-PS, randomised 2:1 (ILUVIEN:sham). Published data from the PSV-FAI-001 study have shown ILUVIEN to be superior when compared to treated sham for multiple study outcomes, including the primary outcome of recurrence of NIU-PS at six months (27.6% ILUVIEN vs 90.5% sham, p<0.001),” said a spokesman for Alimera Sciences, manufacturers of ILUVIEN. alimerasciences.com

Aerie Pharmaceuticals has announced that the US Food and Drug Administration (FDA) has approved Rocklatan™ to reduce elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension. “Rocklatan is a oncedaily eye drop that is a fixed-dose combination of latanoprost and netarsudil, the active ingredient in Rhopressa® (netarsudil ophthalmic solution) 0.02%, a Rho kinase (ROCK) inhibitor specifically designed to target the trabecular meshwork. Rhopressa works by restoring outflow through the trabecular meshwork, while latanoprost increases fluid outflow through the uveoscleral pathway,” said a company spokesman. www.aeriepharma.com

97

%

SCORE

3 YEARS OF PATIENT DATA REPORTS VISUAL OUTCOMES, PATIENT SATISFACTION, SPECTACLE INDEPENDENCE, PCO, AND MUCH MORE

rayner.com/RayPRO EUROTIMES | MAY 2019

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ASCRS is your trusted source for innovative education, philanthropy and advocacy â&#x20AC;&#x201C; for every stage of your career.

Join today: ASCRS.org


ESCRS NEWS

Caption

ESCRS

NEWS

Distinguished speakers at the ESCRS Academy in Kiev

New techniques ESCRS Academy meets in Kiev. Cédric Schweitzer MD reports

Following the invitation of Professor Oksana Vitovska, the current president of the Ukrainian Alliance of Ophthalmologists, and Dr Volodymyr Melnyk, an ESCRS Academy was organised at the annual meeting in Kiev (15-16 March 2019). The meeting covered the latest topics of cataract and refractive surgery and two sessions were run by the ESCRS Academy. Ukraine is a large country of Eastern Europe with approximately 40 million inhabitants and nearly 4,000 ophthalmologists. Since the recent tightening of the relationship between Europe and Ukraine, Ukrainian ophthalmologists have developed close educational programmes with European societies to provide the best standard of care for patients. Before the official meeting, an interactive discussion meeting was organised on March 14 between ESCRS Academy members and representatives of young Ukrainian ophthalmologists to share teaching experience of residents across Europe and give some advice to take benefit of available educational programmes and to optimise the learning process in ophthalmology. The plenary symposium of the ESCRS Academy was organised on the March 15. I gave a talk on the newest minimally invasive glaucoma surgery techniques associated with cataract surgery. Then, Prof Miguel Teus discussed indication and surgical techniques to improve alignment of toric intraocular lenses and to optimise refractive outcomes of patients following cataract surgery. Cataract surgery performed in eyes with poor corneal endothelium can be challenging and preoperative or postoperative management was proposed by Prof Christina Grupcheva. Prof David Spalton gave a talk on exfoliative syndrome from the pathophysiological process leading to the formation of exfoliative materials to the management of cataract surgery in such difficult cases. Prof Paul Rosen provided the latest recommendations following a dropped nucleus in cataract surgery and, finally, Prof Vladimir Pfeifer talked about available surgical techniques of intrascleral haptic fixation. The following day, a video session of “dilemmas in cataract surgery” was run and issues that can be currently observed during surgery were discussed interactively between ESCRS Academy members and the audience. This ESCRS Academy was a great experience and another opportunity to share the most recent recommendations in cataract and refractive surgery with participants and to meet our colleagues from Ukraine. EUROTIMES | MAY 2019

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EyeWorld has a new look ASCRS

ASCRS ASOA PROGRAM PREVIEW

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EyeWorld continues to feature articles on the latest in cataract, refractive, glaucoma, and cornea news, with an updated design and brand new logo.

digital.eyeworld.org


RANDOM THOUGHTS

Showcase your writing skills Judging of the 2019 John Henahan Prize has begun. Colin Kerr, Executive Editor Eurotimes, reports. “Writing is not life, but I think that sometimes it can be a way back to life.” – Stephen King, On Writing: A Memoir of the Craft

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s Executive Editor of EuroTimes, one of my favourite projects is organising the John Henahan Prize for young ophthalmologists, which has been running since 2008. The prize was named in honour of John Henahan, who edited EuroTimes, the official news magazine of the ESCRS, from 1996 to 2001. The purpose of the competition is to encourage young ophthalmologists to develop their writing skills, not only for professional purposes, but also to showcase their talents outside of ophthalmology. Since the competition was launched 11 years ago, ophthalmologists from all over the world have submitted essays in the hope of winning the prize and some have gone on to become regular contributors to EuroTimes. These include including Drs Soosan Jacob, Leigh Spielberg, Sorcha Ní Dhubhghaill and Clare Quigley. The topic for this year's essay, as decided by the ESCRS Publications Committee, was ‘How To Balance Ophthalmology And Family Life’. We received more than 60 essays, one of the highest number of entries ever recorded since the start of the competition, from 24 countries including Australia, Canada, China, Cyprus, France, Greece, Hong Kong, India and the United Kingdom.

DISTINGUISHED WINNERS As always, the judging panel will have a very difficult task choosing a winner, but whoever wins the prize will have the privilege of being added to the roll call of our distinguished former winners. The essays will be judged by Thomas Kohnen, chairman, ESCRS Publications Committee; Emanuel Rosen, chief medical editor, EuroTimes; José Güell, former president, ESCRS; Oliver Findl, chairman, ESCRS Young Ophthalmologists Committee; Sean Henahan, editor, EuroTimes; Paul McGinn, editor, EuroTimes; and Robert Henahan, contributing editor, EuroTimes. The judges will draw up an initial shortlist of the five best essays submitted and will then decide on the winning essay. The shortlisted essays will be published in the June and July issues of EuroTimes. The winner will receive a €1,000 travel bursary to the 37th Congress of the ESCRS in Paris, France, and will be presented with a specially-commissioned trophy during the ESCRS Video Competition Awards ceremony. I would like to thank everybody who entered this year's competition and remind you that even if you do not get shortlisted, there will be another opportunity to enter the 2020 John Henahan Prize. Colin Kerr is Executive Editor of EuroTimes and Project Manager of the John Henahan Prize

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EUROTIMES | MAY 2019

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46

PRACTICE MANAGEMENT

The patient experience

S

A masterclass in building a patient-centric ophthalmic practice that maximises profits

urgeons attending the ESCRS Practice Management Development Masterclass in Paris during the 37th Congress of the ESCRS will gain valuable insight to proven educational and financial strategies employed in both Europe and the US that are allowing physicians to maximise profitability by developing more patient-centric practices. This highly interactive and didactic workshop-based course will challenge attending surgeons to critically assess their effectiveness in various aspects of their clinics (see table below). Attendees will benefit from the global knowledge of Amanda Carones and Michael Malley, who will share ‘Best Practice Pearls’ gained from more than 40 years of combined front-line, in-office ophthalmic practice development for hundreds of practices around the world. Ms Carones is the Founder and CEO of Eligite SRL and Mr Malley is the President & Founder of TABLE 1) Physician time management 2) Practice profit margins 3) Patient education processes 4) Premium services planning 5) Staff conversion training 6) Practice culture commitment 7) Exit-strategy evaluation 8) Staff incentive strategies 9) Maximising surgeon production 10) Costs controls

EUROTIMES | MAY 2019

CRM Group, who recently celebrated their 30th year in ophthalmic marketing. Their expertise includes growth strategies for new and established practices, solo surgeons, university hospitals and corporate chains. “What Mike and I have learned over the years is that practice cultures may vary significantly from one practice to another but the challenges practices face is usually quite similar no matter their global location,” said Ms Carones. “At this year’s Masterclass, we will highlight the most common challenges practices of all sizes and locations encounter and share proven problem-solving implementation strategies,” she said. “This includes helping practices embrace an ‘inside-out’ mindset that focuses on maximising all operational components, patient education opportunities and staff efficiencies inside the practice before even considering external marketing strategies.” Surgeons will also learn time-tested techniques on maximising practice profits by gaining a better understanding of margins, cost evaluations, streamlining process, enhancing surgeon performance and pushing care to the lowest provider level. “Our workshop will unveil the secrets to maximising practice profits by addressing production obstacles on their most profitable procedures with the highest profit margins. When obstacles are removed, production goes up,” said Mr Malley. “In its most basic form, sustained growth and profitability for solo practitioners and larger multi-specialty

practices are as simple as maximising surgical production, streamlining practice processes and controlling overhead costs,” he added. “Because financial belttightening and surgeon efficiency training can be challenging at numerous levels, our course will provide case studies and stepby-step processes surgeons can take back for easy implementation in their practices.” Ms Carones also pointed out how preparing to attend this year’s ESCRS meeting in Paris is similar in many ways to preparing your practice for its journey ahead. “Before you start packing items that may be required for your trip, you first need to define the destination… and how you will get there. Then you can pack accordingly and more efficiently” she said. “Likewise, the first step to building a successful practice is defining goals: What type of practice do you want? What procedures will you offer? Who are your target patients? When properly planned, Ms Carones points out that a vacation can be the perfect opportunity to relax, reset and remind yourself how fortunate you are. “When a practice is properly set up and running efficiently from an operational standpoint, you start to focus on driving more business from your existing patients and eventually by attracting new patients,” she said. “You identify common patient barriers and strive to overcome them. You put yourself in your patients’ shoes and you experience your practice from their perspective. You build confidence and conversions. You make the patient experience enjoyable.”


CALENDAR

LAST CALL

MAY 2019

The 2019 SOE Congress will take place in Nice, France

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

JULY

Bulgarian Society of Cataract and Refractive Surgeons Traditional Conference May 18 Varna, Bulgaria https://st-petka-eyeclinic.bg/en/bscrs/

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

BSCRS-SOBEVECO Spring 2019 Meeting 25 May Liège, Belgium https://bscrs.be/events/in-belgium /joint-spring-meeting-2019/

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

NEW ASRS 2019

26–30 July Chicago, USA www.asrs.org

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

MaculArt 2019

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

NEW 19th EVRS Meeting 27–30 June Lisbon, Portugal http://www.evrs.eu

19th Euretina Congress

5–8 September Paris, France www.euretina.org

10th EuCornea Congress

13–14 September Paris, France www.eucornea.org

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

37th Congress of the ESCRS

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

OCTOBER 32nd APACRS Annual Meeting 3–5 October Kyoto, Japan apacrs2019.org

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

Ophthalmic Imaging: from Theory to Current Practice The 37th Congress of the ESCRS, 19th Euretina Congress and 10th EuCornea Congress will each take place in Paris, France

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

EUROTIMES | MAY 2019

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CALENDAR

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

NEW 18th SOI International Congress 27–30 May Milan, Italy https://www.congressisoi.com

JULY NEW ASRS 2020

23–28 July Seattle, USA www.asrs.org

JUNE World Ophthalmology Congress (WOC)

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

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

OCTOBER

NOVEMBER

20th Euretina Congress

WCPOS V 5th World Congress of Paediatric Ophthalmology and Strabismus

AAO Annual Meeting 2020

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

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

11th EuCornea Congress

38th Congress of the ESCRS

OCTOBER

14–17 November Las Vegas, USA www.aao.org

NEW 100th SOI National Congress 25–28 November Rome, Italy https://www.congressisoi.com

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

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

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

EUROTIMES | MAY 2019

Practice Management

ESCRS

48

& Development


Minimally Invasive Cataract Surgery by Alcon Chondroitin Sulfate OVDs - cornea endothelium protection1-3 Balanced tip - reassurance of better thermal profile on the incision, maximum stroke at the phaco tip to lead to higher surgical efficiency4-6

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Active Fluidics & Torsional - starting from safety in terms of low infusion settings and lower Endothelial Cell Loss respectively, to higher surgical efficiency7

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The Cataract Refractive Suite

BY ALCON

1- Glasser DB, Katz HR, Boyd JE, Shobe SL, Sniffer RL. Protective effects of viscous solutions in declassification and traumatic lens implantation. Arch Ophthalmol. 1989;107(7):1047BY ALCONusing in vivo confocal microscopy. J.Cataract Refract. Surg. 1051. 2- Petroll WM, Jafari M, Lane SS, Jester JV, Cavanagh HD. Quantitative assessment of ophthalmic viscosurgical retention 2005;31(12):2363-2368. 3- Lindstorm RL, Ong M. Protective effect of OVDs against hydrogen peroxide-induced oxidative damage to corneal endothelial cells: in vitro model. Presented at ASCRS; 26 Mar 2011; San Diego, CA. 4- Sudarshan Khokhar, MD, Neelima Aron, MD, Sagnik Sen, MB BS, Ganesh Pillay, MD, Esha Agarwal, MD, “Effect of balanced phacoemulsificationDisCoVi tip on the outcomes of torsional phacoemulsification using an active-fluidics system” J Cataract Refract Surg 2017; 43:22–28. 5- Santaro Noguchi, MD, Shunsuke Nakakura, MD, PhD,OPHTHALMIC VISC Nobuyuki Tokuoka, BS, Hitoshi Tabuchi, MD, PhD, Naoyuki Maeda, MD, PhD, Kohji Nishida, MD, PhD “Difference in torsional phacoemulsification oscillation between a balanced tip Verion ™ IOL Family and a mini tip using an ultra-highspeed video camera”, J Cataract Refract Surg 2016; 42:1511–1517. 6- Demircan, Süleyman et al. AcrySof “Comparison®IQ of 45-Degree Kelman and 45-Degree IMAGE GUIDED SYSTEM Balanced Phaco Tip Designs in Torsional Microcoaxial Phacoemulsification.” International Journal of Ophthalmology 8.6 (2015): 1168–1172. 7- Kerry D. Solomon, MD, Ramon Lorente, MD, Doug Fanney, MBA, Robert J. Cionni, MD, “Clinical study using a new phacoemulsification system with surgical intraocular pressure control”, J Cataract Refract Surg 2016;DuoVisc 42:542–549 Q 2016 ASCRS and ESCRS 8- Decrease in complications during cataract surgery with the use of a silicone-tipped irrigation/aspiration instrument Preston H. Blomquist,VISCOELASTIC SYS MD, Anne C. Pluenneke, MD. 9- AcrySof® IQ UltraSert® Pre-loaded Delivery System DirectionsLenSx for Use. 10Alcon Data on File, available on request. CR-ILN296-P001 (November 29, AcrySof ® IQ ® 2016). 11- Mendicute J, Amzallag T, Martinez A. Multicenter clinical assesment of 3 IOL preloaded at ASCRS ASPHERIC IOL Congress; May 5-9, 2017; Los Angeles, LASER delivery system. Paper presented CA. 12- Amzallag T, Mendicute J, Martinez A. Multicenter Clinical Assessment of a Pre-loaded IOL Delivery System. Paper presented at ASCRS Congress; May 5-9, 2017; Los Angeles, CA.ProVisc® 13- Alcon data on file, available on request. TDOC-0053373 (March 7, 2017). OPHTHALMIC VISC

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