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SPECIAL FOCUS

YOUNG OPHTHALMOLOGISTS

Jul/Aug 2019 | Vol 24 Issue 7/8

RESEARCH FOR YOs CATARACT & REFRACTIVE | ESCRS CONGRESS PREVIEW | RETINA CORNEA | GLAUCOMA | PAEDIATRIC OPHTHALMOLOGY


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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

SPECIAL FOCUS YOUNG OPHTHALMOLOGISTS 04 What it takes to succeed in clinical research

07 Why young

ophthalmologists should not be disheartened by complications

10 Different Directions

Dr Daniel Gosling’s shortlisted essay for the John Henahan writing prize

12 How to make the most out of your fellowship experience

14 Prioritise and Delegate Dr Allie Lee’s shortlisted essay for the John Henahan writing prize

16 The Real Deal

Dr Julia Fajardo-Sanchez’s shortlisted essay for the John Henahan writing prize

CATARACT & REFRACTIVE

29 Looking ahead to the 37th Congress of the ESCRS in Paris, France

30 Ehud I Assia will deliver the

18 How to perform the

phaco of your dreams

20 New developments in 21 Using a bag-in-the-lens technique for phacovitrectomy

28 JCRS highlights

GLAUCOMA 46 How deep learning can tackle the challenges of diagnosis

48 Injectable devices that can monitor IOP and adjust therapy

Binkhorst Medal Lecture

31 The ESCRS Heritage

Lecture will look at the fascinating origins of cataract surgery

32 Exploring the potential of artificial intelligence in ophthalmology

CORNEA 50 EuCornea founding

director awarded CBE

52 Techniques for

transplantation with limbal stem cells

33 Starting Phaco at the

Young Ophthalmologists programme

34 Where to eat and how to get around in Paris

36 Learn to cope with stress

PAEDIATRIC OPHTHALMOLOGY 54 Hand-held probe enables OCT-A imaging in awake neonates

in surgery

RETINA

REGULARS

37 Reducing the burden

56 EBO Diploma Update 58 Outlook on Industry –

38 Unlocking the secrets of

60 Practice Management 61 Industry News 62 My mentor 63 Calendar

linked with intravitreal injections ABCA4 in retinal disease

trans-epithelial PRK

As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between February and December 2018 was 48,900

ESCRS CONGRESS PREVIEW

www.eurotimes.org

42 Can robotics eliminate

hand tremor in retinal surgery?

Schwind

44 Novel treatment for

retinitis pigmentosa

45 Ophthalmologica highlights

Supplement July 2019

Phaco Basics and Beyond

Included with this issue... ESCRS Forum Supplement EUROTIMES | JULY/AUGUST 2019


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EDITORIAL A WORD FROM SORCHA NÍ DHUBHGHAIL MD, PHD

Learning opportunities

GUEST EDITORIAL

Sorcha Ní Dhubhghail

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)

EUROTIMES | JULY/AUGUST 2019

I

ESCRS is a valuable resource for young ophthalmologists

have yet to meet a resident in ophthalmology who is not eager to learn cataract surgery. I am sure they exist, but the vast majority of residents are itching to get some hands-on experience. Unsurprisingly, competition among these young surgeons in the making can be fierce. Time spent in the operating theatre is a scarce commodity, and not every patient or surgery provides equal learning opportunities. Much like the lottery, you’ve got to be in it to win it, but being in the theatre alone is not much of a guarantee you’ll get to learn much that day. But there’s a lot you can learn outside the theatre by joining YO, the Young Ophthalmologists of the ESCRS. YO gets you five years of ESCRS membership for free, and the ability to attend the main event, the summer and winter meetings, at a reduced price. But that discount is just the icing on the cake. If you have never had the chance to touch an eye, you can start out at the YO sessions at the annual meetings. These are presented by some of the biggest names in the game like Findl, Nuijts, Vannas, Malyugin and others like Richard There’s a lot you can Packard. His didactic learn outside theatre cataract surgical course is a must for beginners and by joining the Young more experienced young Ophthalmologists surgeons alike. of the ESCRS. YO The topics and discussions at these gets you five years of sessions are tailored ESCRS membership to YOs, full of learning for free opportunities, yet not overwhelming. No wonder they are usually really well attended. And the lessons you learn from them will come in handy when you encounter the biggest challenge starting out – convincing your trainer to let you actually do things. When you’re a little bit further on, and your phacos have hit the triple digits, you start to select harder cases. As a result, your complications may increase. Again, the ESCRS has your back. Didactic and video-based courses on hard lenses, tough cases and how to manage complications are available at every meeting. The wetlabs on anterior vitrectomy really helped me keep my cool when I needed to do them in real life. Last but not least, the ESCRS has a lot to offers outside the conferences too. The ESCRS YO website at yo.escrs.org is full of resources and opportunities including the iLearn platform, access to landmark articles, and updates from the field.

Sorcha Ní Dhubhghaill is Professor of Anterior Segment Surgery at Antwerp University Hospital (UZA) and a Consultant Surgeon at the Netherlands Institute for Innovative Ocular Surgery (NIIOS)


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SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

Research for YOs Joséphine Behaegel has some useful advice for young ophthalmologists who are doing research

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e all know the picture: after years of tense competition at university, you finally earned that precious residency place in your favourite speciality. You are eager to get started, to diagnose your first herpetic keratitis, to remove an ocular foreign body and to discover all of the truths of the Kanski “bible”. But then, you EUROTIMES | JULY/AUGUST 2019

find out that as part of your residency, you need to have an article published too. A real article, with an impact factor and everything! GASP. An article means research. So how do we start? If you’re very lucky, your supervisor will hand you a pre-made project approved by the ethical committee, along with a list of patients all meeting the study inclusion criteria. And right there along with it, there’s a smiling study coordinator whose new life

purpose is to support you, and a statistician with plenty of spare time offering to crunch the numbers. Unfortunately, this is only a fairy-tale scenario in my experience. I have just finished four years of clinical research as part of my PhD project. During those years I encountered quite a number of challenges that researchers may be confronted with, which I overcame through a combination of trial and error, and guidance from my promoter. Based on


SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

this experience, I am going to share with you some tips and tricks for performing research as a young ophthalmologist.

MOTIVATION IS CRUCIAL The first thing to accept is that research is an adventure, and it is never 100% certain how a clinical study will turn out. While this insecurity may sound daunting for an ophthalmologist who likes to have everything neatly mapped out, research can be most thrilling too! Motivation is a crucial factor. When you’re not excited about your research topic, then it may become a burden. Choose a topic that you are passionate about, and don’t let your choice be guided by your head of department who just-so-happenedto-be an expert in ocular electrophysiology, while you’re fond of the anterior segment. Reflect on the relevance and feasibility of your research, keeping in mind some practical issues such as your available research time, the study-related costs, available funds and the prevalence of the pathology. Then, frame your research question – what is your hypothesis? What are you testing? What is new? This really

helps you from getting sidetracked in the literature review. When you do your literature review, keep it narrow. You need to thoroughly scan the field in literature but you should assume some level of knowledge on the part of the reader. Your research article is not the right place to date the origins of the first descriptions of pterygium back to ancient Egypt. Use more than just PubMed – other databases like Thomson’s Web of Science and Google Scholar can sometimes dig up an extra article. Read the references of the articles you find to see if you can hit upon more relevant papers. Even more important than defining your research question, is the match with your promoter. A good promoter can make or break your research. Choose someone who knows the field and with whom you have a good relationship. In my case, my promoter lifted me up when results were flat or my motivation was fading. With a clear idea in mind and a supporting promoter, it is time to write a study protocol. The clinical study protocol is the road map for your research. Writing a protocol sounds daunting but it shouldn’t put you off. Just define your inclusion and your exclusion criteria and write down the steps that you want to do. Making a nice protocol will help with your ethics request. Bonus – it

will basically be the core of the methods section in your paper! Critically, legal and regulatory requirements are still all too often neglected, increasing the complexity of clinical trials. (As if research in itself wasn’t tough enough...) Before starting, learn about the regulations and more importantly, have the right persons to guide you. Hospitals often (but not always) offer assistance via study coordinators, or even have a full-blown clinical trial centre to give you a helping hand to overcome the administrative hurdle. Apply for ethics as soon as you can. This can take a while to secure and you may need to clarify and resubmit. You can’t do anything until you have approval, so applying early is the key message here.

ACCEPT FAILURE Off to the actual work: performing research! A great research day is one where successful results combine with satisfied study patients. But just as in real life, sometimes things don’t happen as planned, results may be disappointing, delays can be encountered, and complications can (and will) occur. Accept failure and unexpected twists and turns throughout the process; try to learn from it and find out its root cause. And if necessary, readjust your protocol and reframe your clinical question. Everybody acknowledges the following one, and still it is forgotten from time to time: don’t forget to save your data! Make sure to have a good backup plan. Data that EUROTIMES | JULY/AUGUST 2019

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SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

The first writing tip is to aim for a basic skeleton of a paper with bullet points, and maybe a provisional title. Then continue to a rough draft outlining your ideas are stored in only one location are not safe. Remember – patient data are highly sensitive and you need to follow strict anonymisation and the General Data Protection Regulation (GDPR) rules. Now off to the cold-sweat-inducing part for many researchers: statistics! You might start a refresher speed course on statistics or dust off your old course notes from university. If you have access to a statistician, even better, but it is always best to consult him/her before you start for a clear statistical plan rather than dumping a pile of data in front of him/her to make sense of. My advice here is to do as much as possible yourself. This way, you completely understand your own work, and you avoid being speechless in front of a full auditorium if the audience grills you on the statistics of your study. Okay, results are analysed, so now it’s time to write! I’ll be honest, your very first research paper is most likely going to be a disaster. Pretty much like making a pancake. But I promise that things improve with time. Don’t try to aim for perfection when you start, and remember that the most eloquent and experienced professors around you also struggled in the beginning. The first writing tip is to aim for a basic skeleton of a paper with bullet points, and maybe a provisional title. Then continue to a rough draft outlining your ideas. Start flexible. It doesn’t have to be perfect in the beginning. Polishing, refining and discarding text or ideas is for later on. Writer’s block is normal and I have a few tips for dealing with it. Your first option is to have a panic attack and tell yourself that writing is just not your “thing” and spend the day binge-watching Netflix. This can work short-term, but long-term you need another solution. Set yourself small, achievable goals. Accomplishing something (even a micro-goal of five sentences) can put you back on track. Frequently, more ideas pop up during writing, and before you know it you may EUROTIMES | JULY/AUGUST 2019

have finished the complete introduction. If you’re stuck in the introduction, jump to another paragraph. And if you’re really out of ideas, diving into the work of others to get some inspiration might also help. Writing is very often done during your spare time. Therefore, I try to make writing as comfortable as possible. For me this means with an XL coffee on a Saturday morning or a glass of red wine in the evening with some music on the background. Be aware though, from the second or third glass onwards, productivity may dwindle! Keep the references of your paper relevant. This is not school homework. You do not need to prove that you read all the articles, so don’t just throw every reference in. A reference list of 200 papers is not necessary, unless you are writing a comprehensive meta-analysis. Once you think you have finished the article, put it aside for a day or two, then read it again with a fresh mind. You may be surprised how many (small) mistakes you overlooked before. You will probably also notice something that could be improved upon. The last writing ingredient is – again – a good promoter or mentor. A good promoter is an experienced researcher who can revise your paper, give useful feedback, catch inconsistencies in your work and – if you’re lucky – can transform some of your repeatedly re-written sentences into a spectacular-sounding paragraph. Then send your final draft to all of the authors involved and wait for their remarks. It is considered very poor form to send an article away with the name of an author who did not get to correct the final manuscript. If your co-author is not responding quickly, send email or text reminders. It’s annoying but you cannot cut corners here.

FOLLOW GUIDELINES Also don’t forget that a journal has guidelines too. I spent days and nights writing my very first paper, in the most inefficient ways. An eternity later, it was written, corrected, and ready to submit!

When awaiting the reviewer or editor’s response, my advice is to be patient (it may seem endless before you get that reply), but more importantly I encourage you to grow a thick skin

Or so I thought... Until I read the Guide for Authors on the journal’s webpage where I was instructed to reduce my word count to half of it. It took me another eternity to be able to discard parts of text that ALL seemed so relevant to me, and to which I had dedicated so much time. But experience is a good teacher and I now consistently first select my journal and have a quick look at its guidelines before writing in order to tailor the length and structure to the journal’s requirements. I believe this significantly reduced my research frustration time. Try to choose the journal that best suits your research paper before or during writing. Don’t just shoot your article to the NEJM and work down. Think about your target audience. Who do you want to read your work? Try to send your paper to the journals THEY read. When awaiting the reviewer or editor’s response, my advice is to be patient (it may seem endless before you get that reply), but more importantly I encourage you to grow a thick skin. Indeed, the rejection of your research paper can be very demoralising, especially for young researchers. The first time my article was rejected I cried. I couldn’t understand why someone would reject the paper I had been working on for months and had sacrificed so many good night’s sleep for. And why were they so rude? Is it against the reviewer’s guidelines to show some compassion? It made me lose some more good nights’ sleep. As bad as the feeling of rejection was, I was also afraid to disappoint my promoter. Would she agree with the reviewers and think I did a bad job? I was surprised when she just shrugged her shoulders and immediately suggested another journal to submit my paper to. It turns out that a rejected paper is not a big deal. If you care and believe in your work, you will always find a home for it and you’ll always find a journal that accepts your work. Now I have learned to deal calmly with any response from reviewers. I use their advice to boost my paper, and my thicker skin is very useful in real life too. (Okay, perhaps only reviewer two can still make me cry silently on the inside…) The last essential element I want to share is that performing research involves much more than having that paper published. The experience makes you grow, not only as a researcher, but also as a resident and an ophthalmologist, and it will eventually benefit your personal life outside the hospital too. So, don’t be discouraged when you’re struggling. The only way to eat an elephant is one bite at a time! Joséphine Behaegel is a clinical trainee at the University Hospital of Brussels and was the 2018 winner of the John Henahan Prize


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SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

Dealing with complications Soosan Jacob MD says when travelling the road from initiation to becoming a seasoned ophthalmologist, YOs should not be disheartened by complications

E

ugen Bleuler, in a letter to Sigmund Freud in 1911 wrote: “In Science, there is no such thing as unmitigated good.” Lack of efficacy and complications are sometimes the price that not only a young ophthalmologist but even a seasoned one pays. How does one decrease the occurrence of complications and their effects on both patient and physician? This is a time of mixed emotions – confidence and pride in all that is learnt, fear and dread of all the unknown, a presumed wealth of clinical experience and possible inexperience in handling unexpected surgical scenarios, human emotions and real situations. The euphoria that a job well done gives may be followed by deep misery for a complication, whether avoidable or unavoidable. It is truly a rollercoaster time of emotions. So how does one smoothly travel the road from initiation into the ophthalmic fraternity to becoming a seasoned ophthalmologist? The first thing that any YO should do is to embrace the fact that complications will occur. They occur in the best and safest of hands and occur because of controllable and uncontrollable factors. The best way to prevent them is to know them, anticipate them and therefore be prepared for them. Fear of complications is normal but it should not stop one from operating. Prevention and management of complications comes through a continuous process of self-improvement via theoretical learning, attending conferences, listening to other surgeons share their experiences and tough cases, watching live situations and videos of others, wetlabs and simulations, handheld surgeries, independent surgeries, reviewing of one’s own surgical videos – the entire cycle repeated over and over again. A constant learning process is important to avoid getting trapped in a comfort zone that can prevent skill levels from increasing. EUROTIMES | JULY/AUGUST 2019

A

B

C

D

A: Posterior capsule rupture; B: Iridodialysis; C: Nucleus drop; D: Expulsive haemorrhage

AVOIDING COMPLICATIONS Preoperatively, take care to go through the patient’s chart, familiarising yourself with the ocular and systemic condition. Talk to the patient to assess if expectations from the surgery are realistic or not and if not, explain to the patient his/ her condition, expected results, possible complications specific to him/ her as well as general complications that can occur. This should be documented in the case sheet as well as via an informed consent sheet signed by the patient. Remember, it is always better to under-promise and over-deliver than the

reverse; an informed patient is also better equipped to mentally and emotionally handle any complications. Appropriate investigations and planning prior to surgery is important. A mental road map should be formulated chalking out the planned, expected route as well as alternate routes that may become necessary in case of any roadblocks. Make sure that all desired drugs, equipment, devices and instruments are available and working well. It is wise to have a patient anaesthetist and nurse assistant who have experience working with trainees and young ophthalmologists.


SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

MANAGING COMPLICATIONS Never forget a time-out just before surgery to go through the pre-surgical checklist with your team. Intraoperatively, be on watch for situations that can potentially increase risk of complications and treat them if necessary. Don’t try breaking records in speed. Even Usain Bolt had to practise for years before creating records. Most importantly, when facing a complication – do not panic. A classic, oft-quoted example of what not to do is panicking and suddenly withdrawing the I/A probe, accidentally capturing the posterior capsule. Take a moment to reassess and then proceed if confident or call for help. There is no shame in asking a more experienced and trusted mentor/ colleague for help or handing over for further management. Remember it is the eye that matters and not the “I”. Sometimes, one may just have to close the case midway and refer the patient for further management, eg in case of a nucleus or IOL drop. Even though this may be a difficult decision in terms of not having finished surgery, remember – it is better to live to fight another day. It is also important to maintain equanimity and not convey panic to the patient as this can lead to intraoperative

stress for the patient that may worsen the situation. In many operating set-ups, patients are not sedated and thereby are awake and intensely aware of everything happening. Under the drape, some patients try and analyse what they hear even up to the tone of voice of the surgeon. Random jokes, shouting, panicking, complaining, expressing exasperation with the system as well as other casual comments should be avoided, especially if the patient is not sedated, as these may result in the patient drawing wrong conclusions about the situation and how it is handled as well as make the patient panicky.

RECOVERING FROM COMPLICATIONS This applies for both the patient and the YO. Postoperatively, the sense of having got all possible support from the operating surgeon is important, as is having a discussion with the patient about what happened, how it is planned to be managed as well as expected outcomes. Emotional support to patient and family and arranging for any consults is crucial to help the patient out in the unfamiliar and unexpected territory they find themselves in. This also helps in maintaining a rapport with the patient.

Panic and a demoralised feeling is common for the surgeon too after encountering a complication. Emotional support can often be got from family, friends and mentors and this should be sought for and gratefully accepted. It is important to recover soon from the low after a complication and bounce back. Mentors are an important source of help for advice as well, and it is always important to give thanks to them. Post-procedural review and analysis to see if the complication could have been avoided or tackled in a faster/ better way is important and this leads to a process of constant self-improvement. To conclude: do not get disheartened by complications. There is a learning curve for everyone with published data for various procedures. Go step by step to improve your skills. Remember, Rome was not built in a day. And always, even with terrific results, there will be some unhappy patients, as well as deeply grateful ones with suboptimal results. 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

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

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Practice Management

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EUROTIMES | JULY/AUGUST 2019

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SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

Different Directions In his shortlisted essay for the 2019 John Henahan Prize, Dr Daniel Gosling describes how he managed to find a balance between studying, working and spending time with his children

T

en years ago, along with my fellow medical students, I had been studying hard for the first year clinical exams. One week before the exam things changed dramatically for me, when my wife gave birth to our first child, Amy. Holding her in my arms was marvellous. We were parents! Looking into that little baby’s eyes, I realised life had changed, and I was excited about it. What was ahead of us? What would her personality be like? How would our relationship be in 10, 20, 40 years? Attending to the needs of this new person felt like it would give unending satisfaction. However, there was still an exam to sit. It turns out that looking after a baby is good practice for both night shifts and paediatrics, but apart from that it seems that medicine can be pretty inconsiderate of ‘life’. Parental leave passed quickly. The feelings of wonder gradually got watered down by the practicality of everyday life. Meanwhile, medical training had us moving to different towns, commuting, EUROTIMES | JULY/AUGUST 2019

and all the extra work that is demanded: papers, presentations, audit, courses, studying and exams. At times I wondered: why does life and ophthalmology seem to pull in such different directions? Maybe you have had a similar experience to me, at the end of a cataract case. After peeling the drape off, the patient thanks you, and a fleeting thought comes into my mind: ‘how on earth did I come to be doing eye surgery? What a privilege.’ As ophthalmologists we have dedicated ourselves to the art and science of treating ocular disease. We hold the care of our patients in highest esteem, and have the opportunity to make a dramatic change in their lives. However, our patients go home to their own family at the end of the case. And we go home as well. Family comes in many shapes and sizes, and our responsibilities evolve over the years: parents age, relatives need support, children arrive and grow up, relationships start and end. Our families aren’t clinic lists, and they are likely to be around for a whole lot longer than a two week follow up appointment. Our discipline is

demanding, but it is not impossible to be successful both in the home and in the eye clinic. I chose ophthalmology because I didn’t like bottoms or death, but happily, it is also a specialty that can allow for a pretty healthy work-life balance. In those early days with baby Amy, it became clear that studying should not trespass into the weekend. If an exam was on a Monday it felt wrong not to cram the day before, but I discovered quickly that

The other thing I admit to really enjoying, is when my kids draw me a picture of an eyeball for my birthday


SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

protecting family time was win-win. I wouldn’t feel guilty, I made realistic aims for what I could achieve, and it helped focus my mind to be productive at the right time. Once junior doctor work rotas messed up weekends, it became even more important to protect time off. For me, the best time of the day with kids is in the evening before bed time. It puts my day at work into perspective when we get to sing songs, dance, or read stories about dragons or wizards, and tuck them into bed. Occasionally I do a bit of extra work after that, but usually I’m too worn out. Of course, not every day goes to plan, and often the incessant chores and responsibilities can be overwhelming. Many ophthalmologists would admit to a perfectionist streak (I think the work we do demands it), but being realistic with myself has been just as important. I’m not going to get it right all the time, in fact there are days when it all seems to be falling to pieces, but that doesn’t mean it isn’t worth the effort. I think the greatest barrier to family life in my medical career has not been ophthalmology itself, but the work and employment conditions that many junior ophthalmologists are subject to. Though it varies country to country and from clinic to clinic, I have not come across anywhere that has got it quite right. For

example in the UK, in our seven year training programmes we are required to rotate to hospitals that can be hours away from each other, and have little power to control over the location or the terms of our work. Managers seem to perpetually need more from us, for less pay. In addition, ophthalmology and medicine in general, is still far from equal in the opportunities for female colleagues, especially if they choose to have children. For me, discussion with my partner and planning together, has allowed us to ride out the most difficult periods in the training pathway. However, as a profession, we need to be collectively active and vocal in improving the conditions of our work and training. It will lead to a happier workforce and a greater ability to care for our patients. There are some great pay offs for the effort of making time for family life. I really look forward to going on family holiday. It is refreshing to put ophthalmology aside for a couple of weeks and just enjoy doing different things together. The other thing I admit to really enjoying, is when my kids draw me a picture of an eyeball for my birthday. Dr Gosling is an ophthalmology trainee in Sheffield, UK

JOHN HENAHAN PRIZE 2019

EUROTIMES | JULY/AUGUST 2019

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The perfect fellowship Sorcha Ní Dhubhghaill MD shares some tips on how young ophthalmologists can make the most out of their fellowship experience

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or those of you finishing up your residency training, it’s natural for your thoughts to turn to your subspecialty training and your future career. So how do you pick a fellowship? And once you find your dream job, how do you best the competition and secure that precious spot?

KNOW BEFORE YOU GO There is a lot a variation in the amount of exposure to surgical training you can expect to get during your residency. For all attempts at harmonisation, Europe is still a patchwork of different training schemes. Some countries like the Netherlands and Ireland will offer a lot of residency training, while other countries like Belgium and Germany offer far less. When you apply for your fellowship, ask those who went before you about what the opportunities are. Are EUROTIMES | JULY/AUGUST 2019

they prepared to teach from zero? If you arrive with little experience, will you be sidelined or supported? There is nothing more deflating than uprooting your life and moving to another country, only to be left sidelined.

APPLYING FOR A FELLOWSHIP Polish up your CV and get it ready to go out. We all want to make our CVs look as nice a possible but avoid the temptation to overestimate your surgical skills. One complaint I heard recently from an eminent teaching professor was that he was tired of international fellows representing themselves as more experienced than they are. You need to be honest. The best approach is to log all of your surgeries into a surgical logbook. Printing a summary of your surgical experience from your logbook is an excellent addendum to your CV and is a way to reassure your potential trainer.

Even if your numbers are not that high, the effort and diligence will be respected. Having a logbook report will also allow a potential trainer to determine where you fit best and how much support you may need. You may have been required to maintain a logbook as part of your residency training – and this is when it becomes really useful. In the UK and Ireland, trainees are required to log all of their surgeries into www.elogbook. org. If your country does not require you to log your surgeries, you should do it yourself. Log your cataract surgeries into the EUREQUO database and maintain a personal surgical log. Remember though, logbooks must not contain any identifying patient information. For the interview itself – just be you. Your best you, that is. You probably already know why you want to train in that particular centre, so show your


SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS interviewers that you have done your homework. Show them that you know what their main research lines are. Read their most recent articles. If they ask why you want a fellowship with them, “because you teach cataract surgery” is the worst response!

GET YOUR DOCUMENTS INTO THE CLOUD The best practical tip I can give is to scan every piece of documentation you have, and load it up to a place that is always accessible. Dropbox, iCloud or Google drive are all great places to store this – it can be really helpful to have them on hand at all times. This online repository should include copies of your basic medical and ophthalmology diplomas, relevant translations, certificates of good standing, police vetting certificates, language exam certificates – everything you can think of, just scan it in and add it to your files. You will likely need to provide the originals (or officially notarised copies) to the local authority but having electronic backups, particularly your CV, can be a real lifesaver.

APPLYING IN EUROPE The process of securing a local accreditation can be a long one. I would

advise to start the process at least one year in advance. These things always take longer than you would expect. If your basic medical training was in an EU country, there is a system of automatic recognition of professional qualifications for seven “sectorial” professions – this includes doctors. The regulations are outlined in Annex V, points 5.1.1 and 5.1.4 of the Directive 2005/36/EC. More information can be found of the website of the European Commission: http://bit.ly/ET-EC-Annex-V. Automatic recognition of your basic qualifications is not as “automatic” as it sounds, however. While the EU directive supports mobility, every country has its own regulatory authority to determine if you can work there. These bodies typically impose additional requirements, such as language competencies, to ensure that you can work safely in the country you choose. From my own experience, I have obtained accreditation from Ireland, Belgium and the Netherlands and all three countries had their own additional requirements. Securing your basic medical accreditation may be enough for your fellowship but if you choose to stay longer, you may wish to have your specialist degree accredited. Specialist degrees awarded in the EU that are eligible for automatic recognition are

outlined in Annexes V, point 5.1 of the Directive on recognition of professional qualifications.

THINK ABOUT THE FINANCING Fellowships are, in general, poorly paid. Some fellowships are not paid at all. Many fellows not only have to pay rent in the fellowship country but also maintain a mortgage at home – so build up your reserves. The ESCRS now offers fellowship funding of up to €60,000 if you can submit a strong application. Fellowships can be great experiences but are also typically gruelling jobs with long hours. Stay focused and you will be able make the most out of your experience. Remember to stay in touch with the colleagues, contacts and friends you make along the way – these will be your lifelines when you are looking for advice on complex cases later in your career. Sorcha Ní Dhubhghaill is Professor of Anterior Segment Surgery at Antwerp University Hospital (UZA) and a Consultant Surgeon at the Netherlands Institute for Innovative Ocular Surgery (NIIOS). The NIIOS offers fellowships in corneal surgery and research in Rotterdam Sorcha Ní Dhubhghaill: nidhubhs@gmail.com

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SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

Prioritise and Delegate In her shortlisted essay for the 2019 John Henahan Prize, Dr Allie Lee asserts that balance can only come from living a life that accords well with one’s core values and priorities.

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ight-thirty at night, one hand of mine penning this article, the other rested on my bump feeling the joyful kicks of my 24-week baby. My spirited 3-year-old was enthusiastically inviting me to be sous chef for his playdough supper, while my dear husband was questioning the whereabouts of his old crimson square pattern silk tie that he would need the next day. From my phone came the apologetic voice of my resident, “Sorry to call at this hour... I just saw a patient with burst cornea and sclera, but I can’t figure out where it ends...”. Moving from residency to practice, young single life to wedlock and parenthood, the demands of any one of these roles can easily take centre stage in one’s life. EUROTIMES | JULY/AUGUST 2019

I hardly felt like a conquering soul. I was overwhelmed. Overwhelmed by the exhaustion, overwhelmed by being a new mom, overwhelmed by trying to make good on the faith that my colleagues and patients had in me. That steered me towards the question of our time: Can we have it all?

CREATE YOUR OWN VERSION OF BALANCE

I went searching for an answer. I googled. I read biographies. I talked to people. There seems to be no one-size-fits-all gold-standard type of work life balance. Different roles at different stages of life call for different adaptations. The ideal balance of an up-and-coming young trainee can look entirely different to a

mid-career parent of three, and even more disparate from someone near retirement. This balance is fluid and changes over time. It is important to review constantly. Find a state that brings you happiness and personal fulfilment. Live a life that accords well with your core values and priorities. Be mindful of all sorts of extremes as too much of anything can do more harm than good. It is more about devoting manageable amount of time to each aspect of life that matters to you, rather than exact equal shares.

LET GO, PRIORITISE AND DELEGATE

Aspiring. Overachieving. Controlling. Being flawless. Pursuing the absolute best. These consistent character traits of ophthalmologists are indispensable in making us good at what we do, when we are dealing with margin of error in millimetres and microns in our practice. However, giving your all every day to


SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

professional life and equivalent parts to family to such precision is possibly the quickest way to frustration and burnout. You will never feel like you are measuring up. There are only so many hours a day that one can only do so much and still be happy and healthy. Set realistic goals. Identify areas of your life that demands more of your attention and direct your finite energy there. For the rest, get support whenever possible. Effective delegation at work not only helps yourself, but also provides opportunities for others to learn and grow. At home, when you start to outsource, you may be surprised to find that someone can actually get the tasks done much faster and better.

You cannot care for others if you do not care for yourself. Always reserve some “me time” for yourself, however small chunks, to be yourself, relax and recharge

COMPARTMENTALISE AND QUALITY TIME

Have you ever experienced the “alwayson” mentality? Modern technology has enhanced our lives in so many useful ways but also created channels for instant accessibility and distractions. The following would not sound foreign to any of us: checking emails after work, answering calls on days off, doing work while on holiday... It is so tempting to dip into unfinished work. We need to make conscious effort to minimise spillover of work into personal life. Know when to unplug. Be judicious and respect protected time. Another key would be to make quality time true quality time. Your patients appreciate your undivided attention. Your family and friends deserve the very same. When you are physically present, be there mentally too. Real communication builds richer relationships. Our family have adopted a zero screen policy at the dining table. My three-year-old boss would frown and nag “no phone please” until your phone was stowed away. Enjoy the valuable together time. Make memories and make your family feel loved and special.

BE GOOD TO YOURSELF TOO

“Be in charge of yourself, your family, your country and the world, in that order” - an old Chinese proverb that I find much

wisdom in. You cannot care for others if you do not care for yourself. Always reserve some “me time” for yourself, however small chunks, to be yourself, relax and recharge. Treat your body and soul right – eat right, exercise more and get adequate rest. Indulge in little joyful pleasures you well deserve, guilt-free. In career, embrace what you love. You would be more likely to take on challenges and find rewards. Can we really have it all? I am still very hopeful that we can, perhaps just not all at the same time. Now I demur to let someone else set the bar for success for me, and would gladly define for myself what “all” it is I want to strive for. I learnt to take things one at a time, be engaged, smell the roses along the way. Life is a marathon and not a sprint. Start small, enjoy little wins, and build from there. Dr Lee is an Associate Consultant at Hong Kong Eye Hospital, Kowloon, Hong Kong

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SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

The Real Deal In her shortlisted essay for the 2019 John Henahan Prize, Dr Julia Fajardo-Sanchez details how to to juggle the love for your ophthalmological life and your family ties

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am in love. This very subtle and yet powerful sentence is enough for you to know that I am quite a romantic but also that I am, let’s face it, in remarkable trouble. Wait, I am not in love with a person, if that’s what you’re thinking, although that will probably be easier than what I am feeling. I am in love with my work. People who know me are aware that I’m easily infatuated by all the situations that bring me happiness, and my constant wondering and thirst of challenges have become the main reasons to pursuit the sometimes evasive and sometimes ungrateful – but then above all, always beautiful – art of ophthalmology – see how bad this is? Very easily misunderstood, my feeling is not different from the one you experiment when the eyes of that special someone – did I just say eyes? – intertwine with yours for a moment. Or, to add more drama, is not different from the sweet emotion of sharing a comfortable and very long-waited hug with my beloved mother. Probably you are outraged by this last comparison but, my dear reader, please give me some lines to explain myself. I am a twenty-something-year old young ophthalmologist who has travelled a lot. What EUROTIMES | JULY/AUGUST 2019

do I mean by a lot? Well, from Lima to Madrid, then from Madrid to London, trying out a series of intercontinental moves and subsequent ophthalmologic adventures. This nomad – yet sophisticated, c’mon – type of life has taught me what I need to know to expert in everything related to loving with my heart and no with my eyes – did I just…? – being that the way I have been loving my precious family since I was 22. So, taking this hard-learned knowledge into account and with the same confidence and precision we slaughter the periphery corneal tissue to phaco our way-out of that list of cataracts, let me try to draw you down the three basic principles to juggle between the love for your ophthalmological life and your family ties. Juggle? Yes, you read it right. In order to get balance, you need to know how to juggle.

PRINCIPLE ONE – HAPPINESS CANNOT BE COMPARED It is certainly impossible – believe me, I have tried it too – to determine if your happiness will be greater seizing that intricate, indomitable intraocular pressure or managing that difficult intraoperative iris than sharing a cup of hot

cocoa or eating a delicious ceviche – yes! – with your beloved ones. Why? Because there are not happiness units, you cannot calculate the exact amount of happiness with a tonometer for each of these scenarios – although I will be pretty happy to keep everything under 20 mmHg, thank you very much – and you cannot possibly compare the joy of personal fulfilment with the joy brought by family time. They are both joy. They are both happiness.

PRINCIPLE TWO – YES, I LOVE MY FAMILY, AND YES, I LOVE MY LIFE I know, this principle sounds like a line from ‘I Will Survive’ – oldie but goodie – but nothing gets clearer than this. When I began changing addresses across the world, I realised that I missed my family terribly, that I love them so much I was constantly asking myself: Do I need to chase my dreams? Is it necessary to enlighten my heart with the little victories of the everyday ophthalmological training? And my sweet and marvellous dad gave me the answer I needed. He told me: “Go catch your dreams, go fly for them! Otherwise, it would not be you, it would not be your life. And we love


SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

Go catch your dreams, go fly for them! Otherwise, it would not be you, it would not be your life you, not in spite of but because of the way you are”– Bruno, my friend, my dad said it first. I love my life and I love my family for being able to love how my life is.

PRINCIPLE THREE – HOW TO JUGGLE IS THE REAL DEAL So, as I was saying, the juggle thing is a serious thing. As all the incredible

things in life, it has to be learned in a growing scale. To make it simple, I have prepared an excellent metaphor. Let’s try to remember – it should not be too hard for us, young ophthalmologists – when we started with the cataract surgery cravings. Oh yes, terrible, young hunger. They sat us the first time in front of a real patient – no farm friends today – phaco in one hand, feet on pedals, and the experienced surgeon next to us giving the first instruction, carefully looking after their own heartbeat and our hands. “Let’s try the paracentesis” was the whisper our mentor gave us. And what did we do? We – against our own prognostics – after just conquering the first paracentesis ever in our recent lives, try to keep going. I am sure we felt like rock stars while going against our mentor’s goodwill and his health, but at the end – and you know is true – we ended up performing a meh – not brilliant, not good – cataract surgery, even perhaps with our mentor’s rescue performance. So, slow down. To conquer the master of juggling between the love for your family and the love for your career you have to

remember how awesome it was when you did every cataract surgery step at its own time. Do not try to appear in every-singleone of your cousins’ birthdays and read all the Ryan sections at the same time; identify your strengths, add them to your everyday juggle and keep adding as slow and safe as you can go. Of course, you could be thinking “This is easier said than done!” It is not easy, my fellow colleagues, nothing worth our time is. But let me add, remembering my favourite four – there’s nothing you can do that can’t be done – love is all you need. Dr Fajardo-Sanchez is a Clinical Research Fellow at Moorfields Eye Hospital NHS Foundation Trust, London, UK

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CATARACT & REFRACTIVE

How to perform the phaco of your dreams A master of surgery details the steps to the dream surgery for trainee surgeons. Aidan Hanratty reports

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very cataract surgeon, especially when they are learning, would like to perform the perfect phacoemulsification. While a pessimist might say that anything can go wrong, it’s important to remember that with careful planning and preparation, things can go right. Richard Packard MD, FRCS, FRCOphth, Senior Consultant, Arnott Eye Associates, London, UK, explained the steps that can be taken to ensure that everything goes smoothly in the operating room in the best of all possible worlds. “You want to have the correct patient, the correct eye with the correct lens and expected refractive outcome on the operating table in front of you,” Dr Packard said at Pearls for the Young Cataract Surgeon, a Symposium organised by the Young Ophthalmologists Committee at the 23rd ESCRS Winter Meeting in Athens, Greece. “You also need the right sort of cataract – a good red reflex, a 2+ nucleus, no zonular issues, normal axial length and also a cataract that’s not too hard, not too soft, and therefore it’s easy to chop and crack because that’s the one that’s going to be your dream phaco.” The pupil must be well dilated, the patient needs to be calm, the surgeon should be sitting with a straight back, not hunched or stretched, and thus comfortably. Following a perfect, self-sealing incision and a perfectly rounded and centred capsulotomy, the machine settings for removing the nucleus must be right. “If you are chopping on the Centurion, you want to have the intraocular pressure set at about 50mmHg, you need the vacuum set at about 450mmHg and the aspiration flow rate at 30cc per minute.” Using the torsional method, Dr Packard recommends a microburst setting with 35 milliseconds of on time, 40 milliseconds of off time, with 100% torsional power with a standard, Kelman tip, or 60 with a Balanced tip. When it comes to the chop, bury the tip at sufficient depth using foot position 3. Then move to position 2, which will allow the vacuum to build to its preset EUROTIMES | JULY/AUGUST 2019

maximum, at which point you can chop down to the left of the tip and bring the chopper centrally with the left hand. At the same time lift with the right hand this will create the chop (Fig. 1). Rotate the nucleus and make further chops until the nucleus is divided into easily removeable pieces. Four is sufficient for a medium nucleus six or eight for a harder one. “The nice thing about torsional I like, is that the pieces tend to stay near the tip, and they don’t bounce away too much, which means that you’re not going to damage the endothelium,” says Dr Packard. When performing a four-quadrant nucleofractis, or divide-and-conquer technique, it is important to use just enough power that there is no nuclear movement. It is also important that the bevel is exposed at all times, so if using a Kelman tip it is necessary to drop your hand because of that tip’s curve. He also recommends that you lift the tip after the halfway point, otherwise you run the risk of boring into the posterior capsule. Once the cruciate trenches have been created the nucleus is split by placing the long axis of the trench so that it divides the angle between the phaco tip and sideport instrument. These two are then placed at the bottom of the trench and separated so as to create equal and opposite pressure. The cracked pieces can then be removed using the same settings as above. Using bimanual irrigation and aspiration provides access to the whole of the capsular bag. It is important to aspirate centrally with the port pointing upwards, as pointing downwards creates the possibility of picking up the posterior capsule. If this happens, it is essential not to move it. “Just take your foot off the pedal. This will release the vacuum, and then you will be able to get away without breaking the capsule,” Dr Packard suggests. He also recommends removing the cortex underneath the wound first if you are using a coaxial I/A handpiece (Fig. 2): “This is because the cortex and epinucleus will be holding the bag open, so it gives you best access to the cortex underneath here.” The next point of the procedure is insertion of an intraocular lens. Dr Packard

Courtesy of Richard Packard MD, FRCS, FRCOphth

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Fig. 1 (Top): Performing a vertical chop Fig. 2: Removal of the sub-incisional cortex

creates a two-chamber eye, first by filling the capsular bag with OVD and then filling the anterior chamber. This means that when the lens is inserted, it will drop into the bag. If OVD is inserted at the wound, the bag will collapse, making insertion more difficult. At this point, ask your patient to look toward you as you dock the tip of the injector, which will provide counter traction, allowing the lens to slide easily into the eye. Once it is in position, remove the viscoelastic and close the wounds, preventing the chamber from collapsing. Once the chamber is stable, inject some intracameral cefuroxime and a drop of povidone-iodine. “Now it’s time to wake up and make your dream come true,” Dr Packard finished. Richard Packard: mail@eyequack.vossnet.co.uk


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CATARACT & REFRACTIVE

Re-birth of PRK? Continuing refinements of technique and technology are bringing trans-epithelial PRK back to the surface. Roibeard Ó hÉineacháin reports

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aims for epithelial ablation depths of 55μm ransepithelial PRK (T-PRK) centrally and 65μm peripherally. has several patient-friendly “The ablation rate of epithelium is and surgeon-friendly different from that of stroma. The laser advantages over other corneal energy has to be adjusted to account of this surface refractive procedures in order to providing a smooth surface,” in terms of efficiency, epithelial healing Prof Epstein said. and haze, but whether that translates into Some surgeons have been dissatisfied better visual outcomes remains an open with the built-in nomograms and have question, said Daniel Epstein MD, PhD, developed their own modified nomograms, FARVO, Zurich, Switzerland. making comparison of techniques more “Transepithelial photorefractive difficult. Other variations on single-step keratectomy (T-PRK) was originally T-PRK include aiming for over-correction developed as an attempt to improve to compensate for later regression when conventional PRK. I have reviewed the targeting refraction. entire peer-reviewed literature to see if it “Single-step T-PRK is still a work in has achieved that goal and the message progress,” Prof Epstein said. is a bit confusing and contradictory,” Prof Epstein told the 23rd ESCRS Winter Meeting in Athens, Greece. OUTCOMES & COMPARISONS T-PRK originated as two-step To provide an up-to-date perspective procedure, consisting of phototherapeutic on the potential of T-PRK, Prof Epstein keratectomy (T-PTK) directly followed presented the results of a recent nonby PRK. Compared to conventional PRK, randomised study involving 146 eyes the two-step approach was more timewith a mean preoperative spherical consuming and involved more equivalent (SE) of -3.9 and a corneal dehydration. The results mean astigmatism of 0.9 were variable to the point that that underwent single-step many concluded that the procedure. It showed that at alcohol-assisted method was 18 months postoperatively better, he noted. the SE improved to -0.02D However, a single-step and astigmatism was T-PRK now exists, where the reduced to 0.032D, and 98% entire ablation is performed in were within 0.5D of target a single continuous session that refraction. Daniel Epstein is shorter in duration than either The published peer-reviewed conventional PRK or two-step literature indicates that T-PRK. It also has a built-in nomogram that conventional PRK is better than twotakes epithelial thickness into account. The step T-PRK in terms of efficacy, safety nomogram uses a population-based model and complications. However, the studies of epithelial thickness. The laser algorithm suggest that single-step T-PRK outcomes

...T-PRK is an attractive procedure because it is a notouch procedure that does show faster healing of the epithelium and it may cause less pain Daniel Epstein MD, PhD, FARVO EUROTIMES | JULY/AUGUST 2019

are superior to conventional PRK in terms of safety indices and postoperative complications. But efficacy comparisons vary considerably. Comparison studies also indicate that single-step T-PRK is easier to perform, causes less postoperative pain and provides faster re-epithelialisation than conventional PRK, Prof Epstein said. However, he pointed out that 15 years ago the same claims were made for laser-assisted sub-epithelial keratectomy (LASEK) compared to PRK and it took five years to correct that misconception. The studies also suggest that T-PRK’s long-term efficacy is comparable with PRK, superior to alcohol-assisted PRK in high myopia but approximately

equal to alcohol-assisted PRK in terms of refraction, visual acuity and haze. Compared to femto-LASIK, studies suggest that eyes undergoing single-step T-PRK have better visual acuity results but a slower postoperative recovery. However, variations in T-PRK technique and study design make many of these comparisons inconclusive. For, example, some authors use mitomycin C whereas others do not, and there are wide variations in postoperative medication regimens. Moreover, as it is an evolving technique in the midst of evolving technology, T-PRK is undergoing continual modification and refinement. The research shows that single-step T-PRK may induce less haze than alcoholassisted PRK. That is most likely because the transepithelial ablation causes less keratocyte loss with a lower inflammatory response and a smoother stromal bed contour. A study attempting to quantify haze gave alcohol-assisted PRK a score of 0.4 and T-PRK a score of 0.2, he noted. Research has also demonstrated a faster epithelial healing time for singlestep T-PRK, with one study showing that the epithelium was completely healed by a mean of 2.5 days after T-PRK compared to 3.7 days after alcohol-assisted PRK. Re-epithelialisation is also faster after T-PRK than after LASEK and PRK with manual epithelium removal. However, that does not appear to improve visual acuity, the studies indicate. As in all refractive surgery, over- and under-correction remains a problem. It is related to optical zone diameter. Ablations with smaller zones are more prone to undercorrection, and those with larger optical zones are more prone to over-correction. However, the refractive outcome of T-PRK in the long term is similar to standard PRK. Some authors have asserted that the risk of dry eye is less after T-PRK than after LASIK because fewer nerve-endings are severed and the period of stromal dehydration is shorter. “To summarise, there is no question about it. T-PRK is an attractive procedure because it is a no-touch procedure that does show faster healing of the epithelium and it may cause less pain. But it is not clear that the bread-and-butter aim of the procedure, namely refraction and uncorrected visual acuity results, is so much superior to oldfashioned PRK,” he concluded.


CATARACT AND REFRACTIVE

Alternative IOL in combined surgery Bag-in-the-lens approach works well for combined phaco-vitrectomy. Dermot McGrath reports

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sing a bag-in-the-lens (BIL) technique offers surgeons a safe and effective means of greatly reducing the risk of posterior synechiae in combined phaco-vitrectomy procedures, according to a French study. “In our experience, the BIL technique results in the absence of posterior synechiae postoperatively, which also means better visibility of the retina for the ophthalmologist,” said Clément Auchere-Lavayssiere MD at the annual congress of the French Implant and Refractive Surgery Association (SAFIR) in Paris, France. While the BIL technique requires additional surgical steps, notably a primary posterior continuous curvilinear capsulorhexis, it also confers other advantages compared to conventional intracapsular IOL implantation, said Dr Auchere-Lavayssiere. “There is now considerable evidence in the literature of the various benefits of using BIL including a total absence of posterior capsule opacification or phimosis, and therefore no need for Nd:YAG laser capsulotomy. It is also perfectly adapted to paediatric cataract with less requirement for reintervention, and also works well with toric implants as there are no issues of decentration or rotation,” he said. Posterior iris synechiae is one of the more frequent complications of phaco-vitrectomy procedures, noted Dr Auchere-Lavayssiere, with an estimated incidence of between 20% and 30%. “It can be the origin of reduced visual acuity and light sensitivity, difficulty to examine the peripheral retina, and increased risk of acute hypertonia due to pupillary block,” he said.

RETROSPECTIVE STUDY Dr Auchere-Lavayssiere’s retrospective study at the University Hospital in Caen included more than 100 successive phacovitrectomy procedures for all indications over a 38-month period. Patients were divided into two groups: standard implant (IS) and bag in the lens implant (BIL), with both groups assessed for the presence of posterior iris synechiae postoperatively. The BIL IOL, also known as the Tassignon lens (Morcher GmbH) after its inventor, Prof Marie-José Tassignon MD, is made of hydrophilic acrylic and has a 5mm optic that is surrounded by a groove running 360° around the rim of the lens and elliptical haptics. The BIL requires both an anterior and a posterior capsulorhexis, the edges of which are captured in the 360° groove, explained Dr Auchere-Lavayssiere. In the IS group of 55 patients, significant posterior synechiae was detected in 22 cases (40%) compared to just one case of 45 bag-in-lens patients (2%). In multivariate analysis, only use of a BIL implantation (p=0.004) was associated with absence of posterior synechiae. “The results were pretty conclusive and confirmed the advantages of adopting a bag-in-the-lens approach for combined phaco-vitrectomy procedures. The key advantage of this approach is the absence of synechiae, and the resulting optimal pupillary dilation. It resulted in better vision, avoiding the need for laser capsulotomy and also the risk of acute hypertony as a result of pupillary block,” he concluded.

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PAV I L I O N 7, PA R I S E X P O , PORTE DE VERSAILLES

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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 Lunchtime Symposia Boxed Lunch Included 13.00 – 14.00

Halo and Glare? Not a Problem Anymore: The World’s First and Only Sinusoidal Trifocal IOL, Acriva Trinova Moderator: J. Blanckaert BELGIUM Speakers:

Oculentis’ Toolbox for Refractive Lens Surgery: 10 Years Mplus; FEMTIS & Zepto Moderator: P. Versace AUSTRALIA P. Versace AUSTRALIA Functional performance and stability study results of a new capsule fixated EDOF-IOL M. Russell AUSTRALIA Implantation of a capsulotomy fixated IOL utilising Zepto precision pulse capsulotomy M. Prost POLAND Benefits of segmental optics in the field of paediatrics J. Alió SPAIN 10 years segmental optics – what have we learnt

E. Mertens BELGIUM F. Kretz GERMANY J. Mendicute SPAIN M. Tomita JAPAN Sponsored by

Complex Cases, Simplified Moderator: R. Osher USA R. Osher USA Difficult cases simplified by the 2nd generation Malyugin Ring B. Ayres USA Little tools that simplify big cases

Sponsored by

Johnson & Johnson Vision Satellite Meeting Sponsored by

Moderator: T. Seiler SWITZERLAND Speakers: J. Mehta SINGAPORE S.P. Chee SINGAPORE Sponsored by

Moderator: Y. Lachkar FRANCE J. Wasyluk POLAND How glaucoma lasers are different from each other? Y. Lachkar FRANCE SLT: a clinically proven safe and effective first line treatment P. Gouws UK SubCyclo: a new treatment option for advanced and refractory glaucoma F. Oddone ITALY How to enhance SubCyclo laser therapy thanks to the transillumination technique? Y. Lachkar FRANCE Conclusion: how to rank laser in glaucoma treatment?

Sponsored by

B. Malyugin RUSSIA Are we happy with the options available to simplify small pupil surgery? Sponsored by

Unfold your Possibilities

Management of Glaucoma with Subthreshold Laser Therapy

Applications for High Resolution Anterior Segment Imaging Moderator: A. Kasper GERMANY Sponsored by

Ocular Surface Disease Diagnosis and Management: Special Focus on the Lipid Layer Moderators: B. Cochener-Lamard FRANCE J. Güell SPAIN Supported by an independent medical education grant from:


Saturday 14 September

Technological Breakthrough by PhysIOL: Ready to be Amazed Again?

Lunchtime Symposia

Moderator: D. Gatinel FRANCE

Boxed Lunch Included

D. Gatinel FRANCE The first EDOF trifocal IOL: FineVision Triumf concept

13.00 – 14.00 New Developments Using Scheimpflug Technology in Cataract and Refractive Surgery Moderators: C. Roberts USA M. Belin USA A. Abulafia ISRAEL IOL power calculation: clinical outcomes G. Auffarth GERMANY The next generation: NEW Pentacam® AXL Wave M. Belin USA ABCD keratoconus staging and progression: the objective way R. Ambrósio BRAZIL Ectasia risk assessment R. Vinciguerra ITALY Biomechanical assessment post LASIK Sponsored by

Complex, Unique and Exquisite Anterior Segment Cases and New Technology for Improved Outcomes in Cataract Surgery Moderator: G. Savini ITALY Sponsored by

Rethink Advanced Performance: All In Video Moderator: J. Fernández SPAIN R. Ang PHILIPPINES Driving new refractive technology B. Dick GERMANY Go with the flow: adaptive fluidics™ A. Denoyer FRANCE Full vision - live OCT VICTUS® in action I.P. Singh USA Complete FLACS starring the enhanced enVista® platform

R. Ang PHILIPPINES The first EDOF trifocal IOL: FineVision Triumf clinical evaluation R. Bilbao-Calabuig SPAIN Isofocal technology: concept and clinical evaluation

Beyond Barriers: Boost Epi-On CXL with Oxygen Moderator: R. Rajpal USA Sponsored by

Sunday 15 September Lunchtime Symposia Boxed Lunch Included 13.00 – 14.00

Sponsored by

Mastering your Cataract Surgery Workflow with Next Level Technology Moderator: P. Stalmans BELGIUM P. Stalmans BELGIUM How to aim for perfection as the lowest standard for your practice? W.J. Mayer GERMANY Latest technology for higher accuracy and reduced staff time a contradiction in terms? B. Ayres USA Digitally assisted visualization: utility and pearls A. Hamid UK The presbyopia correcting IOL decision tree: a case based discussion Sponsored by

Saturday 14 September Evening Symposia Preceded by a Welcome Reception 18.15 – 19.45 Introducing iStent Inject W: The Trabecular Micro-Bypass Stent for the Cataract Surgeon Moderator: T. Samuelson USA

Sponsored by Sponsored by

Improving Ocular Surface Outcomes with Advanced Therapeutics Moderator: B. Cochener–Lamard

FRANCE

A. Denoyer FRANCE Medical management of dry eye: from old to new G. Garhöfer AUSTRIA Decoding inflammation in dry eye disease: advances in patient management J. Güell SPAIN Maintaining ocular health in cataract surgery R. Nuijts THE NETHERLANDS Strategies to streamline the flow of your cataract surgery list Sponsored by

Mastering Precision & Predictability: Biotech Premium IOLs & Challenging Cases Moderator: B. Toygar TURKEY Sponsored by

Johnson & Johnson Vision Satellite Meeting Sponsored by


Sunday 15 September Lunchtime Symposia Boxed Lunch Included 13.00 – 14.00 Targeting Refractive Outcomes Precision: Beyond the Innovations Moderator: F. Carones ITALY Sponsored by

Sulcoflex Trifocal: A New Opportunity for your Refractive Patients Moderator: M. Amon

New Gold Standards in OCT: 9mm Epithelial Thickness Mapping & AngioAnalytics OCTA Metrics

D. Reinstein UK 9mm ETM in keratoconus detection

Presbyopia and Toric IOL Correction: Keys to success with Multifocal and EDOF IOLs

A. El Maftouhi FRANCE The role of epithelial thickness mapping in dry eye

Moderators: B. Cochener-Lamard FRANCE O. Findl AUSTRIA

Moderator: M. Puech

FRANCE

M. Rispoli ITALY AngioVue OCT-angiography in AMD & diabetic retinopathy: 5 years follow-up M. Puech FRANCE The place of OCTA in the glaucoma imaging armamentarium in 2019 Sponsored by

What do you Expect from Glaucoma Surgery?

AUSTRIA

M. Amon AUSTRIA Sulcoflex platform: the journey through the supplementary IOLs and 12 years of clinical history R. Jayaswal UK Introduction to Rayner trifocal technology: a new refractive enhancement opportunity for patients R. Khoramnia GERMANY Scientific deep dive: clinical results from in-vivo and in-vitro competitor analysis A. Mularoni ITALY Trifocal platform that performs on any optic: long term follow up D. Holland GERMANY The unhappy pseudophakic patient: a new refractive opportunity with Sulcoflex Trifocal

Supported by an independent medical education grant from:

SMILE Equipped for the Future Moderator: D. Reinstein

UK

A. Filip ROMANIA LVC market and individual practices - driving the evolution with SMILE D. Reinstein UK Evaluating options in today’s refractive surgery for my individual patient J. Fernández SPAIN Aiming for perfection as the lowest standard P. Stodulka CZECH REPUBLIC What to expect? An update on SMILE hyperopia

Sponsored by

J. Hjortdal DENMARK What to expect? Intrastromal lenticule rotation for treatment of high astigmatism

Iridex Satellite Meeting

L. Mastropasqua ITALY What to expect? Options for clinical use of stromal lenticules

Sponsored by

Moderator: I. Stalmans

BELGIUM

I. Stalmans BELGIUM Welcome A. Bron FRANCE Unmet need in glaucoma surgery I.K. Ahmed CANADA Real world experience with PRESERFLO™ MicroShunt Panel discussion: I. Stalmans BELGIUM A. Bron FRANCE F. Aptel FRANCE I.K. Ahmed CANADA Sponsored by

Sunday 15 September Evening Symposium 18.15 – 19.45

Sponsored by

Palais Brogniart

Unique Brilliance: New IOL-Family with Segmented Optics & Innovative HybridHydrophobic Material

Innovations in Glaucoma and Cataract

INFOCUS: 2 Minutes to Enhanced OR Experience and Patient Selection! Debating the Topics Most Important to your Practice

Moderator: J. Alió

Moderator: S. Daya UK

Moderator: A. Brezin FRANCE

Sponsored by

SPAIN

Sponsored by

Sponsored by


Monday 16 September Lunchtime Symposia Boxed Lunch Included 13.00 – 14.00

Partnering to Drive Efficiency in your Practice Through Alcon Services and Solutions Moderator: M. Guarro SPAIN

Monday 16 September Evening Symposium 18.15 – 19.45

Sponsored by

Post-Cataract Infections: Prevention, Management and the Future

ORBIS International Symposium: Eye Care for Refugees

Moderator: F. Bandello

Moderator: R. Walters

ITALY

UK

F. Bandello ITALY Welcome and introductions

R. Walters UK Refugee eye care: introduction

B. Malyugin RUSSIA How to best manage postcataract infectious complications – case studies

N. Weil USA Eye care for refugees: the challenges

A. Mearza UK Post-cataract prophylaxis: the present and future T. Kohnen GERMANY LEADER7: a new approach in the post-operative period

S. Behshad USA Treatment of eye conditions amongst refugees R. Walters UK Refugee eye care: thanks Sponsored by

F. Bandello ITALY Q&A, summary and close Sponsored by

Presbyopia Correcting IOLs: Learning from Clinical Evidence

New Concept Monofocal IOL with Continuous Focus Moderator: D. Spalton UK D. Spalton UK Welcome and introduction M. Packer USA Optical comparison of a novel monofocal extended depth of focus IOL and a conventional bifocal extended depth of focus IOL F. Kretz GERMANY First-in-human clinical outcome and patient satisfaction with a novel extended-depth-of-focus IOL satisfying ISO standards for monofocal IOL G. Auffarth GERMANY First clinical experience with a new monofocal IOL with enhanced depth of focus D. Spalton UK Q&A and closing remarks

Moderator: S. Srinivasan UK Speakers:

Schwind Satellite Meeting Sponsored by

Innovative Solutions for Presbyopia and Refractive Errors

J. Fernández SPAIN M. Assouline FRANCE S. Srinivasan UK G. Scharioth GERMANY Sponsored by

Sponsored by

Robotized Ultrafast Photoemulsification of Cataracted Lens Moderator: S. Daya UK

Sponsored by

Optimising the Latest Medical Therapies and Modern MIGS for Glaucoma Cataract Patient Moderators: P. Denis FRANCE R. Bellucci ITALY Supported by an independent medical education grant from:

Sponsored by


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CATARACT & REFRACTIVE

THOMAS KOHNEN European Editor of JCRS

JCRS HIGHLIGHTS VOL: 45 ISSUE: 6 MONTH: JUNE

ABERROMETRY IN SHORT EYES

JCRS SYMPOSIUM

CONTROVERSIES in Cataract and Refractive Surgery

Sunday 15 September | 14.00 – 16.00 During the 37th Congress of the ESCRS, Paris, France

Chairpersons: T. Kohnen GERMANY (EUROPEAN EDITOR) W.J. Dupps USA (U.S ASSOCIATE EDITOR)

IOL calculations 14.00

D. Gatinel FRANCE Artificial intelligence

14.15

G. Barrett AUSTRALIA Modern IOL calculations

14.30

Discussion

Presbyopia-correcting IOLs 14.40

R. Mencucci ITALY EDOF

14.55

J. Alfonso SPAIN Trifocal

15.10

Discussion

Intraoperative antibiotics 15.20

A. Behndig SWEDEN Yes

15.35

A. Brezin FRANCE No

15.50

Discussion

16.00

End of session

Eyes with short axial lengths (ALs) tend to have less accurate refractive outcomes with cataract surgery than those with normal or long ALs. To determine which, if any, preoperative biometrybased formulas might work best in short eyes, researchers conducted a retrospective study of 51 eyes in 38 patients. The predicted residual refractive error was calculated preoperatively using Hoffer Q, Holladay 2, Haigis, Barrett Universal II and Hill-RBF formulas as well as using intraoperative aberrometry. Overall, intraoperative aberrometry was not significantly different from the best preoperative biometry-based methods for IOL power selection in short eyes. In particular, when intraoperative aberrometry disagreed with the preoperative prediction by more than 0.5D, the ability of intraoperative aberrometry to suggest a more emmetropic outcome was no better than chance. S. Sudhakar et al., “Intraoperative aberrometry versus preoperative biometry for intraocular lens power selection in short eyes”, Vol. 45, #6, 719-724.

ABERROMETRY IN HIGH MYOPES A prospective study of 79 eyes of 79 patients compared the accuracy of the Barrett Universal II, Haigis and Olsen formulas in calculating intraocular lens power in eyes with extreme myopia. In eyes with an axial length of 28.0-to-30.0mm, all three formulas were accurate. In eyes with axial lengths of 30.0mm or more, the Barrett Universal II formula was better than the Haigis formula. The accuracy of the Haigis formula in myopic eyes was affected by the axial length and keratometry value, whereas the accuracy of the Barrett Universal II and Olsen formulas was affected by axial length only. X. Rong et al., “Intraocular lens power calculation in eyes with extreme myopia: Comparison of Barrett Universal II, Haigis, and Olsen formulas”, Vol. 45, #6, 732-737.

RAY TRACING AND ABERROMETRY Investigators evaluated the accuracy of a new ray-tracing-based IOL power calculation method in a theoretical prospective study. The refractive spherical equivalent absolute error of the raytracing IOL power calculation method, based on individualised eye model data, a physical lens position predictor, retinal image quality metrics criteria for IOL power selection and exact IOL design information was calculated and compared with outcomes using the Barrett Universal II, Hill-RBF, SRK/T and Haigis formulas. There was no significant difference in absolute error between ray tracing and the Barrett Universal II or Hill-RBF. However, the absolute error was significantly lower compared with the Haigis and SRK/T formulas. The possibility to visualise the expected visual performance might facilitate IOL selection, the researchers note. N. Hirnschall et al., “Pilot evaluation of refractive prediction errors associated with a new method for ray-tracing–based intraocular lens power calculation”, Vol. 45, #6, 738-744. JCRS is the official journal of ESCRS and ASCRS

EUROTIMES | JULY/AUGUST 2019


ESCRS PARIS PREVIEW

ESCRS Heritage Lecture

AI at ESCRS

Interview with David Spalton SEE PAGE 31

How AI can be used in ophthalmology SEE PAGE 32

Exploring Paris

Enjoy the sights in beautiful Paris SEE PAGE 34 – 35

Paris welcomes ESCRS Thousands of ophthalmologists will attend the 37th Congress of the ESCRS in Paris, France, which convenes from 14-18 September 2019

T

he 37th Congress of the ESCRS promises to be one of the most exciting yet. “We will meet at the Paris Expo at Porte de Versailles,” says Professor Béatrice CochenerLamard, President of the ESCRS. “This new, state-of-the-art facility is Europe's largest convention centre and is the perfect setting for a meeting of our size. It is located in the heart of Paris, only 15 minutes from the Eiffel Tower, and is easily accessed by public transport, including the Métro, tramway and buses,” said Prof Cochener-Lamard. “We look forward to meeting thousands of doctors from all over the world and we will also welcome hundreds of companies in the largest ophthalmology exhibition in Europe,” she said. The highlights of this year’s Congress include the Main Symposia, Clinical Research Symposia, Best of The Best Review Session, the Video Awards, Young Ophthalmologists Programme and the Binkhorst Medal Lecture and the ESCRS Heritage Lecture. Prof Cochener-Lamard will have the honour of welcoming delegates to her birthplace France and she said she was especially pleased that Paris should host the Congress in the last year of her twoyear term as President of the ESCRS. This is the fourth ESCRS congress to

THE 37TH CONGRESS OF THE ESCRS BY NUMBERS

ESCRS President Prof Béatrice Cochener-Lamard

convene in Paris, with previous congresses taking place in the French capital in 1992, 2004 and 2010. “At the end of the days when we are engaged in stimulating discussion and debate, we should take the opportunity to explore

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Instructional Courses

76

this truly beautiful city,” said Prof CochenerLamard. “I look forward to welcoming you to the Paris Expo in September.” For more information on the Congress visit www.escrs.org and www.eurotimes.org

Surgical Skills Courses

5

Main Symposia

EUROTIMES | JULY/AUGUST 2019

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ESCRS PARIS PREVIEW

Thinking outside the box Ehud Assia MD will be delivering the Binkhorst Medal Lecture at the 37th Congress of the ESCRS in Paris. Cheryl Guttman Krader reports

E

hud Assia MD will be awarded the 2019 Binkhorst Medal during the opening ceremony of the 37th Congress of the ESCRS on Sunday 15 September. Dr Assia is currently Director of the Center for Applied Eye Research at the Meir Medical Center, Kfar-Saba, Israel, Professor of Ophthalmology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, and Medical Director, Ein Tal Eye Center, Tel Aviv, Israel. Speaking to EuroTimes, Dr Assia said that he is grateful and honoured to have been chosen as the next recipient of the Binkhorst Medal. “I feel that the Binkhorst Medal is a kind of lifetime achievement award that represents one of the highest levels of recognition that a cataract surgeon can receive,” said Dr Assia. “I am thankful to the committee members who selected me for this great privilege, and I am honoured to be joining a ‘club’ whose other members are known for the significant contributions they have made to the field.” Dr Assia is a prolific author of peerreviewed articles and book chapters and

I have always considered issues from different angles and with a non-conventional view because I believe that approach is what leads to creative new ideas Ehud Assia, MD EUROTIMES | JULY/AUGUST 2019

holds patents for several novel devices handpiece and this has not changed in and instruments. In his Binkhorst Medal the last 50 years since the early days Lecture, which is titled “Thinking outside of phacoemulsification. In my talk I the box: new perspective on current challenge some of these traditional surgical technologies”, Dr Assia will be concepts,” he said. speaking about the power that comes from “New technologies have been helpful challenging conventional thinking and for maintaining anterior chamber illustrating this point with examples of stability during phacoemulsification, but how assessing situations from a different still, the anterior chamber collapses and perspective led to his various innovations the IOP often drops to zero whenever the that are relevant to cataract surgery. phaco tip is withdrawn from the eye,” “Throughout my career I have said Dr Assia. been involved in research aimed at “My idea was to look at the situation developing new surgical devices from a different perspective and technologies. In doing so, I to identify a method for have always considered issues maintaining steady pressure from different angles and throughout surgery, with a non-conventional independent of the phaco view because I believe that handpiece, and utilising approach is what leads to an automated pump to creative new ideas,” he said. achieve continuous active In his talk, Dr Assia will maintenance of anterior begin by mentioning the sidechamber pressure.” view technique that he developed Ehud Assia MD In addition, instead of using only with Dr David Apple as a new method for BSS as the irrigating solution, Dr Assia studying the anterior chamber anatomy proposes using a diluted viscoelastic in post-mortem eyes. Also known as the substance, instead of BSS, which provides “keyhole technique”, it involves creating corneal endothelial protection and a uveoscleral window, and it provides allows a slow-motion operation, and a clear, three-dimensional view of the incorporating compounds that are free crystalline lens or pseudophakic implant, radical scavengers to protect against zonular apparatus and ciliary body. corneal endothelial damage caused by ultrasound energy-generated free radicals. PHACO FLUIDICS Dr Assia is working with industry partners to implement his innovations. The major portion of Dr Assia’s lecture In his Binkhorst Medal Lecture he will will be devoted to sharing the work he be presenting videos and a large bank has been doing to improve fluidics during of evidence from preclinical and clinical phacoemulsification and to maintain studies that demonstrate the concepts and corneal endothelial safety during cataract their benefits. surgery. His goal for developing new “The bottom line of my presentation is fluidics technology is to maintain stable that it’s time now for a second thought pressure within the anterior chamber on the conventional way we utilise phaco throughout the procedure. fluidics and there are so many things “My main focus and message relate that we can do to make this simple, yet to phaco fluidics,” he told EuroTimes. important, component of cataract surgery “Phaco surgery depends largely on fluid a much better surgical tool,” he concluded. irrigation and maintaining the volume of the anterior chamber and the intraocular The Binkhorst Medal Lecture will take pressure. For most surgeons this is done place on Sunday 15 September at 10.00 by using a passive irrigation of fluid in the Auditorium (BSS) delivered through the machine


ESCRS PARIS PREVIEW

“Couching, Kepler and charlatans” The ESCRS Heritage Lecture will take delegates on a journey through the rich and fascinating origins of cataract surgery Dermot McGrath reports

T

he renowned British surgeon and former ESCRS President David Spalton will deliver the second ESCRS Heritage Lecture at the 37th Congress of the ESCRS in Paris in September. Prof Spalton’s lecture will focus on the origins of cataract surgery, taking delegates on a journey through ancient Egypt, classical Greece, ancient Rome and the medieval period right through to the advent of extracapsular surgery in the late 18th Century. He will reveal the trials, tribulations and triumphs of cataract surgery as practised through the ages, describing a rich tapestry of medical history interwoven with characters such as Hippocrates, Celsus, Galen, Kepler, Rembrandt and many others. Prof Spalton told Eurotimes that he was honoured to have been asked to deliver the Heritage Lecture at the invitation of the Programme Committee of the ESCRS. At a time when ophthalmologists tend to focus obsessively on the latest technology, he said that it was important not to lose sight of the historical context that has brought cataract surgery to where it is today. “I think it’s a very important thing because quite a lot of today’s surgeons do not realise the rich history and the ways things have evolved to get to the point where we are today. We need to appreciate that cataract surgery, like other areas of medicine, was frequently a question of two steps forwards and one step backwards. I think it is timely and interesting and it adds a lot to the enjoyment of ophthalmology to know the history of it,” he said. As he acknowledges, the early history of cataract surgery is not easy to unravel. “There are a lot of conflicting accounts in the literature and many of the early descriptions

An image from Georg Bartisch’s 1583 manuscript ‘Ophthalmodouleia’, one of the first books on eye disease

are lost in translation, so it is hard to interpret their meaning with any certainty. However, there is good evidence that ‘couching’ was performed in India in about 600 BC and then came to ancient Greece and Europe around 300 BC through the conquests of Alexander the Great,” Prof Spalton said. Couching is the oldest traditional technique documented to treat cataract and involves the use of a sharp or blunt instrument to dislocate the cataract lens and push it back into the posterior segment of the eye. The results were hit-and-miss and an estimated half of patients treated by couching ended up blind. “It wasn’t until the 1600s that people really understood where the lens of the eye was

because the early descriptions always put the lens in the centre of the eye – I wonder if this was due to postmortem artefact?” he said. “The early surgeons thought they were removing a dry material between the lens and the iris, which they called hypochyma.” The ancient Greeks also subscribed to the “extramission’ theory of vision, the idea that light issued from the eyes towards objects, lighting up the world rather like car headlights on a foggy night. Galen thought that the lens was the organ of visual perception, said Prof Spalton, and this idea persisted until the 16th Century. The famous astronomer Johannes Kepler (1571-1630) was responsible for the truly revolutionary observation that the lens formed an inverted image on the retina. “Things outside the realm of optics do appear not to have interested him much, saying in the wonderful terminology that the inverted image was corrected ‘within the hollows of the brain by the spirit of the soul’ – so much for neuro ophthalmology!” Less salubrious characters such as Chevalier John Taylor will also get a mention in his wide-ranging lecture. “Chevalier Taylor was an itinerant quack who blinded Bach and Handel and who travelled around Europe blinding a lot of people,” said Prof Spalton. “There’s a lovely quote about him which goes: ‘Many elements go to the formation of the complete charlatan – bombast, effrontery, dishonesty, ignorance – all these qualities Taylor showed in perfection.’ It was interesting too to learn that – like myself and Harold Ridley – he also trained at St Thomas’ Hospital.” The ESCRS Heritage Lecture will take place on Monday 16 September at 10.30 in the Auditorium

Professor David Spalton trained at Moorfields Eye Hospital and had fellowships with the Royal College of Surgeons, the Royal College of Physicians and the Royal College of Ophthalmologists. He was Consultant Ophthalmic Surgeon at St Thomas’ Hospital where he now has Emeritus Status, the Royal Hospital Chelsea (the Chelsea Pensioners), King Edward VII Hospital and is Professor of Ophthalmology at King’s College, London. At St Thomas’ he specialised in complex cataract surgery and intraocular lens design, and is well known internationally for his interests in teaching, training and research. He is Past President of the ESCRS and of the United Kingdom & Ireland Society of Cataract & Refractive Surgeons (UKISCRS).

EUROTIMES | JULY/AUGUST 2019

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ESCRS PARIS PREVIEW

AI at ESCRS Paris 2019 This symposium will explore potential uses and issues in ophthalmology. Howard Larkin reports

A

dvanced artificial intelligence (AI) applications hold exciting potential in diagnosing and treating a wide range of diseases in healthcare and are already making an impact on current clinical practice in many disciplines. Ophthalmology is on the cutting edge of artificial intelligence (AI) in medicine. Indeed, the first AI device passed by the US FDA for use by nonspecialist clinicians was the IDx-DR, approved last year for the screening of diabetic retinopathy. Ophthalmic AI applications are rapidly developing for uses ranging from diagnosing and predicting glaucoma and macular degeneration, to identifying biomarkers for pharmaceutical development and use, to driving smart accommodating lenses, to assessing cardiovascular risk based on fundus images. This year’s 37th Congress of the ESCRS, Paris 2019, features a comprehensive symposium examining the state and future of AI in ophthalmology. Chaired by ESCRS President Béatrice Cochener-Lamard EUROTIMES | JULY/AUGUST 2019

MD, PhD, of France and Guy Kleinmann MD of Israel, the session will also explore potential issues involving AI use. The session is scheduled for 11.00 on Monday, 16 September.

ISSUES AND ADVANCES Prof Barry O’Sullivan PhD, director of the Insight Centre for Data Analytics at University College Cork, Ireland, will lead off with a discussion of ethics and AI. He conducts research into artificial intelligence, decision analytics and related areas, has presented on AI issues at the UN, and was recognised as researcher of the year by the Science Foundation Ireland in 2016. Anat Loewenstein MD, Tel Aviv, Israel, will review AI’s role in advancing age-related macular degeneration diagnosis, prognosis and treatment, including use of progression biomarkers identified by machine learning analysis of OCT images. Xiulan Zhang MD, Guangzhou, China, will present on AI in diagnosing glaucoma. His research focuses on glaucoma pathogenesis, early diagnosis,

individualised treatment and preciselytargeted intervention, as well as treatment for refractory and complicated glaucoma, neuroprotection and stem cell therapy. Gwénolé Quellec PhD, Paris, France, a leading biomedical engineer, will discuss generalising AI technologies including image analysis across ocular pathologies and imaging devices. His work includes automated assessment of AMD drusen, detection of microaneurysms and lesions in the retina and assessment of nerve head characteristics using OCT, fundus photography and other imaging devices. Dimitri Azar MD, Chicago, USA, will present research on using AI to develop a smart accommodating contact lens, providing a potential presbyopia treatment. The device is under development by Verily. Renowned roboticist Bradley Nelson PhD, Zurich, Switzerland, will deliver an update on robotics in ocular surgery. His work includes development of magnetic actuators for robotic surgery and intravitreal injections. Artificial Intelligence in Ophthalmology will take place on Monday 16 September at 11.00 in the Auditorium


ESCRS PARIS PREVIEW

YO Programme: Starting Phaco The young ophthalmologists programme will be one of the highlights of this year's ESCRS Congress. Colin Kerr reports

W

e can all learn from our mistakes. That is why the Young Ophthalmologists Programme (YOP) day-long session devoted to the topic of “Starting Phaco”, including ‘Learning from the Learners’, will be one of the highlights of this year’s ESCRS Congress. The Programme will be held on Saturday 14 September and will run from 08.30 to 16.00. During the Programme, which will be chaired by Oliver Findl, Simonetta Morselli, Filomena Ribeiro and Kaarina Vannas, young ophthalmologists will be taken on an instructive journey through the various key stages of phacoemulsification, from the initial incision through to hydro-dissection, fragmentation and IOL implantation. The emphasis will be on interaction and participation rather than passive learning, with young ophthalmologists submitting videos illustrating problems encountered or mistakes made in the course of their own early steps into cataract surgery. During the presentation, Dr Findl and his co-chairs will comment on the individual videos, suggesting how the YOs might have taken a different approach to ensure a better outcome. Dr Findl, Chairperson of the ESCRS Young Ophthalmologists committee said that the interactive nature of the Programme is very important. “It’s a brave thing to do, highlighting one’s errors for the benefit of discussion, in order to help others overcome similar situations that might crop up in their own surgeries,” he said. “Everybody can take something home, because these are the type of experiences that we all have as surgeons, particularly when we are starting out in our surgical careers,” he said. Dr Findl says it is also important to note that there are not always correct or incorrect answers when dealing with complex surgical challenges. “We have an experienced panel of surgeons and they will emphasise that

Panellists and presenters who attended the Young Ophthalmologists Programme at the 36th Congress of the ESCRS in Vienna in 2018

there are several different approaches which can be taken when dealing with a complication or an issue that arises during surgery.”

FEAR OF FAILURE While all ophthalmologists, young or old, will have an inherent fear of failure, the internationally acclaimed musician and writer Tracey Thorne has pointed out that there is a thin line between success and failure “…….failed job interviews, infertility, divorce, illness. Human frailty, vulnerability, and, ultimately, that one great failure none of us can avoid, mortality – they glue us together, or should do,” said Thorne in an article in the New Statesman magazine (New Statesman, 20 February, 2019). This view was also shared in a recent EuroTimes Eye Contact interview with Dr Sorcha Ní Dhubhghaill, Professor of Anterior Segment Surgery at Antwerp University Hospital (UZA) and a Consultant Surgeon at the Netherlands Institute for Innovative Ocular Surgery (NIIOS).

“There is a saying ‘The master has failed more than the trainee has tried’,” said Dr Ní Dhubhghaill. “When you see this amazing surgeon doing amazing surgery, so quickly and so elegantly, you may wonder ‘how will I ever get there’. “You have to remember that the surgeon you are observing did not come out of medical school doing that. They have had bad days, they’ve had failures.” Dr Ní Dhubhghaill said that part of her job as a mentor is to try and convince young surgeons not to quit out of the surgical programme. “Every young surgeon, when they have their first complication, sits at home, loses sleep and wonders ‘should I have let somebody else do this procedure?’ You need, as a mentor, to help them over these roadblocks because you have to remember that someone helped you over your roadblocks,” she said. The Young Ophthalmologists Programme will run all day on Saturday 14 September in South 2 EUROTIMES | JULY/AUGUST 2019

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EXPLORING PARIS

Caption

Sunset on the River Seine

PARIS

3

TO TRY...

MOTOTAXI If you are going to – or from – the Palais des Congrès from an airport in Paris you can save time and enjoy a novel experience – book a motorbike taxi. It comes with an experienced driver plus protective clothing that keeps you warm, dry and safe. The mototaxi can carry one piece of cabin luggage weighing around 12kg, plus a small bag or computer case. Rain or shine, you make the journey in approximately half the time taken by an ordinary taxi. There’s a time calculator on the website, but from CDG, for example, count on 40 minutes plus or minus five-to-seven minutes. No meter, a fixed cost, which to or from CDG to the Neuilly area is €85. For more details and to book online: les-taxis-motos.com

MOBILE CONCIERGE A concierge in your pocket for only €5 a day. Connect by SMS or phone with a real-life Parisian who will answer questions in your language. Your City Helper will book restaurants and attractions, outline sightseeing possibilities specifically tailored for you, instantly translate a menu or sign into your language and of course, help you deal with any emergency. The City Helpline app can be downloaded free on the App Store and the Google Play Store in a choice of languages. The service is currently available Monday through Saturday from 10.00 to19.00 local time but plans are to offer a 24-hour service later this year. https://www.facebook. com/ParisCityHelpline/

LAND A JET You probably can’t count how many times you’ve been a passenger strapped in your airline seat while the pilot prepared the flight for take-off and then again for landing. Here’s a chance to put yourself in his place. The world’s original Boeing flight simulator is in Paris, and for €199 you can give yourself a 60-minute experience to remember. After a 15-minute briefing you’ll choose which of the world’s airports you’d like to tackle and in what weather conditions. In high definition you’ll take it on. One or two friends can come along without charge. Shorter and longer flights available; see https://paris.flightexperience.fr/

EUROTIMES | JULY/AUGUST 2019

Only in Paris The City of Lights is a city of sights. Congress delegates should keep their camera ready, says Maryalicia Post

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here can you capture the best view of Paris? Notre Dame’s South tower always featured prominently on any such list; the effort of climbing the 387 steps in the narrow spiral staircase was repaid by an unforgettable panorama of Parisian rooftops. The tragic fire of April 15 removed this option for now, but many photogenic overviews of Paris remain, all worth seeking out – from the steps of Montmartre, to the banks of the Seine. And though the list has temporarily lost ‘something old’, there is also ‘something new’ – the viewing platform of a tethered balloon. The biggest hot air balloon in the world – the Ballon de Paris Generali – is a combination weather station and tourist attraction and it is moored in the Parc André Citroën in the 15th arrondissement. The basket of the helium-filled balloon can accommodate up to 30 people; there is plenty of room to walk around and enjoy the views from 150 metres above Paris on the 10-15-minute flight. The balloon flies daily – weather permitting – from 9am until 30 minutes before the park closes and costs €12 for an adult ticket. That ‘weather permitting’

is not a casual comment. It really does depend on the weather, principally the wind factor. You are asked to ring in the morning to confirm if flights are taking place on the day you plan to visit. Tel. +33 (0) 1 44 26 20 00; tickets available at the Ballon kiosk or online: https://www. ballondeparis.com A riverboat excursion on the Seine has always been a highlight of a visit to the city, as has dinner at a fine restaurant. Put them together and you have Ducasse sur Seine, a luxury sightseeing cruise centred on a gourmet meal afloat. The boat is electric-powered and silent; the meal is the creation of Ducasse, one of the premier chefs of France; the views of Paris are incomparable. Luncheon and dinner cruises offer a choice of menu and wine possibilities with prices ranging from €100 to €290. For an exceptional occasion, consider the ‘Paris est une fête’ cruise – a six-course menu paired with exceptional wines at a table offering unobstructed river views at €500 per person. Reservations can be made online at https://reservation. ducasse-seine.com Or plan a dinner-dance evening on a Bateau Mouche; the cruise is complete with orchestra and singer. You will enjoy a fine meal at a table next to the window from which you can admire the illuminated


EXPLORING PARIS

bridges and monuments along the Seine. The traditional French menu with a modern twist, is prepared on board by Chef Yves Gras and his team. A package, priced from €299 per person, is offered by Paris City Vision and includes pickup from your hotel in Paris and return. www. pariscityvision.com/en/privilege-dinnercruise-minibus If you’d rather stay ashore and admire the Seine up close, you’re not alone. In the 1800s, guinguettes were popular drinking establishments located in the suburbs of Paris often along the Seine. Both Monet and Renoir painted scenes of these lively outdoor venues where people came to drink guinguet, a sour white light wine produced in the vineyards of Clos Guinguet, on the

hills of a town called Belleville. After a slump in popularity in the 1960s and 70s, the guingette is again alive and well. Delegates to the Palais de Congrès meeting are near a charming example, La Guinguette de Neuilly. In bygone times, this was a cafe where boaters on the Seine shared a drink or a meal; the restaurant, with its old-fashioned stove and red benches, retains the character of those days. It is on the Île de la Jatte, in the Seine, about a 10-minute taxi ride from the Palais de Congrès. For more details and to book a table: www.la-guinguette-de-neuilly.com Delegates based in the 15th arrondissement will find a modern version of the guinguette nearby. La Javelle is a new, lively open-air establishment near the Parc André Citroën – the area where ‘eau de Javel’ or bleach was first manufactured. Come in the daytime to enjoy street food from around the world. In the evening there is dancing on the terrace. At any time, it’s a relaxed young atmosphere. Check out the La Javelle website for concerts, shows and Latin dance lessons. La Javelle is open every summer day from midday to midnight unless adverse weather intervenes. Season closes end of September. www.lajavelle.com While the Seine offers the most iconic views of Paris, the city’s canals are worth exploring too; there are 40km of waterways to discover. Hire a self-drive electric boat for yourself and up to 10 friends – you don’t need a license. Order a picnic basket in advance and enjoy it on board or at one of the parks along the way. If you would like a boat with a table specify that at time of booking. Important note: the driver of the boat must not drink alcoholic beverages. This rule is strictly enforced by the river police. Details at www.boating-parismarindeaudouce.com/

Dine aboard a Bateau Mouche on the River Seine

The view from Montmartre

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SERVICE WITH A SMILE? On going into any shop greet the staff with ‘bonjour’. (If there are other customers include them with a smile). In a bakery, for example, do not rush in and snap ‘one croissant’. Start with bonjour and end with merci. You can’t go wrong if you wait to be shown where to sit, even in an informal cafe. If in any doubt, just stand and look bewildered; someone will point you to a seat, and you’re off to a good start. Don’t feel rebuffed if sales attendants ignore you. In most cases the custom is for them to be available when/if you want help and to stay away until addressed. And, nothing personal, but a French waiter is not automatically your new friend. A smile may not be on the menu.

SPEAK THE LANGUAGE Don’t construe a runny omelette, bloody lamb or smelly cheese as indifference. Au contraire. It’s the way ‘they’ like it and they assume any reasonable person would as well. Make a polite request for a change if necessary. Use whatever French you have. I got used to asking a question in French, which would be answered patiently in English, leading to my next question in French, also answered in English… a kind of bilingual duet. When the answer comes in French, buy yourself a drink.

GETTING AROUND If you can’t walk to your destination even in your most comfortable shoes (which you should bring for this very purpose), take the Métro. The best reason for taking the Métro is to avoid taking a taxi. If you take a taxi you may well find yourself up close and personal with a very rude person indeed. He or she may pretend not to know where you want to go – I always write out the destination and show it in advance – or will bury you under an avalanche of explanations in French as to why he or she is approaching the city via Versailles.

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ESCRS PARIS PREVIEW

Managing stress Surgeons can learn how to cope with stress at one of the major symposia in Paris

EUROTIMES | JULY/AUGUST 2019

Courtesy of Casper Tybjerg

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tress, anxiety and depression are all common factors of modern life. With everything from work to politics and sports likely to cause a spike in blood pressure, it’s almost impossible to avoid stressful aspects of life. The medical profession is no different. Recent research published in The BMJ showed that the risk of depression was 66% in medical students with high levels of burnout, with 35% of clinical students showing high levels of burnout, up from just over 25% in pre-clinical students. While ophthalmologists are regularly shown to be among the most satisfied with their chosen field in medicine, it is still essential to watch for and manage stress. This can manifest itself both in terms of operating on patients and in the day-to-day running of a clinical practice, with all its associated paperwork, overheads and so forth. A special symposium at the 37th Congress of the ESCRS in Paris will look at this particular factor of life for the ophthalmologist. In a wide-ranging series of talks, doctors can see how to manage specific difficult cases and complications, as well as learning about stress on a broader level, and having the opportunity to learn techniques to combat stress in the moment. Doctors will talk about complications like the running out rhexis (Brian Little, UK), the constricting pupil (Boris Malyugin, Russia), the wobbling lens (Vladimir Pfeifer, Slovenia), the challenging phakic IOL (José Güell, Spain) and the DMEK flap upside down (Marc Muraine France). There will also be discussions on understanding and quantifying stress (Michaela Bayerle-Eder, Austria, and Stefan Palkovits, Austria). Dr Palkovits will discuss quantifying the stress of the surgeon during surgery itself. Using a tool called Neuromaster to evaluate different stress parameters including sweating, heart rate and respiration, his department measured surgeons of different skill levels during cataract procedures. They then evaluated a range of methods to help reduce stress. Dr Palkovits will present this work as well as examining other methods of qualifying stress. These talks are aimed at cataract surgeons, those performing IOL implantations and corneal procedures. But

Stig Severinsen, who will be delivering a lecture on “Relaxing the surgeon: stress control for your next surgery” during the Young Ophthalmologists Symposium

it’s not just the surgeon who needs to be at ease for these surgeries to be successful. Andrew Presland from the UK will give a talk on relaxing the patient, who must never be forgotten in discussions about surgery! One of the highlights of the 22nd Winter Meeting of the ESCRS in Belgrade was a talk given by record-breaking freediver and motivational speaker Stig Severinsen, Denmark. He spoke about Breatheology, a method of breath control that can help shift the way doctors respond to stress.

Courtesy of Vasilios Diakonis MD, PhD

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CONTROLLING YOUR MIND “Nothing is more powerful than breath control,” Mr Severinsen told ET Today. “The way you breathe is the way you feel, so when you breathe too quickly it is not productive. It produces adrenaline, it increases the heart rate, it gives you less ability to co-ordinate your movements. With surgery, that is not what you want.” Speaking about the benefits of controlled breathing, he continued: “When you control your breathing, you control your mind and you don’t go into the negative spiral of panic. Panic leads to bad decisions and will not optimise your surgical precision.” Mr Severinsen will be speaking in Paris on “Relaxing the surgeon: stress control for your next surgery”. Anyone who

Panellists at the Keep Calm: Stress Management During Cataract Surgery symposium during the 22nd ESCRS Winter Meeting in Belgrade, Serbia

attended the presentation in Belgrade will know that a fascinating and entertaining talk awaits. This Symposium will be of great interest to young ophthalmologists starting their careers as well as more seasoned colleagues who may be looking for a new approach to stress both in and away from the workplace. Surgeons Under Stress will take place on Sunday 15 September at 11.00 in the Auditorium


RETINA

Treating retinal vascular disease New anti-VEGF molecule aims to reduce burden of treatment. Dermot McGrath reports

A bright vision on illumination

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novel anti-VEGF antibody biopolymer conjugate currently undergoing clinical trials aims to significantly reduce the burden of treatment associated with intravitreal injections by delivering enhanced efficacy and ocular durability, according to J. Pablo Velazquez-Martin MD. “This new antibody biopolymer conjugate (ABC) aims to improve real-world outcomes of anti-VEGF therapy, which are currently restricted by treatment burden and insufficient durability of existing anti-VEGF agents,” he told delegates attending the 9th EURETINA Winter Meeting in Prague. KSI-301 is an antibody stably linked to a biopolymer with a high molecular weight. The combination belongs to a new class of molecules: antibody biopolymer conjugate, or ABC, medicines. KSI-301 was designed to optimise both size and formulation strength to improve durability in the eye, said Dr Velazquez-Martin. “This agent clinically targets VEGF using an intravitreal injection in an optically clear solution with no ocular residues. However, unlike current anti-VEGF agents, KSI301 is designed for ocular durability, fast systemic clearance and improved bioavailability, biocompatibility, and stability,” he said. In a recent phase I study, KSI-301 was tested for safety on previously-treated or naïve subjects with diabetic macular oedema (DME). The open-label, single ascending dose study at five different centres in the United States included nine study eyes, three per dosing cohort, who received a single dose of KSI-301 (1.25mg, 2.5mg or 5mg) via a standard intravitreal injection and were then followed for 12 weeks. In terms of safety outcomes, no drug-related adverse events, intraocular inflammation or dose-limiting toxicities were observed. “The absence of intraocular inflammation is very important for a new molecule. The study eyes all showed optically clear media after each injection. No anti-drug antibodies were detected in any patient and all dose levels were well tolerated,” he said. Patients also showed improvements in vision and retinal thickness after single-dose administration of KSI-301 over the 12-week follow-up period. “Rapid-onset, high-magnitude improvements in bestcorrected visual acuity with corresponding reductions in macular thickness on OCT were observed at all dose levels and the median improvements were durable out to 12 weeks,” noted Dr Velazquez-Martin. Further studies of the drug are planned in the near future, including an ongoing phase Ib trial evaluating multiple doses in treatment-naïve wet AMD, DME and retinal vein occlusion (RVO) and a phase II trial in treatment-naïve wet AMD with dosing as infrequently as every 20 weeks after the initial loading phase. “The objective is ultimately to make this the ‘go-to drug’ for induction and maintenance therapy of retinal vascular diseases,” concluded Dr Velazquez-Martin. J. Pablo Velazquez-Martin: pablov@kodiak.com

Directional Chandelier system delivers illumination where you need it

Directional function Patent Pending

29G Spotlight Directional Chandelier A new generation chandelier with major improvements in functionality and ease of use. • Directional Chandelier system designed to enhance illumination control • Wide view fiber tip for global endo-illumination • Easy insertion and fixation of the fiber with 29G valved entry system • 29G minimal invasive incision

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vitreq.com

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RETINA

Inherited

RETINAL DISEASE Research is slowly unlocking the secrets of ABCA4 in retinal disease. Dermot McGrath reports

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esearchers have identified a number of promising therapeutic strategies for a range of retinal diseases associated with mutations in the ABCA4 gene, some of which are entering human trials in the next few years, according to Caroline Klaver MD, PhD. “The ABCA4 gene is one of the most implicated genes in retinal dystrophies and it is also a bit further ahead of any of the other genes in terms of potential therapies. It is very important to register patients with ABCA4-related disease into a national database so they can be evaluated for inclusion in future trials, many of which will be commencing over the next few years,” she told delegates attending the 9th EURETINA Winter Meeting in Prague. The ABCA4 gene is a complex molecule that is part of the family of ATP-binding cassette (ABC) transporters and is expressed exclusively in retina photoreceptor cells, explained Dr Klaver. Mutations in ABCA4 lead to accumulation of A2E, a toxic lipofuscin fluorophore, resulting in atrophy of the retinal pigment epithelium (RPE) and death of the photoreceptor cells. Many blinding diseases are associated with these mutations including Stargardt’s disease, cone-rod dystrophy, retinitis pigmentosa (RP) and increased susceptibility to agerelated macular degeneration. “The gene has a very important and complex role in the visual cycle. It transports vitamin A and suppresses accumulation of A2E. When it does not function well there is an accumulation of toxic A2E, which eventually causes the RPE cell to die after lipofuscin deposits are formed. That whole process can be suppressed by rearing the photoreceptor cell in darkness or by inhibiting the RPE65 gene,” she said. Although Stargardt’s disease used to be considered a juvenile macular dystrophy, that definition no longer holds true, Dr Klaver noted. “It most commonly presents in the second or third decade of life but some cases present really late, after the age of 75. We know that these cases are not just AMD EUROTIMES | JULY/AUGUST 2019

Caroline Klaver MD, PhD

because these patients have mutations in the ABCA4 gene. In general, the later the onset the better the prognosis. The earlier the onset the much harder the diagnosis can be in terms of phenotype because there are so few distinguishing features to identify. The classic textbook Stargardt’s disease is usually intermediate onset with characteristic yellow-white flecks on fundus autofluorescence (FAF) imaging, and a progressive bilateral visual loss,” she said. While electroretinogram (ERG) testing is not commonly performed in Stargardt patients, it can prove useful as a prognostic tool, said Dr Klaver. “Recent studies have shown that ERG abnormalities worsen prognosis, and the progression of RPE atrophy goes faster for these patients. Most of the lateonset Stargardt has some form of foveal sparing but it can develop to severe visual impairment after the diagnosis,” she said. A number of novel interventions are currently under investigation to treat Stargardt’s disease, including stem cell therapies, gene therapy and pharmacological approaches, said Dr Klaver. Human embryonic stem cells (hESC) transplantation has shown potential as a treatment option for Stargardt’s disease.

Two prospective phase I/II studies in the United States reported good safety and tolerability of subretinal transplantation of hESC-derived retinal pigment epithelium in nine patients with Stargardt’s disease, with further trials planned in the near future. In terms of gene therapy, the SAR422459 trial, previously known as StarGen, uses a lentivirus as the vector to deliver the corrected ABCA4 gene into the host cell. The Phase I/IIa dose-escalation trial is currently ongoing at centres in France and the United States. A number of pharmacological agents are also under development, many focusing on the prevention of lipofuscin accumulation associated with Stargardt’s disease, said Dr Klaver. The most advanced of these is emixustat, which is currently undergoing a phase III clinical study of 160 patients at 30 sites worldwide. Emixustat modulates the visual cycle by inhibiting RPE65 and slowing the visual cycle to reduce the availability of vitamin A derivatives to form precursors of A2E and related compounds. Another compound currently entering phase II trials is remofuscin, which targets the harmful lipofuscin in the RPE cell, concluded Dr Klaver.


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

Francesco Bandello ITALY

Richard Lecture Grazia Pertile ITALY

Saturday 22 September

IV

WORLD RETINA DAY

DAY

Kreissig Lecture Jost Jonas GERMANY

Including the Ophthalmologica Lecture

Rosa Dolz Marco SPAIN

www.euretina.org


Thursday 5 September

Friday 6 September

Friday 6 September

Boxed Lunch Included 13.00 – 14.00

9.45 – 10.45

Boxed Lunch Included

Lunchtime Symposia

Transforming DME Clinical Practice Moderators: A. Loewenstein ISRAEL B. Kuppermann USA

Morning Symposia

Keeping a Step Ahead of the Disease: Proactive Treatment for nAMD Moderator: L. Kodjikian FRANCE

Lunchtime Symposia 13.00 – 14.00

Ranibizumab in Retinal Diseases Moderator: R. Tadayoni FRANCE Sponsored by

Sponsored by Sponsored by

Clinical Applications of Swept Source OCT & Angiography Moderator: P. Keane UK Sponsored by

Photobiomodulation: An Innovative, Mitochondriatargeted Therapy for Dry AMD and Other Ocular Diseases (An Update) Moderators: J. Eells USA M. Munk SWITZERLAND

Sponsored by

ILUVIEN for the Prevention of Relapse in Recurrent Non-infectious Uveitis Affecting the Posterior Segment of the Eye Moderator: B. Bodaghi FRANCE

Sponsored by

A New Vision in Retinal Gene Therapy: From Clinical Trials to Clinical Practice Moderator: B. Leroy BELGIUM

Translating Molecular Properties to Patient Outcomes Moderator: F. Behar-Cohen FRANCE Sponsored by

Sponsored by

Seeing the Invisible Transparent Subthreshold Treatment with Navigated Microsecond Pulsing Laser Moderator: G. Staurenghi ITALY

Breaking the Cycle of Recurrence in DME: Where Research Meets Clinical Practice Moderator: L. Kodjikian FRANCE Sponsored by

Sponsored by

Take Another Look: Uncovering New Advances and Future Applications of Ultra-widefield Moderator: T. Peto UK Sponsored by


Friday 6 September

Saturday 7 September

Saturday 7 September

Boxed Lunch Included

9.45 – 10.45

Boxed Lunch Included

Lunchtime Symposia 13.00 – 14.00

Morning Symposia

Lunchtime Symposia 13.00 – 14.00

Illuminating the Role of Angiopoietins in Retinal Diseases

The Vitreoretinal Procedure - Integration, Stability, Speed

New Horizons in nAMD Treatment

Moderator: J-F. Korobelnik FRANCE

Moderator: R. Tadayoni FRANCE

Sponsored by

Moderator: F. Holz GERMANY

Sponsored by Sponsored by

New Mirante Multimodal Imaging and OCT-A Analytics Can Help Breakthrough Tricky Cases of Retinal Disorders Moderator: G. Staurenghi ITALY

Sponsored by

Reimagine your Retina Surgery with Bausch + Lomb Moderator: Y. Le Mer FRANCE Sponsored by

Aflibercept in DME: Designed for Unsurpassed Vision Gains and Optimized Patient Outcomes Moderator: J-F. Korobelnik FRANCE

Ready for Prime Time: Clinical Evidence of Advances in 27G Surgery Moderator: P. Stalmans BELGIUM Sponsored by

Sponsored by

nAMD Management: Beyond the Horizon Moderators: F. Bandello ITALY A. García-Layana SPAIN Sponsored by

Applying Advanced Digital Technology in Practice Sponsored by

Complement C3 Inhibition in Geographic Atrophy Moderator: F. Holz GERMANY Sponsored by

Innovation and Opportunities in Retinal Diseases? Moderator: A. Tufail UK Sponsored by

Management of Retinal Diseases with Subliminal Laser Therapy Moderator: V. Chong UK Sponsored by

Delivering the Future of nAMD Management Moderator: R. Tadayoni FRANCE Sponsored by


RETINA

HIGH-PRECISION T R E AT M E N T S

with robotic assistant A new surgeon-controlled robot can nearly eliminate hand tremor in retinal surgery. Leigh Spielberg MD reports

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itreoretinal surgery requires a level of precision that pushes the boundaries of what is humanly possible. The need for accuracy is high and the margin of error is very low, considering the Marc de Smet MD fragility of the tissues in the posterior segment. The successful outcome of such vitreoretinal procedures requires during the surgical procedure. fine motor skills of the greatest precision. The goal of the robot is not to replace A Dutch company, Preceyes, has the surgeon, nor is it intended to developed an intuitive, surgeon-controlled perform surgery independently. Instead, robot to assist surgeons. The robotic “the robot supports the surgeon by assistant, called the Preceyes Surgical improving existing surgery and enabling System (PSS), scales down the movements of the surgeon’s instruments inside the eye, translating larger movements into smaller ones. By doing so, it nearly eliminates hand tremor, adding a level of precision to what are already finely tuned manoeuvres. The precision of robotassisted movements in the eye is enhanced at least 10-fold and made tremorfree as compared to manual movements by the surgeon. This allows for an intraocular precision of 10 microns or less. This precision, combined with standby functionality and automatic instrument retraction in case of patient motion decreases the surgeon’s stress Koorosh Pouya MD performing the first robotic peeling with the Preceyes system

We’re certainly not the first to approach the concept of vitreoretinal robotics, but we were the first to get into the eye

Courtesy of Koorosh Faridpooya MD

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EUROTIMES | JULY/AUGUST 2019

the development of new, high-precision treatments”, says Preceyes’ Chief Medical Officer, Marc de Smet MD. The PSS assists not only with the movements, such as membrane peels and subretinal injections. It can also be used simply to hold an instrument, such as a light pipe used to illuminate the retina. This static positioning eases surgeon strain and allows him or her to concentrate on the task at hand. “We’re certainly not the first to approach the concept of vitreoretinal robotics, but we were the first to get into the eye,” said Dr de Smet, who described the four different robotic concepts in eye surgery: the handheld tool, instrument comanipulation, instrument telemanipulation and magnetic control. Each varies in the degree to which the robot can filter tremors, scale motion and allow automation. Preceyes collaborated with the Rotterdam Eye Hospital (REH) to initiate the world’s first clinical trial of a robot in routine vitreoretinal surgery. The goal of the study was to evaluate the robot’s ability to improve both the precision & reproducibility of surgical tasks in everyday vitreoretinal surgery, seeking to reduce the burden on surgeons and improve outcomes. Specifically, can the PSS robot help the surgeon perform the peel more precisely


RETINA and reproducibly than the surgeon alone? To answer this question, Preceyes and the REH joined forces to initiate a randomised, prospective, open-label surgical intervention study to compare robotic assistance to standard manual surgery. A total of 15 patients are being randomised for this study: 10 patients will be operated on using the robot and the remaining five patients will be operated on in the traditional manner. The outcomes include feasibility and safety profile, surgery duration; number of attempts required to initiate and peel the membrane; and anatomical and functional outcomes at one and three months after surgery. Koorosh Faridpooya MD, senior retinal surgeon and primary investigator at the REH, has been collaborating with the Preceyes team. He recently performed the first complete robot-assisted peeling of an epiretinal membrane (ERM). “This is an important step in vitreoretinal surgery. It was the first time that all steps other than the vitrectomy and laser, were carried out during an a complete ERM peeling with robot assistance. The robot helped increase the accuracy of peeling, which is the crucial component of the procedure. We therefore expect that we will be able to reduce the number of complications and ultimately improve patient outcomes. The robot will allow us to develop new revolutionary treatments for some eye diseases that till now are almost impossible to perform manually.” As a vitreoretinal surgeon myself, I was recently invited to test the PSS. I was most impressed with the scaling down of movement and the intuitive nature of the robot’s control mechanism. The scaling down of movement can be compared to the stabilising effect of a gimbal, an electronic tool used in cinematography

Dr Spielberg using the PSS robotic system coupled to the EyeSi simulator during the 18th EURETINA Congress in Vienna

The robot helped increase the accuracy of peeling, which is the crucial component of the procedure Koorosh Faridpooya MD and is now available to consumers. A gimbal smoothens the motions of a video camera, eliminating abrupt movements and shaky images, vastly improving the quality of the finished product. Dr de Smet echoed my sentiments, noting that other surgeons who had tested the robot found “the use of the forceps fully operated by the robot with multiple grabs to peel a membrane as the most

TURKISH LANGUAGE EDITION IS ONLINE

impressive part of the operation, closely followed by the fact that interchangeable instrument tips can be placed on the robot to carry out different tasks”, before adding: “The surgeon can, in essence, choose the instrument he or she needs and use it with the robot, and use it with high precision.” Marc de Smet: doctors@retina-uveitis.eu

Türkiye

Visit: www.eurotimesturkey.org

EUROTIMES | JULY/AUGUST 2019

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RETINA

Gene therapy with new medical device First optogenetic trial for retinitis pigmentosa under way. Dermot McGrath reports

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EURETINA is delighted to host the

8th Retina Race at the 19th EURETINA Congress in Paris

Date: Saturday 7 September 2019, 6.30am Online & Onsite Registration Fee: €45 in Aid of Orbis* *The registration fee includes €30 donation to Orbis, start number, chip, official race t-shirt, first aid, bag deposit service, changing location and refreshment points

Information at www.euretina.org

novel optogenetic therapy for retinitis pigmentosa has commenced its first clinical trial in humans with early results of the initial cohort expected later this year, according to Barrett Katz MD. “There is no therapy at the moment for this family of diseases and because of the multitude of genetic contributions the strategy for intervening has to be different than a treatment that is directed against any one gene,” he told delegates attending the 9th EURETINA Winter Meeting in Prague. Dr Katz noted that this is the first ever study in humans of a combined gene therapy and medical device. The gene therapy is administered via a single intravitreal injection and then combined with special optronic goggles to enhance effects of the light sensitive protein encoded into the gene. “The therapy transfers the ChrimsonR gene, which encodes for a light-sensitive protein into the retinal ganglion cells. It effectively changes the retinal ganglion cells into photoreceptors, thereby making them responsive to light and bypassing destroyed photoreceptors,” he said. The special goggles are required because cells expressing optogenetic proteins are less light-sensitive than normal photoreceptors, explained Dr Katz. “ChrimsonR would not be activated by usual ambient light, so we intensify the projection system focus using a wavelength of 590nm. The goggles also capture the visual scene in realtime, processes it on to a beam of amber light and projects this on to the transfected retina,” he said. The open-label open-masked non-randomised dose escalation study is being conducted at three centres: Moorfields Eye Hospital in the UK, Quinze-Vingts Hospital in France and the University of Pittsburgh Medical Center in the United States. Eligible patients in the three cohorts are all affected by endstage non-syndromic retinitis pigmentosa with very severe vision loss. The patients will be administered an increasing dose of the therapy via a single intravitreal injection in their worse affected eye. The primary outcome analysis will be the safety and tolerability at one-year post-injection, noted Dr Katz. Functional tests involving mobility and orientation tasks will also be performed as part of the trial. “This is the first combined intervention of gene therapy and a medical device in humans. If this technology is shown to be effective it will be easily transferable to any disease in which the photoreceptors are gone but the ganglion cells are preserved. The compelling possibility and promise, of course, is to be able one day to use this therapy for a disease such as dry AMD,” concluded Dr Katz. Barrett Katz: bkatz@gensightbiologics.com

EUROTIMES | JULY/AUGUST 2019

The therapy transfers the ChrimsonR gene, which encodes for a lightsensitive protein into the retinal ganglion cells Barrett Katz MD


RETINA

SEBASTIAN WOLF Editor of Ophthalmologica

OPHTHALMOLOGICA VOL: 242 ISSUE: 1 PREMIER EDGE® Microsurgical Knives

EVIDENCE SUPPORTS ANTI-VEGF FOR CME SECONDARY TO BRVO A new meta-analysis appears to confirm the safety and efficacy of anti-vascular endothelial growth factor (anti-VEGF) therapies for patients with cystoid macular oedema secondary to branch retinal vein occlusion (BRVO). The meta-analysis included a total of 1,236 eyes from 22 peer-reviewed randomised controlled trials and observational studies identified using PubMed, Embase and Cochrane electronic databases. The analysis showed that, overall, anti-VEGF treatment improved best-corrected visual acuity at 12 months by a mean of 14 letters (p<0.001) and reduced central foveal thickness by a mean of 228 µm (p<0.001). Furthermore, the BCVA gains persisted at 24 months with a mean gain of 12.5 letters (p<0.001) as401 well as reduction of CFT of 238 µm (p<0.001) compared to baseline values. No cases of endophthalmitis or glaucoma were reported in any study. K Spooner et al, “Current Outcomes of Anti-VEGF Therapy in the Treatment of Macular Oede0ma Secondary to Branch Retinal Vein Occlusions: A Meta-Analysis”, Ophthalmologica 2019, Volume 242, Issue 1.

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BILATERAL SAME-DAY INTRAVITREAL ANTI-VEGF INJECTIONS APPEARS SAFE Same-day bilateral intravitreal anti-VEGF injections have a low rate of complications and are well tolerated, according to the authors of a retrospective study. The single-centre study included 524 eyes of 262 patients who underwent an average of 18.7 concomitant bilateral intravitreal anti-VEGF injections. The incidence of endophthalmitis was 0.01%, and there were two episodes of acute intraocular inflammation among the 9,798 injections (0.02%). There were two deaths (0.76%) due to non-vascular causes but no vascular-related systemic adverse events were reported. VR Juncal et al, “Same-Day Bilateral Intravitreal Anti-Vascular Endothelial Growth Factor Injections: Experience of a Large Canadian Retina Center”, Ophthalmologica 2019, Volume 242, Issue 1.

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NO EXCESS IOL TILT OR DECENTRATION AFTER COMBINED CATARACT SURGERY AND VITRECTOMY Compared to balanced salt solution, air tamponade does not induce significantly more tilt or decentration of the IOL in combined phacoemulsification and vitrectomy procedures, according to the findings of a new randomised study. In 34 patients scheduled for the combined procedure, tilt of the IOL was on average 4.1±1.9°, without significant differences between the balanced salt solution and air tamponade groups (p=0.462). There were also no significant differences between the groups regarding decentration, which had an overall mean value of 0.31mm (p=0.42). C Leisser et al, “Effect of Air Tamponade on Tilt of the Intraocular Lens after Phacovitrectomy” Ophthalmologica 2019, Volume 242, Issue 1.

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45


GLAUCOMA

Glaucoma meets AI Researchers are employing deep learning to tackle the challenges of glaucoma diagnosis. Cheryl Guttman Krader reports

R

esearchers at the National University of Singapore are aiming to apply deep learning to optical coherence tomography (OCT) images in order to modernise and simplify the diagnosis of glaucoma and to obtain a better understanding of how the disease progresses over time. At the annual meeting of the Association for Research in Vision and Ophthalmology (ARVO) in Vancouver, Canada, Alexandre Thiéry PhD discussed the work being done by the Optical Coherence Tomography & Artificial Intelligence for Glaucomatous Optic Neuropathy (OCTAGON) team. Dr Thiéry is Professor, Department of Statistics and Applied Probability, National University of Singapore, and is co-principal investigator of OCTAGON with Michaël JA Girard, PhD, Professor of Biomedical Engineering, National University of Singapore, Singapore. Dr Thiéry explained that the project focuses on the optic nerve head because it represents the main site of glaucoma damage, and it is based on threedimensional (3D) segmentation. “Glaucoma is a complex disease that affects connective and neural tissues with 3D structural changes. By exploring these 3D structures, we can provide a diagnosis and prognosis of glaucoma more accurately than current gold standards,” Dr Thiéry said. Dr Girard told EuroTimes: “In fact, we have empirically proven that our method is 30% more accurate at diagnosing glaucoma than traditional methods based on fundus imaging or retinal nerve fiber layer thickness assessment.”

BUILDING THE SYSTEM First, the OCTAGON researchers used deep learning to develop an algorithm that could automatically and robustly segment the optic nerve head using a raw OCT scan. “Our method produces expert-level 3D segmentation and is device robust in the sense that it is agnostic to whatever OCT machine is being used for the imaging,” said Dr Thiéry. The software computes in 3D the following unique parameters: prelaminar depth, prelaminar thickness, lamina cribrosa depth, lamina cribrosa curvature, peripapillary scleral angle and choroidal thickness. “People have been focusing on retinal nerve fiber layer thickness as a diagnostic EUROTIMES | JULY/AUGUST 2019

Courtesy of Alexandre Thiéry PhD

46

Reflectivity 4.0: a 3D AI companion to simplify and improve glaucoma management

parameter for glaucoma. The main advantage that we see for our approach is that we are able to extract parameters that are highly correlated with glaucoma but that are impossible to measure accurately with conventional methods,” said Dr Thiéry. He added that the algorithm also allows development of interactive software and image enhancement technologies that permits practitioners to annotate the OCTs, explore the optic nerve head and enhance visualisation to ultimately better understand the disease.

DEVELOPING THE DIAGNOSTIC TOOL In order to develop an algorithm that could accurately diagnose glaucoma, the team tried initially to use conventional deep learning techniques. After working for several years without success, they turned instead to a different approach. “Conventional artificial intelligence methods are completely unable to capture the complexity of the 3D disease, and more advanced methods were necessary to provide a more accurate diagnosis,” Dr Girard told EuroTimes. First, a neural network was trained with raw OCT volume data in order to segment the neural and connective tissues of the optic nerve head, as well as to extract all of the structural information contained in the OCT volume data. In a second stage, to obtain a robust glaucoma diagnosis, the raw OCT signal,

segmentation information and all of the structural 3D parameters were blended into another neural network. Recognising that conventional neural networks do not model uncertainty well, the OCTAGON team also implemented advanced Bayesian methods to achieve more robust probabilistic forecasts. “If you use a conventional neural network to predict whether or not a person has glaucoma, the probabilistic predictions are typically not well calibrated. Indeed, standard deep learning methods are known to not model uncertainty well – that is a big issue when used for medical diagnosis.” Dr Thiéry said. To translate the 3D artificial intelligence technologies developed by OCTAGON (http://bit.ly/ ET-OCTAGON) for commercial use, Dr Thiéry and Dr Girard founded a start-up company, Abyss Processing (http://abyssprocessing.com/), and its 3D artificial intelligence software is now available. “Reflectivity v4.0, which is the latest version, offers unique features for glaucoma diagnosis and prognosis, and it is more powerful than its predecessor as it improves visibility of the optic nerve head in the OCT images through the ability to remove noise, shadows and artefacts,” Dr Girard said. Alexandre H Thiéry: a.h.thiery@gmail.com Michaël JA Girard: mgirard@nus.edu.sg


ESCRS

Glaucoma Day 2019 Friday 13 September Pavilion 7, Paris Expo, Porte de Versailles Challenges in Medical and Surgical Management of Glaucoma Organisers: B. Malyugin RUSSIA, R. Bellucci ITALY, P. Denis FRANCE, L. Pinto PORTUGAL, G. Sunaric Megevand SWITZERLAND, C. Traverso ITALY

Scientific Programme will include: • Early glaucoma: diagnosis and management in the context of cataract and refractive surgery

• Critical thinking on glaucoma management • Glaucoma surgery today • My most challenging glaucoma surgery • Audience interaction and voting • Debates

13.00 – 14.00

Navigating the MIGS Maze Moderator: I.P. Singh Sponsored by

glaucomaday.escrs.org

USA


48

GLAUCOMA

Glaucoma microsensors Injectable devices that can monitor IOP and adjust therapy 24/7 are on the horizon. Howard Larkin reports

M

icroelectronics now in development may soon solve one of the biggest problems in managing glaucoma â&#x20AC;&#x201C; detecting and responding to fluctuations in intraocular pressure (IOP). An IOP microsensor small enough for a mouse eye already exists, and a prototype 3mm x 6mm implantable device combining an IOP sensor with a drug reservoir designed to respond to IOP spikes is not far off, Marlene Moster MD told the Glaucoma Subspecialty Day at the 2018 American Academy of Ophthalmology Annual Meeting in Chicago. Further miniaturisation and integration will greatly improve the usability, reliability and affordability of such devices over existing 24-hour IOP monitoring devices, making them practical for widespread clinical use, she added. â&#x20AC;&#x153;Eventually, a series of ultra-miniature tools that communicate with each other will have the potential to transform not only our monitoring of pressure, but will enable more effective treatment of glaucoma in real time. In several years the sensors will be delivered through a needle at the slit lamp in your office,â&#x20AC;? said Dr Moster, of Wills Eye Hospital, Philadelphia, USA.



24-HOUR IOP MONITORING The value of continuously measuring IOP is well established, Dr Moster said. Studies going back more than 15 years show that IOP is generally higher at night than day, and when lying down rather than sitting (Liu, Zhang, Kripke, Weinreb. Invest Ophthalmol Vis Sci 2003; 44:1586-1590). More recently, contact lens sensor studies found patients with normal tension glaucoma have a wider range of IOP fluctuation than non-glaucoma patients (Tojo N et al. J Glaucoma 2017; 26(3): 195â&#x20AC;&#x201C;200); that sleep position affects IOP and may contribute to progression (Beltran-Argullo et al. Br J Ophthalmol 2017;101(10):1323-1328); and that larger IOP fluctuations may help identify patients at higher risk of visual field loss (De Moraes CG et al. JAMA Ophthalmol 2018; 136(7):779-785). However, while promising, current continuous IOP sensors have significant drawbacks, Dr Moster noted. Contact lens-based sensors are expensive â&#x20AC;&#x201C; about â&#x201A;Ź500 per single-use disposable lens plus â&#x201A;Ź6,000 for a handheld reader/charger â&#x20AC;&#x201C; and cumbersome, requiring an antenna mask to download data. Long-term accuracy issues also Marlene Moster MD have emerged in tests. Implantable monitors address the accuracy issue and eliminate expensive consumables, making them much easier to use, Dr Moster said. The current model of the Eyemate-IO (Implandata Ophthalmic Products, Hanover, Germany), which received the CE mark in 2017, has been implanted in the ciliary sulcus through a 3.2mm incision in 44 patients to date, with a planned reduction to 2.5mm in a future version.

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According to unpublished data, the current Eyemate-IO design has produced no instances of sterile inflammation, or angle narrowing, pigment dispersion or pupillary distortion seen in a trial of a bulkier early version tested in six patients in the ARGOS-01 study (Koutsonos A et al. Invest Ophthalmol Vis Sci 2015; 56(2):10639). The device has documented differences in the range of IOP fluctuation using different medications, which may help customise therapy. Versions in preclinical tests will allow standalone insertion into the suprachoroidal space or vitreous body. Similarly, the QSmart IOP pressure system (Qura Inc), in preclinical development, is incorporated into a posterior chamber IOL for insertion in dog eyes and may be attached to a capsular tension ring for humans. It communicates directly with devices or tablets and can issue real-time warnings of IOP spikes through wireless networks. A device measuring less than 1.0 cubic mm has been tested in mouse eyes (Ha D, et al. Biomed Microdevices 2012;14:207â&#x20AC;&#x201C;215. Bhamra H, et al. IEEE Trans Biomed Circuits Syst. 2017 Dec;11(6):1204-1215). Combining microsensors with micro-delivery devices could create system capable of detecting and immediately responding to IOP spikes, Dr Moster said. A 1mm x 2mm device with a 100-micron micropump is the wave of the future. Other developments that will make implanted sensors practical include eliminating handheld devices to recharge and read data, and improved battery life, which currently could reach 20 years. â&#x20AC;&#x153;The future is now,â&#x20AC;? Dr Moster concluded.


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50

CORNEA

Queen honours Dua with CBE EuCornea founding director and former president recognised for his services to ophthalmology

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

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P

rofessor Harminder Dua, founding director, board member and former president of EuCornea, has been appointed by Her Majesty Queen Elizabeth II as Commander of the Most Excellent Order of the British Empire (CBE) for Services to Ophthalmology. He received the honour for his services to eye healthcare, health education and ophthalmology. “I am humbled by this great national honour, which reflects the glory of the whole team and individuals and institutions that have influenced my career, in which the EuCornea among others, figures prominently. The thoughts and vision in the creation of EuCornea has been borne out and will endure through Time.” Professor Dua was one of the founding members of EuCornea and served as the society’s president from 2011 to 2013. He is currently Editor-in-Chief of JEuCornea, the official journal of EuCornea. Professor Dua also won international recognition when he and his research group discovered a previously undetected layer of the human cornea in 2013. The Pre-Descemet layer is now popularly known as Dua’s Layer. The discovery of Dua’s Layer was presented to the ophthalmic community for the very first time during the EuCornea Medal Lecture presented by Professor Dua at the EuCornea congress in Milan in September 2012. In 2009 he co-founded EuCornea with professors Vincenzo Sarnicola, Francois Malecaze and José Güell. Professor Dua is Professor of Ophthalmology and Visual Sciences, in the Division of Clinical Neuroscience, School of Medicine at the University of Nottingham and Head of the Division of Ophthalmology and Visual Sciences, Nottingham, UK. EuCornea President Jesper Hjortdal said: “It is a great pleasure to see that co-founder of EuCornea, Prof Harminder Dua has been appointed by Her Majesty Queen Elizabeth II as Commander of the Most Excellent Order of the British Empire (CBE) for Services to Ophthalmology. “On behalf of EuCornea I congratulate Prof Dua with this exceptional order, which is very well deserved for his long-standing and widely recognised impact in research and teaching related to corneal and ocular surface diseases. “We hope Prof Dua also in the years to come will continue his dedicated commitment as a superb contributor to the annual EuCornea meeting and as Editor of the Journal of EuCornea.” Professor Harminder Dua

I am humbled by this great national honour, which reflects the glory of the whole team and individuals and institutions that have influenced my career...


10th EuCornea Congress

13 – 14 September 2019 | Paris Expo Porte de Versailles

2 Days 7 Courses 8 Focus Sessions 3 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

Ocular Surface Disease Diagnosis and Management: Special Focus on the Lipid Layer

Supported by an independant medical education grant from

Moderators: B. Cochener-Lamard FRANCE J. Güell SPAIN

Scientific Programme, Registration & Hotel Bookings

www.eucornea.org


CORNEA

Limbal deficiency Studies give insight on the best technique for transplantation with limbal stem cells. Cheryl Guttman Krader reports

O

utcomes from long-term follow-up of patients treated for stage 3 limbal deficiency favour a transplantation approach that uses cultured autologous limbal stem cells (LSCs) rather than cultured allogeneic cells or limbal tissue transplantation. At the 2019 meeting of the Association for Research in Vision and Ophthalmology (ARVO) in Vancouver, Canada, Vincent M Borderie MD, PhD, presented findings from two studies – a phase II prospective trial comparing the efficiency and safety of transplantation of autologous and allogeneic LSCs cultured on human amniotic membrane with no feeders, and a retrospective study of patients who received allogeneic or autologous limbal tissue transplants. He reported that the cultured autologous LSC transplant was associated with the best graft survival, safety profile and vision improvement, and the long-term survival rate was also similar to that reported in published large studies evaluating transplantation of cultured autologous LSCs. Autologous limbal grafts had good survival but lower safety than the cultured autologous LSCs. Grafts using allogeneic cultured LSCs or limbal tissue were associated with a low long-term success rate and a high rate of serious adverse events. “Currently, we have several therapeutic approaches that can be used to treat advanced LSC deficiency, but we are missing studies that compare the different techniques to help us determine which would be best for a given patient,” said Dr Borderie, Professor and Chairman, Department of Ophthalmology, University Paris VI Pierre & Marie Curie, Paris, France. All of the patients enrolled in the prospective study had stage 3 limbal deficiency with superficial vascularisation and late fluorescein staining, and they had poor visual acuity (VA; 20/200 or worse). Following transplantation, regardless of the type of graft received, all patients were treated with topical corticosteroids and artificial tears. Additional therapies included autologous serum eye drops for patients who received cultured LSC transplants, topical cyclosporine for those who received allogenic stem cells and one year of systemic immunosuppression for patients who received allogeneic cultured LSC transplants. EUROTIMES | JULY/AUGUST 2019

Courtesy of Vincent M Borderie MD, PhD

52

“We hypothesised that we would have less rejection and therefore avoid the need for systemic immunosuppression after transplantation of the allogeneic cultured LSC graft compared to LSC transplantation because we thought that we would avoid having immune cells in the cultured graft. However, the allogeneic tissue and cultured cell grafts behaved the same way,” Dr Borderie said.

STUDY RESULTS The estimated five-year survival rate was 71% for the autologous cultured LSCs and 75% for the autologous limbal transplant. The difference between groups was not statistically significant. Five-year survival was only 33% for the allogeneic limbal transplant and 0% in the allogeneic cultured LSC group. Visual acuity improved only in patients who received an autologous transplant, and declined in the allogeneic transplant groups. In the autologous groups, the mean improvement was higher in patients who received the cultured LSC transplants than in the limbal tissue group (+9.2 vs +3.3 lines). Other assessments showed that subjective symptoms improved after transplantation of the cultured autologous LSCs, and eyes treated with this technique had a significant reduction in fluorescein

staining. The area of the cornea that was free of superficial vessels also increased significantly in the cultured autologous LSC group compared with both baseline and the change observed in the allogeneic LSC group. Fluorescein staining increased after transplantation of the allogeneic LSC transplant. Dr Borderie also reported that compared with failed grafts, the successful grafts had a greater decrease in fluorescein staining from baseline, a greater vascularisationfree area in the superficial cornea, lower variability of corneal epithelial thickness and higher corneal epithelial basal cell density.

SAFETY REVIEW Dr Borderie observed there were “major” differences in safety between groups. “Adverse events occurred at a low frequency and were minor in the group that had transplantation with autologous cultured LSCs. Patients who had autologous limbal tissue transplantation were more likely to experience adverse events, some of which were sightthreatening. Patients who got allogeneic stem cells had a high-frequency of sightthreatening adverse events,” he said. Vincent Borderie: Vincent.borderie@upmc.fr


WS P OS SUBSP EC IALT Y DAY Preliminary Programme

Friday 13th September | 08.20 – 18.30 08.20 – 08.30

Welcome and Introduction D. Bremond-Gignac

FRANCE

08.30 – 09.55

Paediatric Ocular Surface Disease FRANCE , S.Wei Leo SINGAPORE

D. Bremond-Gignac

10.00 – 10.30 Free Papers I

D. Godts

BELGIUM

BREAK (10.30 – 11.00)

11.00 – 12.25

Paediatric Retina

Y. Fong Choong

MALAYSIA

12.30 – 13.00 A.O. Adio

Free Papers II

NIGERIA ,

M. Tekavcic-Pompe

SLOVENIA

LUNCH (13.00 – 14.30)

14.30 – 15.55

Strabismus and Neuro-Ophthalmology Y. Morad

ISRAEL ,

A. Fernandez

COLOMBIA

16.00 – 17.45

Paediatric Cataract and Visual Screening K. Nischal UK/USA , R. Kekunnaya INDIA

17.50 – 18.30

M. Younis

Video Symposium LEBANON , L. Welinder DENMARK

www.wspos.org


PAEDIATRIC OPHTHALMOLOGY

Bringing OCT-A to the bedside Hand-held probe enables imaging in awake neonates. Cheryl Guttman Krader reports

I

nitial clinical experience with an investigational handheld sweptsource optical coherence tomography angiography (OCT-A) device suggests it has the potential to become a new diagnostic tool for retinopathy of prematurity (ROP), according to researchers who presented their findings at the 2019 annual meeting of the Association for Research in Vision and Ophthalmology (ARVO) in Vancouver, Canada. “This is the first report showing successful OCT-A imaging in awake, premature infants in the neonatal intensive care unit,” said Ruikang Wang PhD, Professor of Bioengineering and Ophthalmology, University of Washington, Seattle, USA. “Our prototype, however, still has some limitations, and we are working to make modifications that will address those issues.” The miniature SS OCT-A device is designed to make the examination easy for the operator and safe and comfortable for the infant. It is light in weight (<1kg) and features an on-probe display along with a live pupil-finding video that provides feedback to facilitate probe positioning. It is non-invasive, can be used without an eyelid speculum or sedation and provides rapid image capture. The prototype has an imaging speed of 200kHz and each volume is acquired in less than five seconds with

an approximately 30° field-of-view. To assess the performance of the device for providing high resolution images, Yasman Moshiri BS, a University of Washington medical student, evaluated images obtained in eight premature infants (mean gestational age 27.3 weeks) who were undergoing routine ROP screenings at the University of Washington Medical Center Neonatal Intensive Care Unit. The images were acquired with the infants lying on their back. Each infant was imaged between one and six times, for a total of 19 imaging sessions. Images were considered to be “good quality” if detailed microvasculature could be visualised in at least one retinal layer without significant motion artefact or defocus. The review showed good quality images were obtained of the foveal microvasculature in 11 (58%) of the imaging sessions for six (75%) infants and of the peripapillary microvasculature in 14 (74%) imaging sessions for five (63%) infants. “The majority of the images were of sufficient quality to screen for pathology, and we hope that we can implement the use of this device in other settings,” said Ms Moshiri. Ongoing efforts to improve the device include reconfigurations to increase the field-of-view. “Although the largest field-of-view provided by our system is regarded as ‘wide-

Typical OCT B-scan from an infant at 28-week gestational age. White bar = 0.5mm

Courtesy of Ruikang Wang PhD

54

Wide field retina SS-OCTA captured from an awake infant at 28-week gestational age with retinopathy of prematurity. White bar = 0.5mm

field’, it is not large enough to cover the peripheral retina where there are essential characteristics of ROP,” said Dr Wang. Ruikang Wang: wangrk@uw.edu

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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


56

EUROPEAN BOARD OF OPHTHALMOLOGY

Christina Grupcheva and Wagih Aclimandos

EBO exam harmonises European standards Record-breaking 667 candidates step up to take comprehensive exam. Dermot McGrath reports

A

t a time when European political integration is under pressure from all sides, the European Board of Ophthalmology diploma (EBOD) examination continues to showcase the positive virtues of European cooperation and collaboration, according to Professor Christina Grupcheva FEBO, President of the EBO. “We are proud to say that the EBOD continues to go from strength to strength. We are here to celebrate the achievements of the EBO comprehensive exam, which was created in order to harmonise ophthalmic education and training standards in Europe. Since Peter Eustace pioneered the first exam in Milan 24 years ago, we have seen interest and participation in the exam increase every

year, so there is clearly a viable demand there, which is being fulfilled,” she said. Held every year in Paris, Prof Grupcheva explained that the EBOD examination is designed to assess the knowledge and clinical skills requisite to the delivery of a high standard of ophthalmic care both in busy hospitals and in remote clinical practices. This year’s comprehensive exam drew a record-breaking 667 candidates from 27 European countries. “The exam is designed to promote optimal standards of care in ophthalmology by ensuring high levels of knowledge and training. While the EBO is also responsible for accreditation for training centres, as well as providing fellowships and monitoring European continuous medical education (CME), the examination is really the core of what we do,” she highlighted.

Tireless educator recognised for his contribution to ophthalmology Wagih Aclimandos FRCOphth, FEBO, was honoured at the European Board of Ophthalmology (EBO) Diploma Award Ceremony as the recipient of the Peter Eustace Medal for his contribution to ophthalmic education in Europe. “This Peter Eustace Medal is awarded to an ophthalmologist who has made a telling contribution towards European

EUROTIMES | JULY/AUGUST 2019

ophthalmology. Today we award the medal to Wagih Aclimandos, a tireless worker, teacher and ophthalmologist who has enjoyed a long and distinguished career and is a very fitting recipient of this accolade,” said Prof Christina Grupcheva. As consultant ophthalmic surgeon at King’s College Hospital, London, and lead clinician for paediatric ophthalmology

Candidates who succeed in passing the examination receive an EBO certificate or Diploma. The latter is awarded only after recognition of specialist status in the home country of the candidate and is complemented by the right to use the title “Fellow of the European Board of Ophthalmology (FEBO)” as affiliation. Dr Saski Imhof FEBO, Chair of the EBO Education Committee, paid special tribute to the 318 examiners from 27 countries who put the candidates through their paces over the two parts of the examinations. “No exam can take place without examiners and we are extremely grateful for the dedication and expertise of our team of examiners. The quality of the exam has really improved over the years and that is really thanks to the organisation and also the motivation of the examiners,” she said. Prof Grupcheva thanked the French Society of Ophthalmology (SFO), which hosts the exam every year in conjunction with its annual meeting, as well as Théa Laboratories for their active support to the examinees over many years. Prof Grupcheva proudly announced that from 2020, candidates will have a second opportunity to sit the exam in Germany, as part of the German Ophthalmological Association (DOG) annual meeting. “This makes sense because of the phenomenal growth of the EBO over the past few years. We are going to run a second site together with the DOG, starting at the Berlin meeting in September 2020. This will give young European ophthalmologists the same standard for both examinations, but with double chances of success,” she said. The EBO exams this year also included the second subspecialty paediatric and strabismus examination, with seven candidates from five different European countries participating. The exam is primarily intended for those who have recently completed one year of fellowship training in strabismus and paediatric ophthalmology or equivalent training and are starting independent practice. EBO now validates several subspecialty examinations including glaucoma and cataract and refractive surgery, with more expected to follow in the future.

and strabismus services at King’s College London, Dr Aclimandos served as President of EBO from 2011 to 2013. Accepting the Peter Eustace Medal, Dr Aclimandos said it was a great privilege and honour to receive such an award. “I feel that this Medal should go to a team rather than an individual. Working with others as a team helps us to achieve things we could never do alone. Teaching and supporting others have always been hugely important to me. It is much more gratifying to give rather than to receive. I think the ultimate pleasure is receiving a medal for having had the privilege of giving,” he said.


EUROPEAN BOARD OF OPHTHALMOLOGY

An important stepping stone in my career Louise Ramsköld Cabaça from Sweden, overall winner 2019

Louise Ramsköld Cabaça

In Sweden, taking the EBO examination is optional but sitting it was a long-term goal of mine. I view it as an important stepping stone in my career in ophthalmology and a way to receive international recognition for

the training that I have undertaken. I was overjoyed to win the highest overall score award, especially as I was 34 weeks pregnant and didn’t feel like I was quite able to perform to my own personal standards. Currently, I am embarking on a career in ocular oncology, which I find truly fascinating and

rewarding on both a personal and professional level. It has a wonderful mixture of clinical work, theatre time and research, which allows me to continuously challenge myself and develop in several areas. I have also started a PhD in retinoblastoma to further deepen my involvement in research alongside my clinical work.

An internationally recognised certification Ivanka Dacheva from Germany, first place in MCQs 2019

Ivanka Dacheva

My initial goal in taking the EBO exam was to obtain an internationally recognised certification in ophthalmology and gain clinical knowledge and skills beyond our national Board

Exams. I was glad to meet peers from all across Europe. I was very surprised to do so well in the exam, as I am sure every candidate put a lot of effort in preparing for this comprehensive examination. I would definitely recommend other residents to take the

examination. The curriculum of the FEBO exam is a valuable fundament for the ophthalmologist in training. In terms of future plans, I am currently in my last year of residency and I am looking forward to pursuing an academic career in ophthalmology.

A natural and necessary step in my career Judyta Jankowska-Szmul from Poland, second place MCQs 2019

Judyta Jankowska-Szmul

The EBO exam is now recognised as equivalent to the national exam in ophthalmology in Poland, so sitting the exam in Paris was a natural and necessary step in my career to obtain the completion of my specialty training in general

ophthalmology and enter the specialist register. The exam was well organised and the examiners were very friendly and helpful. The MCQ was a well-balanced mixture of questions, covering the most essential topics but also going into a few more detailed issues. The Viva Voce part tested clinical skills and knowledge

from a broad spectrum of subspecialties. All the questions were clinically relevant and we were expected to provide quick and accurate answers. I have had a pleasure to work in an outstanding eye department in a hospital in London for two years. I have just started a new fellowship and I hope to carry on with my further training there.

A solid basis in ophthalmology Damien Haution from France, overall third place 2019

Damien Haution

My main motivation for taking the EBOD, which counts as a national examination in France at the end of residency, was to have a solid basis in ophthalmology before starting my fellowship. I would definitely recommend other residents to take the

examination in the future as it is a perfect way to deepen their knowledge in all the subspecialties of ophthalmology before eventually concentrating on one specific part. My own practice has changed since I sat the examination. During a patient’s examination, I now pay more attention to certain details than before, and I make diagnoses I would surely have

missed without the help of a more experienced practitioner. I am also better able to understand the ophthalmologic vocabulary in medical reviews. In the future, I plan to take a fellowship in Dr Philippe Gohier’s ophthalmologic unit in the regional university hospital of Angers, France, specialising in medical retina and oculoplastic surgery.

EUROTIMES | JULY/AUGUST 2019

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OUTLOOK ON INDUSTRY

Schwind innovation Eye-tracking FS laser will enable lenticule extraction in high astigmatism. Howard Larkin reports

L

enticule extraction is a promising method in corneal refractive surgery, offering visual outcomes similar to TransPRK or LASIK. Yet lenticule extraction remains mostly limited to myopia and low astigmatism, largely because current femtosecond lasers lack refinements that excimer lasers added long ago, notably eye tracking. Schwind eye-tech-solutions is changing that. At this year’s ESCRS Congress in Paris, Schwind is introducing the first femtosecond laser for lenticule extraction with eye tracking. Market launch is planned for early 2020. In development for almost four years, the system’s innovations should improve vision and surgical experience, advancing lenticule extraction and making it available for many more patients. “We will not settle for the current status of lenticule extraction,” says Rolf Schwind, CEO of the Kleinostheim, Germany-based manufacturer of high technology refractive and therapeutic corneal lasers. “With an eye tracking-guided docking procedure we offer an objective focusing function to optimally align the patient’s eye to the laser. An objectively determinable treatment offset enables the surgeon to make further fine adjustments. This ensures high precision and optimal postoperative visual acuity,” Mr Schwind explains. Eye tracking also allows cyclotorsion control, which is important for correcting higher astigmatism, he adds.

LESS STRESS IN THE LASER SUITE The new laser helps make lenticule extraction operations easier for both surgeons and patients, Mr Schwind says. “The technique offers better options for positioning the eye and improved ergonomics for the surgeon.” A small footprint conserves space in tight operating theatres and allows the system to be positioned more easily for optimal access in surgery. An innovative interface reduces corneal applanation and the suction needed for laser docking, optimising treatment precision and patient comfort. Eye tracking also helps surgeons recover cases should the system lose suction in surgery. Theo Seiler MD, PhD, Zurich, Switzerland, reported successfully redocking the Schwind system and completing surgery in one of the first cases he operated in Bangalore, India. Dr Seiler believes eye tracking EUROTIMES | JULY/AUGUST 2019

The Schwind Femtosecond Laser

will expanding lenticule extraction indications. “The whole area of myopic astigmatism is now open.”

ENHANCED LENTICULE DISSECTION Schwind’s new femtosecond laser addresses another common challenge – dissecting the lenticule. Software features including sophisticated laser pulse characteristics and positioning algorithms reduce adhesions between the lenticule and surrounding stroma. This makes for an easier, smoother lenticule dissection and extraction, said Rohit Shetty MD, who performed the first human trials with the new laser in Bangalore. Studies show a smoother lenticule dissection reduces post-op inflammation, which speeds visual recovery and may improve visual outcomes. Results from the first patients treated with the Schwind femtosecond laser are consistent with these literature findings. “Our first study with 34 myopic patient eyes showed positive results one month after treatment,” Mr Schwind says. After lenticule extraction to correct spherical equivalent errors ranging from -2.0 to -8.0 dioptres, uncorrected distance visual acuity of treated eyes was equal to or better than pre-op corrected distance visual

acuity. The quality of the incision and the roughness of the lenticule were evaluated by the surgeon as consistently good. “It is noteworthy that the visual recovery was very fast: nearly 90% of eyes achieved visual acuity of 20/20 one day after surgery. Also, in terms of predictability and safety, the first clinical results have confirmed our expectations. Further studies are under way,” Mr Schwind adds.

BRIGHT FUTURE Mr Schwind believes that the improvements he is making in his femtosecond laser platform will attract more surgeons to lenticule extraction. “In addition to TransPRK and LASIK, lenticule extraction will be an important further option in refractive surgery.” Adding a femtosecond laser also helps diversify and strengthen the firm’s product portfolio, positioning it for another year of market growth, Mr Schwind adds. After that, the sky is the limit. “Our new technology and platform provide versatile possibilities for integrating additional features and applications in the future. We already have specific ideas ready to be implemented in a short time and would mean a new disruptive model for refractive corneal surgery,” Mr Schwind concluded.


ESCRS

Practice Management

& Development

15 – 16 September 2019

Practice Management Masterclass Sunday 15 September | 08.30 – 18.00 Chairpersons: A. Carones ITALY & M. Malley USA

Moderator: K. Morrill FRANCE

Building A Patient-Centric Ophthalmic Practice That Maximises Profits A ‘Patient Experience’ Summit: This highly interactive and didactic workshop-based course presented by Amanda Carones and Mike Malley will challenge attending surgeons to critically assess their effectiveness in various aspects of their clinics including Physician time management; Practice profit margins; Patient education processes; Premium services planning; Staff conversion training; Practice culture commitment; Exit-strategy evaluation; Staff incentive strategies; Maximising surgeon production; and Costs controls.

Practice Management and Development Programme Monday 16 September | 08.00 – 18.00 Chairperson: P. Rosen UK

Moderator: R. Solar UK

Challenges and Opportunities for the 21st Century Practice Topics Include: •

Next-Generation Marketing

Diversification: Your Key to Digital Success

GDPR – Lessons Learned

ESCRS Innovation Prize

Ask the Experts

Build a High-Performing Practice by Investing in Your Staff and Patients

Optimising Patient Flow in a Busy Practice

How to Negotiate

www.escrs.org


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PRACTICE MANAGEMENT

Enhancing services through innovation Why is it you can often struggle to innovate when it comes to marketing or enhancing customer service? Rod Solar reports

I

nnovation is the art of introducing something new, and cataract and refractive surgery have an impressive history of innovation. Think phaco and small incisions, foldable IOLs, refractivisation of cataract surgery, customised ablation, femtosecond LASIK and SMILE. As an ophthalmologist, your practice constantly challenges you to think divergently, come up with new solutions for patients and pivot when initial ideas fail in order to achieve the results you want. It’s in your nature. So why is it you can often struggle to innovate when it comes to marketing or enhancing customer service? Perhaps you just need some inspiration. Here are some useful ways you can foster innovation within your practice: Be a conscious consumer. Whenever you’re engaging with any business as a customer, ask yourself, what’s the story they’re selling? Who is the ideal customer they are trying to attract? How do I differ from that? How do I fit? What stage of the sales funnel am I in? What phase of the customer value journey am I at? Hundreds if not thousands of messages impact you every day. Consume consciously and you’ll be on the way to picking up valuable ideas and lessons from your daily interactions with companies. Maximise everything. When you see robust marketing communications or experience superior customer service, ask yourself – how could I apply this to my practice? How would I make this even better? How could I make this even more customer-oriented? Copy existing ideas. You don’t need to reinvent the wheel or be the first person in the world to come up with an original plan. The most creative people also tend to be excellent copiers. The famous EUROTIMES | JULY/AUGUST 2019

composer Igor Stravinsky supposedly said: “Immature artists copy, great artists steal.” That doesn’t mean to plagiarise. Instead, find inspiration in the work of others, then use it as a starting point for original creative output. What great ideas already exist that you could apply to your practice? Generate lots of bad ideas. Self-censorship is the thief of creativity. Don’t reject your ideas too early. Just get them out (write them down, speak them out) and only evaluate them on their merits once you’ve spent all of your creative juices. Embrace constraints. Some would argue that constraints are a necessary condition for innovation to occur. How can you make the boring, sexy? How can you get attention with no money? How can you stand out in a sea of established competitors? How can you make a commodity feel like an experience? When faced with limited options, you’ve got to think your way out of a little box – and therein lies the breakthrough. Remember, ideas are typically free and when executed with enough flair and passion can bring huge rewards even on a tight budget. If you’re an ophthalmologist with an innovation that enhances patient services, you should enter the ESCRS Practice Management and Development Innovation Award 2019. Shortlisted entrants will be invited to give a presentation on their projects at the 37th Congress of the ESCRS in Paris. The winning entrant will receive a €1,500 bursary to attend the 38th Congress of the ESCRS in Amsterdam, The Netherlands in October 2020. Visit http://bit.ly/ET-PM19 to enter. https://www.liveseysolar.com/


INDUSTRY NEWS

NEWS IN BRIEF DETAILED EVALUATION

INDUSTRY

NEWS

From left: Prof Peter Wiedemann (ICO President), Neeru Gupta (ICO Vice President), Dr Matias Iglicki, Prof Berthold Seitz (ICO Director of Fellowships)

Fellowship Award

A panel of leading experts has selected groundbreaking research into diabetic retinopathy and telemedicine as the winner of this year’s International Council of Ophthalmology (ICO) and Allergan Fellowship. Dr Matias Iglicki from the University of Buenos Aires in Argentina is the second recipient of the ICO-Allergan Fellowship Award. The award of a $50,000 grant, announced at the 2019 European Society of Ophthalmology meeting in Nice, France, will enable Dr Iglicki to continue his research into diabetic retinopathy and telemedicine, which he has been working on since 2004. https://www.allergan.ie/en-ie/home

NEW ALLIANCE THROUGH PARTNERSHIP AGREEMENT OPHTEC BV has signed a partnership agreement with VSA to commercialise Ophtec’s products in the Argentinian marketplace. The Precizon™ IOL line as well as the Artisan® and Artiflex® line of Iris-Fixated Intraocular lenses are some of the products that will be commercialised by VSA. Teresa Filhó, Ophtec’s Export Manager, said: “Ophtec has a passion for vision and we look forward to continuing serving the Argentinian market and introducing our cataract lenses Precizon™.” Mauro Alvarez, sales director at VSA, noted: “I am proud to introduce this new alliance between VSA Alta Complejidad and Ophtec in Argentina: “It is undoubtedly a great opportunity to start working with such a prestigious company as Ophtec, which over its 35 years has remained faithful to his own ideas, always developing avant-garde concepts and products for the most demanding ophthalmologists.” https://www.ophtec.com/

WEB-BASED DATABASE SCHWIND has announced SCHWIND WiseNET which, according to the company, offers a new intelligent web-based database to ensure and optimise treatment quality. “SCHWIND WiseNET is a valuable help in securing a high level of treatment quality,” said a company spokeswoman. “With this web-based database the user can capture and evaluate refractive treatment data quickly and precisely, and present it graphically for all sorts of uses in daily clinical work. Diagrams show visual acuity, refraction including astigmatism and follow-up periods, so that treatment outcomes can be systematically monitored and improved. WiseNET is a valuable tool for individual analysis, in single practices as well as in large eye clinics. “Providing the patients their treatment outcomes makes the individual performance transparent and builds trust. WiseNET also helps to meet regulatory requirements for the long-term documentation of treatment outcomes,” according to Schwind. https://www.eye-techsolutions.com/en

German manufacturer VRmagic says the current software version for the Eyesi ophthalmic surgical simulator offers trainee ophthalmologists a detailed evaluation of their own surgical performance and a comparison with the results of other users. This is made possible by networking the worldwide training systems, says VRmagic. “Using the Eyesi virtual reality simulator, ophthalmologists can practise surgical techniques in a risk-free environment. After each training unit, the simulator shows a detailed performance evaluation. Users can now access a statistical analysis, which shows their own performance in comparison with the anonymised training data of other surgeons,” said a company spokesman. https://www.vrmagic.com/

OPHTHALMOLOGY AWARDS VSY Biotechnology is accepting applications for the “Stars of Ophthalmology” awards. The winning entries will be selected from applicants who have had a scientific article published in an ophthalmology journal since January 2018. The articles must be in English and must be already published in order to be eligible for the awards. The application deadline is 15 August 2019. Three winners will be announced at the “VSY Biotechnology Satellite Symposium” during the 37th Congress of the ESCRS, in Paris, France, on 14 September. Applicants should submit their articles at the link below, and send any queries to starawards@vsybiotechnology.com http://www.vsybiotechnology.com/ starawards

NEWER OPTICAL DESIGNS NIDEK CO., LTD. has announced the launch of the YC-200 S plus Ophthalmic YAG and SLT Laser System / YC-200 Ophthalmic YAG Laser System. The YC-200 S plus / YC-200 is the advanced successor to the YC-1800 laser. The YC-200 S plus YC-200 of lasers builds on the popularity and technology of the YC-1800 by incorporating newer optical designs, engineering and software advances to ensure precise targeting of pathology, while ensuring efficacious treatments and enhancing surgeon visualization of laser delivery. Two rotatable aiming beams for YAG mode and a parfocal aiming beam for SLT mode help the surgeon accurately target pathology. NIDEK has included YAG laser system enhancements to the YC-200 S plus / YC-200 that achieve 1.6mJ plasma threshold in air. These enhancements allow for robust, homogeneous laser energy delivery, said a NIDEK spokesperson. https:// www.nidek-intl.com/

EUROTIMES | JULY/AUGUST 2019

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MY MENTOR

The value of mentoring in ophthalmology Valuable advice is just as important as professional training. CĂŠdric Schweitzer MD reports

I

n Greek mythology and Homerâ&#x20AC;&#x2122;s Odyssey, Mentor was the name of Ulyssesâ&#x20AC;&#x2122; experienced advisor and was in charge of the education of his son, Telemachus, during the war against the Trojans. While Ulysses was away, Mentor gave Telemachus wise advice to help him making appropriate decisions and help him keep the control of the kingdom of Ithaca. In our modern era, a mentor is not only a supervisor but also an experienced and trained adviser who guides you in shaping your career and helps you in developing your professional skills. When I started my residency in ophthalmology, I was fascinated by visual function and research about eye disorders. I could also observe the permanent improvement in diagnosis or treatment of common eye disorders and I was impressed by all innovations improving visual care and health benefit for patients. However, my interest in ophthalmology has been particularly raised by the professional skills, the charisma and the visionary approach of my first supervisor, Professor Joseph Colin

When I started my residency in ophthalmology, I was fascinated by visual function and research about eye disorders (Bordeaux University Hospital, France). As a doctor and a professor, he taught me the best clinical and surgical practice in ophthalmology. As a professional supervisor, he also shared his enthusiasm, he provided constructive and accurate comments and always encouraged me to develop my professional skills. But, most importantly, he also gave me valuable and wise advice to collaborate with best experts in my field and to be in the forefront of innovation in visual science and care. Owing to his mentorship, I could develop research and collaborations in corneal biomechanics or intraocular lens biomaterials as clinical issues related to glistenings. I could also perform a multicentre clinical trial on intraoperative

floppy iris syndrome in collaboration with Dr David Chang from USA and most importantly, he strongly supported me to develop research in the field of femtosecond laser cataract surgery. His support was also decisive to design and set up the FEMCAT trial, which aimed to compare visual and anatomical outcomes between phacoemulsification cataract surgery and femtosecond laser surgery. Before passing away, he provided very wise advice to lead this multicentre trial from the initial to the final steps of the process. Mentorship is a continuous process, it is our duty to provide similar advice to the following generations of ophthalmologists in order to provide the best research and care in ophthalmology.

INDIA VISIT OUR WEBSITE FOR INDIAN DOCTORS EUROTIMES | JULY/AUGUST 2019

www.eurotimesindia.org


CALENDAR

The 37th Congress of the ESCRS, 19th EURETINA Congress and 10th EuCornea Congress will each take place in Paris, France

LAST CALL

JULY 2019

ASRS 2019 26–30 July Chicago, USA www.asrs.org

AUGUST 2019 Forum Ophthalmologicum Baltic

OCTOBER 32nd APACRS Annual Meeting

5–8 September Greater Amman, Jordan https://meacojordan.com/home.html

19th Euretina Congress

3–5 October Kyoto, Japan apacrs2019.org

Ophthalmic Imaging: from Theory to Current Practice

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

5–8 September Palais des congrès Paris, France www.euretina.org

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

10th EuCornea Congress

13–14 September Paris Expo Porte de Versailles Paris, France www.eucornea.org

EVER 2019

17–19 October Nice, France www.ever2019.org

WSPOS Subspecialty Day 13 September Paris Expo Porte de Versailles Paris, France www.wspos.org

37th Congress of the ESCRS

23–24 August Vilnius, Lithuania www.fob2019.lt

SEPTEMBER NEW MEACO 19

14 –18 September Paris Expo Porte de Versailles Paris, France www.escrs.org

Advances in Glaucoma Research and Clinical Science Meeting 2019

26–28 September Palais des congrès Amsterdam, The Netherlands www.glaucomacongress.com

EUROTIMES | JULY/AUGUST 2019

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CALENDAR

2020

The 11th Annual Congress on Controversies in Ophthalmology: Europe (COPHy EU) will take place in Lisbon, Portugal

FEBRUARY NEW 6th Annual Congress on Controversies in Ophthalmology Asia-Australia (COPHy AA) 14–15 February Bangkok, Thailand http://cophyaa.comtecmed.com/

MARCH NEW 11th Annual Congress on Controversies in Ophthalmology: Europe (COPHy EU) 26–28 March Lisbon, Portugal http://cophy.comtecmed.com/

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

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

JUNE

OCTOBER

NOVEMBER

World Ophthalmology Congress (WOC)

WCPOS V 5th World Congress of Paediatric Ophthalmology and Strabismus

AAO Annual Meeting 2020

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

JULY ASRS 2020

OCTOBER

23–28 July Seattle, USA www.asrs.org

20th Euretina Congress

JUNE

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

20th EVRS Meeting 2020

11th EuCornea Congress

June 11 – 14, Stockholm, Sweeden http://www.evrs.eu

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

38th Congress of the ESCRS

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

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

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24th ESCRS Winter Meeting

M arrakech

In conjunction with SAMIR (Moroccan Society of Implant & Refractive Surgery)

21 – 23 February 2020 Mövenpick Hotel Mansour Eddahbi & Palais des Congrès, Marrakech, Morocco

www.escrs.org


YOUR NAVIGATING PARTNER IN OPHTHALMOLOGY

www.ziemergroup.com

The FEMTO LDV Z8 and the GALILEI G4 are CE marked and FDA cleared. For some countries, availability may be restricted due to regulatory requirements. Please contact Ziemer for details.

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EuroTimes Jul/Aug 2019 | Vol 24 Issue 7/8  

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