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February 2020 | Vol 25 Issue 2



SmartSight: level up your vision. Minimally invasive for maximum delight.

SCHWIND SmartSight® • Intelligent eye tracking for maximum safety • Cyclotorsion compensation for effective treatment • Improved eye comfort through innovative patient interface geometry • Fast achievement of good vision through smooth lenticular surface • High flexibility through compact design

SCHWIND SmartSight® is the most advanced minimally invasive femtosecond laser procedure without a flap. This innovative refinement of lenticule extraction combines maximum safety with highly predictable vision outcomes. Intelligent eye tracking with pupil recognition and cyclotorsion compensation enable very easy and precise centring. The curved patient interface substantially reduces pressure on the eye during positioning, for more patient comfort. The compact design and user-friendly operation provide maximum flexibility and allow very efficient corneal surgery workflow.

SCHWIND eye-tech-solutions · fon: +49 6027 508-0 · email: info@eye-tech.net · www.eye-tech-solutions.com · #SchwindLaser


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

4 The past, present and future

Colour and Print W&G Baird Printers

of intraocular lenses

transplants already submitted to ECCTR registry

6 Femtosecond lasers can

20 Experience of the surgeon

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


perform highly accurate IOL power adjustments

7 Add-on lenses offer

astigmatism correction and multifocality

8 Achieving the holy grail of accommodation restoration

9 Surgeons can now deliver a truly customised approach

10 The range of presbyopic

IOLs continues to expand

11 Multicomponent IOLs with exchangeable optics can provide a safety net

CATARACT & REFRACTIVE 12 We hear from the

President of the ESCRS Rudy MMA Nuijts

13 Optimisation of the ocular surface is a key factor for surgical success

14 A double-angle plot tool to display standardised astigmatism outcomes is now available

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

16 Most SMILE

intraoperative complications are related to learning curve


18 More than 12,000

often determines choice of DMEK or DSAEK

21 Modern corneal

tomography measurements more reliable than Kmax

RETINA 22 Corticosteroids may

still play a role in DME where anti-VEGF is contraindicated

23 Ophthalmologica highlights

24 Increases in tuberculosis and syphilis in present new challenges

26 Anti-VEGF injections may

lead to greater risk of posterior capsule rupture

27 Recent decades have seen

a paradigm shift in the understanding of diabetic retinopathy

P.36 PAEDIATRIC OPHTHALMOLOGY 30 Measles remains a leading cause of blindness in paediatric population


33 Books 34 Inside Ophthalmology 35 Industry News 36 Random Thoughts 38 Practice Management 39 Calendar


Optimising the latest Medical Therapies

Supplement February 2020

Supplement February 2020

& Modern MIGS for the Glaucoma Cataract Patient

Supplement February 2020

28 Better trabeculectomy

outcomes are important because patients are living longer

29 Cost and social pressure

spark innovations in access, efficiency and research

Presbyopia Correcting IOLs for Phakic & Pseudophakic Eyes EPS Technology1: A Special Concept with Multiple Applications

Approaches to the Diagnosis and Management of

Important Corneal Disorders in the Cataract and Refractive Patient


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Included with this issue... Cornea and Glaucoma Education Forum Supplements and Medicontur Supplement EUROTIMES | FEBRUARY 2020




The right IOL? Doctors must be careful not to raise their patients’ expectations.

Oliver Findl


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)


am very pleased to be invited to write this editorial for EuroTimes, which has a special focus this month on nextgeneration IOLs. As my colleague Soosan Jacob points out in this issue, intraocular lenses (IOLs) have come a long way since Sir Harold Ridley’s first implantation in 1949 after noticing inert acrylic plastic splinters from aircraft canopies in eyes of pilots during World War II. Currently, with more than six million IOLs implanted yearly, there is understandably tremendous research directed at improving visual and quality and at decreasing complications. As surgeons, our first obligation should be to to use the lens that we are most comfortable using. We should also ask ourselves what is the lens that is best suited to the individual patient? With increased use of social media, patients have greater access to information about the exciting new technologies emerging. They may think that after a lens is implanted, they will have almost perfect vision but we must have serious ...intraocular lenses discussions with them (IOLs) have come about the need to have realistic expectations. a long way since Our message should be Sir Harold Ridley’s honest and simple. We first implantation in will always do our best and we, like our patients, will 1949 after noticing hope for the best possible inert acrylic plastic outcomes. splinters from It also needs to be aircraft canopies in pointed out that every procedure is different and eyes of pilots during every patient is different. World War II Another challenge we face is the challenge of choosing the right IOL power, optical biometry, modern formulae and optimised IOL constants, and precise measurements of anterior and posterior corneal curvature by two or more devices have greatly improved IOL selection accuracy. Future developments such as intraoperative measurements to refine IOL selection and adjusting lens power after surgery may further improve outcomes. So how do we explain this to our patients? In my opinion, a good doctor is like a good teacher, with the gift of being able to explain complex ideas in a manner that is easy to absorb for the patient. I hope that after reading this issue of EuroTimes with a special focus on IOLs, you the reader will also have learned a bit more, so happy reading!

Oliver Findl is Secretary of the ESCRS and Chairperson of the Young Ophthalmologists Committee EUROTIMES | FEBRUARY 2020

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GENERATION IOL S With more than six million IOLs implanted yearly, there is tremendous research directed at improving visual quality and at decreasing complications. Dr Soosan Jacob reports

ntraocular lenses (IOLs) have come a long way since Sir Harold Ridley’s first implantation in 1949 after noticing inert acrylic plastic splinters from aircraft canopies in eyes of pilots during World War II. The first IOL, made from polymethylmethacrylate (PMMA), was manufactured by Rayner. With more than 6 million IOLs implanted yearly, there is tremendous research directed at improving visual quantity and quality and at decreasing complications. As the new decade begins, I’d like to share some trends, some of what I have learnt, the type of IOLs that I prefer and what I would like to see in the future.

PRESENT TRENDS One of the most important things that we have learned with time is that it is important to identify what the patient expects from surgery and in what way as well as how much of what he/ she wants, we would be able to deliver. Once cataract extraction has been decided on, one of the things I discuss most importantly is their lifestyle – whether they have a preference for distancedominated, intermediate or near-dominated work. Other things that matter are their occupation, how much they are willing to wear spectacles, whether they would accept some trade-off in terms of photic phenomena as well as some loss of contrast sensitivity, checking what their expectations EUROTIMES | FEBRUARY 2020

are from the surgery and setting right these expectations, the terms of their insurance as well as willingness for co-payment etc. Other important issues to be looked at are factors such as dry eye, macular pathology, irregular corneal astigmatism, large angle kappa, history of previous refractive surgery etc. as well as to explain to the patient the effect of these on choosing the right IOL and the expected outcomes. One of the categories of lenses I now like, post its evolution over the years is the pseudoaccommodative IOL. These include multifocal IOLs and EDOF IOLs. Until recently, the term, “Multifocal” referred to bifocals with only two distinct foci, one for near and another for far. Though we earlier sometimes used a modified monovision strategy by combining the expanded range of vision offered by different multifocals, eg., a low add +2.75 or +3.25D in one eye and a high add +4.00D in the other depending on visual needs, disadvantages were still present. Blurry intermediate vision, presence of significant photic phenomena, decreased contrast sensitivity etc. were some of the reasons of dissatisfaction with these bifocal lenses resulting in multifocal explantation becoming a major indication for IOL explantation the world over. Missing the target refraction would compound problems and patient unhappiness further. However, recent advances have made me

enthusiastic about this class of IOLs again. Traditional trifocals such as the AT LISA (ZEISS), FineVision (PhysIOL), Alsafit (Alsanza) and Acriva Reviol (VSY Biotech) have two add powers at 40 and 80cm in addition to distance. The PanOptix (Alcon), which is a quadrifocal IOL, has add powers at 40, 60 and 120cm. Trifocals provide better intermediate vision with fewer side-effects by using second-order light diffraction and asymmetric light distribution. PanOptix™ is manipulated to act as a trifocal by redistributing the intermediate focal point (120 cm) to distance resulting in higher transmission of light (88%) with 3mm pupils unlike other trifocals. This improves contrast sensitivity and quality of distance vision. Currently, I find that trifocals are a good solution for spectacle independence as they give clear vision over all distances. Defocus curves of both bifocals and trifocals have shown better vision for distance with larger pupils (4.5mm) and for other focal points with smaller pupils (3mm). Another group of IOLs I like using are the EDOF IOLs such as the Tecnis Symfony (Johnson & Johnson Vision) and the AT LARA 829MP (ZEISS), which provide an elongated area of focus that extends depth. Minimally affected peak resolution allows reasonably clear vision at all distances with lesser glare, haloes and loss of contrast as compared to multifocals. However, as near vision with these IOLs is

SPECIAL FOCUS: IOL UPDATE not as great as with multifocals, I implant it in the dominant eye first followed by a micromonovision strategy with EDOF IOL or a multifocal in the non-dominant eye. I also prefer these IOLs over multifocals in eyes with maculopathy, irregular corneas, glaucoma and in those patients with greater night driving needs. They have been variably reported to have better contrast to no difference in contrast as compared to trifocals. Trifocals, however, do show more pupil independence than bifocals and EDOFs with EDOFs, showing best visual acuity at 2mm pupil size. While I haven’t used any of the rotationally asymmetric segmented bifocal IOLs (Mplus, Mplus X [Oculentis] and SBL-2 and 3 [Lenstec]), I have been encouraged reading reports about these. The sector-shaped nearvision segment results in two focus zones for better depth of focus while reducing photic phenomena. Other interesting IOLs are the Precizon Presbyopic IOL (Ophtec), with a butterfly-shaped geometry that makes it more tolerant of decentration and limits dependence on angle kappa, and the Mini WELL (SIFI), a progressive aspheric EDOF IOL with two concentric central zones with spherical aberrations of opposite sign and an external monofocal zone. Two small-aperture IOLs using pin-hole principle – the IC-8™ IOL (AcuFocus) and the XtraFocus Pinhole Implant (Morcher) – extend depth of focus and may also be effective in post-LASIK, post-RK eyes and irregular corneal astigmatism. For irregular corneas, however, I use a technique described by myself – CAIRS (Corneal Allogenic Intrastromal Ring Segments) – to implant allogenic tissue segments (similar to Intacs™) into femtosecond laser-dissected intra-corneal channels before proceeding with cataract surgery. As ours is a very high-volume practice, we still implant many monofocal IOLs and often employ a monovision strategy. We also frequently implant toric IOLs, advising them for patients with astigmatism more than 1D. Lesser amounts can be managed by making the incision on the steep axis, limbalrelaxing incisions or opposite clear corneal incisions. Multifocal and EDOF torics are good for patients desiring freedom from glasses for all distances. Customised torics can be made to order for very high cylinders. We do pay a lot of importance to the type of astigmatism, amount of posterior corneal astigmatism, accurate biometry, appropriate IOL formulae, reference marking etc. We also commonly utilise aspheric IOLs, especially in patients with larger pupils, preferring zero spherical aberration IOLs (Akreos AO®, Bausch + Lomb) to improve depth of field and in some patients, to decrease the impact of IOL decentration/ pupil eccentricity. We advise negative spherical aberration IOLs in post-myopic LASIK, those with large mesopic pupils or with night-time driving requirements. The Tecnis® (Johnson & Johnson Vision), with -0.27microns of spherical aberration, compensates corneal positive aberrations

Precision up to 0.01D, ability to change and even reverse multiple times, ability to use on almost any lens from any manufacturer. What could be better? completely whereas the AcrySof IQ Aspheric® (Alcon ), with -0.20microns of spherical aberration, compensates partially. Both mono- and multifocal IOLs are available in aspheric design. For post-hyperopic LASIK patients, we prefer traditional spherical IOLs with positive spherical aberration. The TECNIS Eyhance® IOL (Johnson & Johnson Vision) is a new monofocal that I would like to try as it is claimed to give some amount of intermediate vision as well. Of course, most newer IOLs are micro-incision lenses allowing sub-2mm cataract surgery.

WHAT IS THE FUTURE? With the flurry of technological advancements, surgeons as well as patients would justifiably love to have more and more of better and better. Youthful vision at all distances completely free of glare, haloes and decreased contrast; regained accommodation; refractive outcomes not so crucially dependent on IOL calculation formulae and biometry; the ability to easily adjust and readjust refractive errors at any point postoperatively; predictability, repeatability etc would all be highly desirable. The future does promise to be very exciting with much in the pipeline. The SmartIOL (Medennium) uses a solid rod of thermodynamic hydrophobic acrylic material that softens at body temperature to transform in about 30 seconds into a biconvex, soft gel-like material, 9.5mm wide and from 2-to-4mm thick that completely fills the capsule and has precise dioptric power and dimensions. In-the-bag accommodative IOLs are another very exciting prospect with many new technologies: antero-posterior movement giving near and distant vision with single-optic IOLs such as Crystalens (Bausch + Lomb), 1CU IOL (HumanOptics), Tetraflex (Lenstec); changing accommodation by increasing and decreasing fluid within the optic (FluidVision [PowerVision]); modular IOLs with monofocal base lens and fluid-optic accommodating component (Juvene [LensGen]) etc. I particularly look forward to the futuristic Sapphire IOL (Elenza), which is electronically controlled, remotely programmable, customisable and utilises artificial intelligence to auto-adjust focus in response to pupillary changes. Accomodative IOLs placed within the bag, however, are susceptible to capsular fibrosis and IOL tilt. To solve this, sulcusimplanted accommodative IOLs that are not affected by capsular bag fibrosis have been developed. IOLs here are the

Dynacurve IOL (NuLens), which changes curvature in response to accommodation by using the collapsed bag-zonular complex as a mobile diaphragm, activating a piston that modifies a flexible membrane to provide spherical or aspherical dynamic surface, thus giving accommodation; and the Lumina lens (AkkoLens), which has two optical elements shifting in a plane perpendicular to the optical axis, producing accommodation. In addition to these IOLs, the other big thing that I look forward to is postoperative refractive adjustment. Though this can be via adjustable IOLs such as the Light Adjustable Lens (LAL – Calhoun Vision), containing light-sensitive macromers that are modified postoperatively using digital light delivery to attain desired refraction, and multicomponent IOLs that allow adjustability through changeable optic component and fixed base component (Precisight [IVO] and Harmoni [ClarVista Medical]). What I can’t wait to incorporate into my practice is the concept of refractive postoperative adjustment using the Perfect lens (Perfect Lens LLC). This technique (Laser Induced Refractive Index Change – LIRIC) allows postoperative refractive index adjustment of the IOL using femtosecond laser-created patterns in the IOL, thereby correcting myopia, hyperopia, astigmatism and higher-order aberrations. Precision up to 0.01D, ability to change and even reverse multiple times, ability to use on almost any implanted lens from any manufacturer are huge advantages. What could be better? Two other interesting developments that I look forward to utilising are the ability to preoperatively offer simulation of the type of vision expected with different kinds of IOLs (SimVis [Spanish National Research Council]) and the ability to assess preoperatively the patient’s objective behavioural data, allowing better understanding of specific visual needs (Vivior Monitor [Vivior AG]). I also like the Gemini Refractive Capsule (Omega), an intra-capsular device that holds the capsular bag open and has ridges allowing precise effective lens position, accurate refractive prediction, ability to shift IOL between ridges to achieve refractive changes and ability to place other IOLs, drug delivery systems, sensors etc within it. Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India and can be reached at dr_soosanj@hotmail.com. EUROTIMES | FEBRUARY 2020



IOL power adjustment Non-invasive femtosecond laser technique provides accurate refractive adjustment to IOLs without harmful effects. Roibeard Ó hÉineacháin reports


n vitro and in vivo studies show that the femtosecond laser can be used to perform multiple intraocular lens (IOL) power adjustments with a high degree of accuracy and can add premium features to the most commonly used lenses, said Professor Liliana Werner MD, PhD, John A Moran Eye Centre, University of Utah, Salt Lake City, Utah. “IOL power adjustment with a femtosecond laser can be used in hydrophilic or hydrophobic IOLs. It is non-invasive and only requires topical anaesthesia. It can add and remove premium functions. And unlike the light-adjustable lens, it requires no special spectacles before the locking in of the refractive change,” Prof Werner told the 37th Annual Congress of the ESCRS in Paris, France. The femtosecond laser IOL power adjustment system was developed by Perfect Lens LLC (Irvine, CA, USA). Using green light with a 520nm wavelength, the laser operates at energy levels that are below the threshold for ablation or cuts. It enables the power adjustment of previously implanted commercially available acrylic IOLs. The laser induces a chemical reaction in a targeted area of the IOL optic substance causing a localised increase in hydrophilicity. That, in turn decreases the refractive index in that area which can be used to increase or decrease the IOL’s dioptric power, among other adjustments. In vitro studies carried out by Dr Werner and her associates have shown that in the laboratory setting the laser technique can modify refraction with a high degree of accuracy. In commercially available hydrophobic IOLs that underwent femtosecond laser power adjustment with a targeted change of 2.0D, the mean change was 2.03D. The studies also showed that the technique can convert a standard hydrophobic monofocal IOL to a multifocal and then back. The studies also show that the treatment does not affect the clarity of the lens to the point where it became clinically significant. For example, a mean power change of -2.037D was associated with a modulation transfer function (MTF) change of -0.064 cycles/mm and reduced light transmittance, as measured by spectrophotometry, by only 1.4%. Backlight scattering, as measured with a Scheimpflug camera, increased within the IOL optic in the zone corresponding to the laser treatment at levels that are not expected to be clinically significant (Nguyen J, Werner L, Ludlow J, et al J Cataract Refract Surg. 2018;44(2):226-230). Results from in vivo studies with the rabbit eye model showed

Commercially available hydrophobic acrylic IOL after in vitro power adjustment by femtosecond laser


Commercially available hydrophobic acrylic IOL after in vivo (rabbit model) power adjustment by femtosecond laser

similar accuracy of refractive change and also support the biocompatibility of the technique. In a series of six rabbits implanted with a commercially available single-piece hydrophobic acrylic IOL, the femtosecond laser adjustment with a target of +3.6D resulted in a mean change of +3.7D. In addition, slit lamp examination showed no inflammatory reaction and there were no glistenings or damage to the IOL (Werner L, Ludlow J, Nguyen J, et al J Cataract Refract Surg. 2017;43(8):1100-1106). Furthermore, no postoperative inflammation or toxicity was observed in the treated eyes, and postoperative outcomes and histopathological examination performed two weeks postoperatively showed results were similar to those in untreated eyes. The change in power obtained was consistent and within ±0.1D of the target. A second in vivo eye study supported those findings. It involved rabbits implanted bilaterally with a commercially available hydrophobic IOL and femtosecond laser power adjustment was done in one eye of each rabbit between two and three weeks afterwards. At six months' follow-up, slit-lamp examination showed there was again no inflammatory reaction or glistenings or damage to the IOL and again implant cytology and histopathology showed no significant differences between the laser-treated and nontreated eyes. In addition, there was no difference between the two groups in terms of the late complications typical in the rabbit model, such as significant posterior capsule opacification, synechiae, partial pupillary optic capture and cell deposits. Dr Werner noted that the first human trials with femtosecond laser adjustment are due to begin shortly in Panama. She added that it is conceivable that a femtosecond laser system could be designed with which a surgeon could perform not only IOL power adjustment, but also femtosecond laserassisted cataract surgeries and corneal refractive procedures such as LASIK and SMILE. Liliana Werner: liliana.werner@hsc.utah.edu

...unlike the light-adjustable lens, it requires no special spectacles before the locking in of the refractive change Liliana Werner MD, PhD

Courtesy of Liliana Werner MD, PhD




Add-on IOLs Sulcus-implanted IOLs provide multifocality through a simple and reversible procedure. Roibeard Ó hÉineacháin reports


FOUR-POINT HAPTIC MORE ROTATIONALLY STABLE However, he noted that despite the safety, ease of surgery and good results achieved with the lens, he does not use the toric designs because he feels that its C-loop haptics do not provide adequate rotational stability. If C-loop haptics are used they should have a three-piece design and have a large optic, he said. One such design is the HumanOptics add-on IOL. However, that IOL has the disadvantage of requiring a 3.2mm incision. Add-on IOLs with four-point haptics such as 1stQ Add-On IOLs (Medicontur) are very rotationally stable, which make the outcomes their toric designs more predictable, Dr Breyer said. He cautioned, however, that the IOL’s haptics are very fragile and that he has broken haptics in a couple of procedures with the lens. Dr Breyer noted that there are now a number of refractive and diffractive multifocal IOLs now available that offer the option of easy reversibility, should a patient be unhappy with their outcomes. They include the refractive and diffractive Sulcoflex multifocal add-on lenses and the 1stQ diffractive trifocal and toric

A diffractive Optic

Courtesy of Detlev Breyer MD

dd-on intraocular lenses have come a long way from the days when standard IOLs were combined for additional refractive correction. The latest generation of lenses are designed for implantation in the sulcus and have optional features including astigmatism correction and multifocality, Detlev Breyer MD told the 37th Congress of the ESCRS in Paris, France. Back in the late 1990s, eyes with piggy-back IOLs were affected by complications such as interlenticular opacification, the induction of hyperopic defocus and iris capture. The new sulcus-fixated add-on IOLs provide greater clearance between the add-on and primary IOLs and have haptics more suitable for sulcus implantation, reported Dr Breyer, Breyer Kaymak Klabe Augenchirurgie & Premium Eyes, Dusseldorf, Germany. Prominent among these new lenses are the Sulcoflex add-on IOLs (Rayner). The lenses are composed of a hydrophilic material, which has a high uveal compatibility and a low tendency for erosion of the sulcus. In addition, the 6.5mm optic is large enough to provide good optical quality and prevent iris capture, with a round edge to prevent dysphotopsias. It has a concave posterior surface to prevent optical distortion and also maintain a safe distance between the two optics. Moreover, the overall length of the sulcus-implanted lenses, including the haptics, is large enough to provide good centration. The haptics have an angulation of 10 degrees, to provide uveal clearance and thereby prevent pigment dispersion and iris capture, and they are soft to decrease tissue reaction, he explained. The original injector allows insertion of the lens though a 2.4mm incision. Dr Breyer noted that he implants the lenses through a 1.8mm incision with a cartridge from ZEISS and a single-hand push shooter. He performs the procedure using irrigation, without viscoelastics. He reported that in his patients, postoperative Scheimpflug photography shows a good clearance of around 0.5mm between the primary and add-on IOLs and the procedure does not induce any astigmatism. Moreover, the mean overall thickness of the two IOLs combined is only around 2.4mm, compared to the 4.5mm thickness of the crystalline lens preoperatively. That makes the lens particularly advantageous in very short eyes.

A refractive Optic

trifocal add-on lenses. The Sulcoflex refractive multifocal add-on distributes 60% of focused light to distance and 40% to near. The diffractive Sulcoflex multifocal IOL distributes 52% of light to distance, 22% to near and 26% to near, leaving only 11% of light out of focus. Dr Breyer noted that to determine whether a patient is likely to be happy with a particular multifocal IOL he developed the Dusseldorf miLens© strategy based on publications in peerreviewed journals and his own investigations. It is designed to match the patient’s psychology to the most appropriate multifocal IOL, based on its optical properties. The strategy involves obtaining patients’ responses to a questionnaire regarding their psychological tendencies, particularly with regard to compulsive checking, competence, orderliness and dutifulness, high levels of which predict greater subjective disturbance by haloes and glare. Dr Breyer puts great emphasis on the principle of shared decision making by showing charts of photopic phenomena and defocus curves to his patients during counselling. He added that the three factors in multifocal IOL design that correlate most closely with potentially disturbing dysphotopsias are the power of the near add, the use of diffractive optics to achieve the multifocality and non-emmetropic postoperative refraction. Detlev Breyer: d.breyer@augenchirurgie.clinic EUROTIMES | FEBRUARY 2020



The holy grail of IOLs IOL technology closing in on the elusive goal of restoring accommodation. Roibeard Ó hÉineacháin reports


fter many disappointments in the past, a new generation of IOLs offers hope of at last achieving the holy grail of accommodation restoration, Florence Cabot MD told the 37th Congress of the ESCRS in Paris, France. “Restoring accommodation means creating a device that has a continuously variable, adjustable, active, near-focusing ability. Ideally, we need to restore three-to-five dioptres,” said Florence Cabot MD, Assistant Professor of Clinical Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida USA. She noted that the first generation of accommodating IOLs supposedly provided accommodation by a forward movement in the axial position of the IOL’s optic in response to ciliary muscle contraction. However, this change in focus was slight and studies have shown that the apparent improvements in near vision might have been partially due to an increase of optical aberrations that provide a better depth of field. Furthermore, studies using optical coherence tomography (OCT) have shown that not only was there no forward movement of the optic in response to accommodative stimulus, the optics sometimes move backwards instead. The new generation of accommodative IOLS uses a variety of mechanisms to achieve a more physiological form of accommodation. They include in-the-bag and sulcus-implanted IOLs and rely on ciliary muscle movements or pupillary changes to stimulate a change in shape or alteration of the optic’s refractive properties. Among the first of the new lenses is the Juvene (LensGen). It is a single-piece IOL with two fluid reservoir haptics, two optics attached by a flexible actuator and active and passive fluid chambers. The capsular forces exerted on the haptics during accommodation cause the fluid to be pumped centrally into the optic resulting in a shape change and increased refractive power without splitting the light like multifocal IOLs. The lens is designed for implantation in the capsular bag through a sub4mm incision. A clinical trial, the "Grail Trial", is now under way in Mexico and the Dominican Republic. So far, the lens has been implanted in 44 eyes with very good results, Dr Cabot said. “One of the drawbacks of this IOL is its bulkiness and the

difficulty of injecting it through a small incision. On the other hand, because of its shape, the early trials have not shown much PCO, besides which there is none of the glare that is common with multifocal IOLs.” Another of the new accommodative lens concepts, still in the experimental stages, is the Sapphire autofocus IOL, (Elenza, USA). It ticks all the boxes of modern technology. It is electronically controlled and utilises nanotechnology, artificial intelligence and advanced electronics to auto-adjust focus in response to pupillary changes. It uses pupillary responses to stimulate changes in the liquid crystal within the lens that alter its refraction. The speed and amplitude of pupil response are used to differentiate between light and accommodative stimuli. The lens has a power-cell that requires recharging every three-to-four days. It has a hibernation mode and a fail-safe mechanism that converts it to monofocal status till recharged. It also allows the physician to remotely adjust the sensitivity and magnitude of the switching point of the add power in the IOL, based on the needs of patient The Dynacurve (Nulens) is an out-of-the-bag IOL in which the PMMA haptics are secured by internal scleral fixation to the sulcus without sutures. Its optic changes curvature in response to accommodation by using the collapsed bag-zonular complex as a mobile diaphragm, which activates a piston that modifies a flexible membrane to provide spherical or aspherical dynamic surface. The Lumina IOL (AkkoLens) out-of-the-bag/sulcus IOL has two optical elements shifting in a plane perpendicular to the optical axis producing accommodation. The dual-optic, hydrophilic acrylic lens has two complementary refractive plates, which, translated laterally, produce a progressive change in optical power. “There are lots of options and interesting concepts in the pipeline with good results in both in vitro and animal studies, with some lenses still awaiting clinical trials. True accommodative IOLs remain the holy grail of ophthalmic surgery,” Dr Cabot concluded. Florence Cabot: fcabot@med.miami.edu


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IOL evolution Ten-year review shows steady improvement for multifocal IOL outcomes. Dermot McGrath reports time to in step with advances in IOL technology and design. “From 2008 to 2010 we started with the ReSTOR and Tecnis lenses with apodisation and bifocality, then made the transition to AT LISA. Then came trifocality with the FineVision IOL, which was a very successful lens in France from around 2015 to 2017. I then moved to mix-and-match with the combination of Lentis Mplus in the dominant eye and the Bi-Flex 677MY in the other eye. The majority of my current multifocal cases are Bi-Flex 677MY, which is the most balanced polyvalent lens on the market, and I am also trying newer lenses such as PanOptix and PresbySmart (Innophta) to see what additional benefits that might bring,” he said. Summing up the overall outcomes of the study, Dr Assouline said he believed that the most useful recent innovation was the restriction of the diffractive structure to the central portion of the optic of MIOL (3mm for the Medicontur and 4.5mm for the PanOptix), which leaves a purely refractive surface in the periphery to improve distance vision with a large pupil (night vision) and reduce untoward phototic phenomenons. In addition, he mentioned that he has discontinued the Lentis IOL after cases of calcification (requiring explantation of two lenses from a total 901 cases), until a satisfactory feedback and long-term followup of the corrective action can be provided by the company. “You need to have confidence in the material you are using. The Medicontur Bi-Flex “LIBERTY” lens is made of a proven material that comes with a very low chromatic aberration index. It has an original and very convincing design with the optical bench simulation, which is matched by excellent outcome in the clinic,” he concluded. Michael Assouline: dr.assouline@gmail.com

We really wanted to establish the correlation between the different energy distribution of different MIOLs and the clinical results obtained

Grow Your Practice Through Innovation Win a €1,500 Bursary ESCRS Practice Management and Development Innovation Award

Submission Deadline Friday 24 July 2020

Practice Management



dvances in multifocal IOL design and technology mean that surgeons now have the possibility to deliver a truly customised approach for their patients with excellent clinical outcomes and very few of the drawbacks associated with early-generation lenses, according to Michael Assouline MD, PhD. “We did a long-term study of a number of different multifocal IOLs that we have used over the years in our clinic and have seen how the ongoing innovations in IOL design are reflected in improved clinical outcomes for our patients,” he told delegates at the annual meeting of the French Implant and Refractive Surgery Association (SAFIR) in Paris, France. Dr Assouline’s retrospective study of more than 2,000 MIOLs focused particularly on the ability of more recent lenses to enhance the quality of intermediate vision for patients. “We really wanted to establish the correlation between the different energy distribution of different MIOLs and the clinical results obtained. The functional outcomes show that the more advanced designs clearly result in better intermediate vision, which is very useful in everyday life, compared to the older bifocal models,” he said. The study included consecutive cases of seven different lenses: AT LISA (Zeiss) in 193 patients; Lentis Mplus X (Oculentis/ Topcon) in 751 patients, Lentis Comfort in 172 patients, FineVision (PhysIOL) in 234 patients; Bi-Flex 677MY (Medicontur) in 577 patients; PanOptix (Alcon) in 117 patients; and a selection of other IOLs in 55 patients. Outcome variables included best-corrected and uncorrected visual acuity for near, intermediate and distance, monocular and binocular defocus curves, subjective eye preference in mix-andmatch cases for all distances and Nd: YAG capsulotomy survival curves. Dr Assouline said that the lens choice he offers his patients has evolved over

& Development

For further details email: innovation@escrs.org

Michael Assouline MD, PhD EUROTIMES | FEBRUARY 2020



IOL range expanding New optical designs for presbyopic IOLs offer patients more options. Roibeard Ó hÉineacháin reports


he range of presbyopic IOLs continue to expand with new diffractive extended depth of focus (EDOF) optical designs and new hybrid and accommodating IOLs on the horizon, reports Jorge Alió MD, PhD, FEBO, Universidad Miguel Hernández, Alicante, Spain. “New presbyopic IOLs present opportunities for the present and the future, but to use them properly we have to be aware of what they offer and how they fit our patients’ needs,” Prof Alió told the 37th Congress of the ESCRS in Paris, France. Among multifocal IOLs there are new diffractive models that target the decrease in haloes and glare by decreasing the near optical power, substituting it by an EDOF effect. There are also new refractive multifocal IOLs with new optical profiles, and new materials.

WHAT IS EDOF? Prof Alió noted that the EDOF IOL concept has become very popular, but there is some confusion about what constitutes an EDOF lens. EDOF IOLs manipulate the spherical aberration of the IOL in a way that elongates the defocus curve. That in turn eliminates the overlap of near and far images and therefore theoretically eliminates the halo effect. “The trade-off is a decrease in the quality of the retinal image, which limits their performance as there is a degradation of the vision quality. This is why the near vision capability has to be limited to about one dioptre,” he added. New EDOF IOLs include the Mini WELL (SIFI, Italy), which generates multifocality by having positive spherical aberration in the centre and negative spherical aberration in the mid-periphery. Employing an entirely different strategy for multifocality or extended depth of focus are new IOLs and implants that use the pinhole effect. One example is the IC-8

(AcuFocus) IOL, which has a 3.23mm opaque mask with 1.36mm aperture imbedded within the optic. Another new idea is the XtraFocus Pinhole Implant (Morcher), designed for ciliary sulcus implantation as a piggyback lens. Composed of a black hydrophobic acrylic material, it has an overall diameter is 14mm and a 1.3mm central aperture. The implant’s material blocks visible light and is transparent to infrared light above 750nm, allowing retinal examination with optical coherence tomography and scanning laser ophthalmoscopy.

HYBRID MULTIFOCAL-EDOF IOLS Prof Alió noted that some of the so-called EDOF lenses available today are really multifocal lenses with low near-add power. By manipulation of spherical aberration these lenses leave part of the light out of focus to avoid the overlapping of images and the consequent haloes and glare. “EDOF lenses should be called such only when they do not have either refractive or diffractive added multifocality. If they do, they should be called hybrid multifocal-EDOF IOLS,” Prof Alió said. Among multifocals of this type is the Tecnis Symfony (Johnson & Johnson Vision). This is a single-piece, hydrophobic acrylic, foldable lens with a biconvex, wavefront-designed anterior aspheric surface, an addition of +1 .75D at the IOL plane and an echelette design to correct chromatic aberrations and theoretically improve depth of focus. However, research shows that although the correction of chromatic aberrations improves contrast sensitivity it does not increase depth of focus. Another of the new multifocal-EDOF hybrids is the AcrySof IQ PanOptix (Alcon), a diffractive trifocal unapodised lens. It distributes light to four focal points, with half of the light devoted to

The trade-off is a decrease in the quality of the retinal image, which limits their performance as there is a degradation of the vision quality Jorge Alió MD, PhD, FEBO EUROTIMES | FEBRUARY 2020

Courtesy of Jorge Alió MD, PhD, FEBO


A prototype multifocal phakic IOL used in a pilot study for near and far visual correction in presbyopia in 2005

distance and half devoted to near and intermediate with respective addition powers of +2.17D and +3.25D. The posterior lens surface is spherical, and the anterior surface is aspheric, with a central 4.5mm diffractive portion. Among the new refractive multifocalEDOF hybrids is the Acunex Vario (Teleon), which has a unique sectorial optic design with a 1.5D addition with a smooth transition between zones to provide an extended depth of focus with sharp visual acuity results for the intermediate and distance ranges.

ADD-ON MULTIFOCALS Other options include phakic and piggyback multifocal IOLs such as the Presby IPCL (Care Group) which has a trifocal diffractive optic, designed for phakic presbyopic patients. There are also piggyback multifocal IOLs such as the Sulcoflex (Rayner), the ReSTOR (Alcon), AT Lisa (Zeiss), and Mplus (Oculentis). Although these implants can provide good results, success with the lenses is highly dependent on a near perfect alignment of the optical axes of the piggy-back and primary IOLs. Finally, there is the re-emergence of the accommodating lens, now with new technologies that no longer attempt to use the forward movement of the optic to achieve accommodation. Among these new IOLs is the AkkoLens Lumina, which uses two optical elements shifting perpendicular to the optical axis to produce accommodation. Studies with the lens to date have shown that it can restore visual function and accommodation, with no effect on the contrast sensitivity, Prof Alió said. Jorge Alió: jlalio@vissum.com



A new approach for unhappy patients Multicomponent IOL systems offer attractive option in certain scenarios. Cheryl Guttman Krader reports

Courtesy of Harvey S. Uy MD


ulticomponent IOLs are a safe and effective option for correcting errors of refraction and addressing multifocal IOL intolerance after cataract surgery, said Harvey S. Uy MD, at the 37th Congress of the ESCRS. “A significant proportion of premium IOL patients are unhappy with their outcome, and a major cause for their dissatisfaction is residual refractive error. A published analysis of EUREQUO data (Lundström M, et al. J Cataract Refract Surg. 2018;44(4):447452) showed that one-in-14 patients will have a significant refractive error of 1D or more and one-in-100 patients will have a refractive surprise of 2D or more. These data translate into cataract surgeons having one patient with an unsatisfactory refractive outcome for every OR day,” said Dr Uy, Medical Director, Peregrine Eye and Laser Institute, Makati, Philippines. He suggested that primary implantation of a multicomponent IOL with an exchangeable optic provides a safety net in premium IOL cases. In the future, the applications for multicomponent IOLs might also include intraocular medication delivery and blood sugar concentration detection. Multicomponent IOLs are modular systems made of one permanent element that sits in the capsular bag and a detachable/ exchangeable piece. Dr Uy has worked with two multicomponent IOLs – the Precisight (InfiniteVision Optics), which is commercially available in Europe, and the Harmoni Modular IOL System (ClarVista Medical), for which he did the first clinical study. The Harmoni IOL consists of a donut-shaped hydrophobic acrylic base component that sits in the capsular bag and a hydrophilic acrylic optic that is attached to the centre. The Precisight IOL consists of two refractive components. The base lens is a hydrophobic acrylic lens that remains in the capsular bag permanently, while the front detachable optic is made of hydrophilic acrylic and comes in monofocal, multifocal, extended depth of focus and toric versions. “The secondary optic has tabs that attach to the bridges on the base component and lock the lens in place,” Dr Uy said.

A slit lamp photo of the Precisight with both components within the capsular bag

The primary procedure for Precisight IOL implantation is done with injection through a 2.4mm incision. The procedure for exchanging the front optic with the Precisight IOL is done through the original surgical incision and has a fairly short learning curve. It requires no additional equipment and is very safe, Dr Uy said. “Use of the multicomponent IOL removes the time pressure that accompanies an exchange procedure for a conventional IOL. The longer we wait to exchange a conventional IOL, the more nervous we get because capsular fibrosis sets in, and so the surgery becomes more complex. With the Precisight IOL, the later you do the exchange, the easier it becomes because capsular fibrosis makes the base component more stable.” he added.

CLINICAL PROOF Data from a study including 65 eyes implanted with the Precisight IOL demonstrate the safety and effectiveness of the exchange/enhancement procedure. The front optic was exchanged more than three months after the primary surgery in eyes with MRSE greater than 1D. Mean logMAR UDVA was 0.2 pre-enhancement and 0.0 at three and 12 months post-enhancement. “CDVA was unchanged after the exchange procedure, and the endothelial cell count

Assembly of a Precisight IOL outside of the eye

was stable too, which demonstrates the safety of the exchange,” Dr Uy said. Mean manifest refraction spherical equivalent (MRSE) was 1.3D preenhancement and 0.0D at three and 12 months post-enhancement. At one year post-enhancement, MRSE was within 0.25D of target in 79% of eyes, ±0.50D in 92%, and ±1.0D in all cases. “The IOL position is stable after the enhancement. The data in this series show that the exchange procedure is associated with very robust correction of refractive error and good refractive stability,” Dr Uy said. Harvey S. Uy: harveyuy@yahoo.com EUROTIMES | FEBRUARY 2020



New ESCRS president As Prof Rudy Nuijts takes over the Presidency of ESCRS, he plans to expand the Society’s role in research, education and consensus building


t is very exciting and a great honour to take on the role of president of the ESCRS, one of the major societies in the world of ophthalmology. It is the largest in Europe, has the largest number of members and our Congress is probably second in the world in terms of attendees after the American Academy of Ophthalmology. That shows the enormous impact of the ESCRS on European but also global ophthalmology. We know that people really want to attend our meetings because the content is excellent. What is a continuous challenge of course for us to meet, I am happy that I can be part of that decision machine that tries to put these meetings together as best we can. My career at the ESCRS began when Gabriel van Rij, who was at that time the chair of the Netherlands IntraOcular Implant Society (NIOIC), proposed me to be a co-opted member on the board of the organisation. Then I was elected board member and over the years I have been active in various committees within the ESCRS. Peter Barry mentored me and made me enthusiastic for the position of treasurer, a role that was assigned to me by the board for almost eight years. As a university-based ophthalmologist I have always had a great interest in evidence-based medicine. At our University Eye Clinic in Maastricht we have conducted various randomised clinical trials in the field of cataract and lamellar corneal surgery, eg. comparing toric vs monofocal IOLs and comparing different multifocal IOLs and DMEK vs UT-DSAEK. The funding and organisation of landmark research projects addressing important questions, such as the ESCRS endophthalmitis study and the ESCRS PREMED study, has also had an international impact on ophthalmology, crossing the borders of Europe and stimulating discussion and changing practice patterns around the globe. There is an emphasis nowadays on evidence- and valuebased healthcare because we need to determine how can we add value to our treatments in a costeffective way. During my presidency we will certainly enhance our efforts in sponsoring research projects that can really give us good answers to the questions that we still have. For the next two years, starting under my presidency, we will put a working group together to establish ESCRS

Peter Barry mentored me and made me enthusiastic for the position of treasurer, a role that was assigned to me by the board for almost eight years


guidelines for cataract and refractive surgery. This is one of the goals that came out of the strategic review that Béatrice Cochener-Lamard initiated during her presidency, asking all the committees what they believe should have the attention of the society over the coming years. Using ideas from this review and evidence from landmark studies we will close the loop and have implementation of our scientific work in the ESCRS guidelines. We will also put more emphasis on the digital era. We will establish a new committee in the ESCRS, a digital health committee, which will carry out an inventory of the ideas in our membership to apply digital innovations and artificial intelligence to our existing questionnaires and registries. Another project we are working on will involve collaboration with the American Academy of Ophthalmology, who are currently developing a presbyopiacorrecting IOL patient-reported outcomes questionnaire. We would like to adapt that and make it suitable for different European countries and languages. In this way we will create an instrument that can be used to make the interpretation of the outcomes of these studies on a global scale much more uniform. I foresee that this may have significant impact on the development of new devices on the regulatory processes related to bringing innovations to the market. We are continuously trying to improve our meetings and we are very keen to have the younger membership of our Society more involved to connect them to our meeting. It becomes exceedingly difficult to have a free paper accepted or posted because we have so many submissions and not everybody has access to good research facilities. At our most recent Meetings, particularly our Congress in Paris, we have been using a tracking system to see what our members are doing, how much time attendees spend at the meeting and their preferred symposia. We will be using this information to gradually change how we organise our sessions. One thing we have certainly seen is that people are interested in interactive sessions, where the audience can have some input, as well as integrated panel discussions. Therefore, for the next Amsterdam meeting we will have sessions in which especially young people, can present a case report and we can discuss it. In this way trying to keep the day-today connection with what we are doing in practice – the patient sits in front of you and they have a problem and you have to solve it. So on the one hand ESCRS wants to put efforts into large landmark studies, and on the other I think as a Society our goal is to connect people and educate and assist them in their day-today medical decision making. Rudy MMA Nuijts MD, PhD, is Professor of Ophthalmology, Vice-Chairman, and Director of the Cornea Clinic and the Center for Refractive Surgery at the University Eye Clinic Maastricht, Maastricht Medical University , The Netherlands From an interview with EuroTimes Contributing Editor Roibeard Ó hÉineacháin


Satisfaction after cataract surgery Attention to the ocular surface key for planning and visual function. Cheryl Guttman Krader reports


ptimisation of the ocular surface is a key factor for achieving success in cataract surgery because an abnormal tear film affects visual performance and the accuracy of biometric measurements used for IOL power calculation, said Béatrice Cochener-Lamard MD, PhD, at the 37th Congress of the ESCRS in Paris, France. “The tear film not only provides protection. It has real optical power,” said Dr Cochener-Lamard, Professor and Chair of Ophthalmology, University Hospital of Brest, France. “Preoperative treatment of ocular surface disease to restore tear film stability and ocular surface integrity will allow for more accurate measurements and better functional outcomes.” Data showing that dry eye disease and meibomian gland dysfunction (MGD) are common in the cataract surgery patient population and often asymptomatic reinforce the need for surgeons to look for these conditions and not just rely on subjective reports from patients to identify individuals with dry eye. “Take time to detect ocular surface disease. Look at ocular surface staining, tear stability, keratometry and topography,” Dr Cochener-Lamard advised. “Blinking frequency and the capacity of the lid to cover the cornea are also very important and can now be measured, and new diagnostic tools can assess tear meniscus height, tear break-up time and meibomian gland morphology.”

THE TREATMENT LADDER Ocular surface optimisation is approached using a graduated therapeutic strategy. All patients, however, are advised to use artificial lubricants, preferably preservative-free, and educated about their condition and lifestyle and environmental modifications to address exacerbating factors. An anti-inflammatory medication may be needed as a second step. A topical corticosteroid can act quickly to improve the ocular surface, but should be given only as a short course. Topical cyclosporine is indicated for more severe disease, but its side-effects can cause patients to discontinue treatment before onset of efficacy. “Concomitant short-term use of a topical corticosteroid will accelerate the improvement at the stage of the introduction of cyclosporin with a synergistic effect of the combination,” Dr Cochener-Lamard said. Because evaporative disease due to MGD is the principal cause of dry eye in the cataract surgery population, intervention is also likely needed to restore the tear film lipid layer. Targeted therapies include lipid-containing ocular lubricants and multiple methods to reduce meibomian gland obstruction and improve the biofilm. Topical and oral antibiotics that have anti-inflammatory activity can also be used. Clinicians also should not overlook the possibility of Demodex infestation, which can be identified as cylindrical lash deposits and treated with products containing tea tree oil. Other interventions to consider include essential fatty acids and punctal plugs. Rehabilitative exercises can help improve blink quality. Abnormalities of eyelid conformation should also not be overlooked. Béatrice Cochener-Lamard: beatrice-cochener-lamard@chu-brest.fr

The editors of the JCRS extend congratulations to the annual award winners!


Surgical Management of Negative Dysphotopsia Samuel Masket, MD, Nicole R. Fram, MD, Andrew Cho, BS, Isaac Park, BA, Don Pham, BS J Cataract Refract Surg 2018; 44:6–16


Streamlined Method for Anchoring Cataract Surgery and Intraocular Lens Centration on the Patient’s Visual Axis Vance Thompson, MD J Cataract Refract Surg 2018; 44:528-533





Getting to grips with

ASTIGMATISM Free-to-download double-angle plot tool offers clear, precise astigmatism data analysis. Dermot McGrath reports


double-angle plot tool that can be used by clinicians and researchers to display standardised vectoral astigmatism outcomes is now available for download via the ESCRS, ASCRS, and JCRS websites. The tool, which has been refined and improved over many years of research, enables clinicians to generate three figures and associated outcomes data that are optimal for describing all forms of astigmatism and astigmatic change. With it, clinicians can quickly and easily evaluate their current surgical outcomes and finetune their approach to potentially improve future outcomes. The key difference with this tool, unlike the some of the other plot tools currently available, is that it uses double-angle plots to display astigmatism data. “The double-angle plot is critical to displaying astigmatism data properly,” explains Douglas Koch MD, Professor in Ophthalmology at the Baylor College of Medicine in Houston, Texas, and one of the key figures behind the development of the tool. He acknowledges colleagues Adi Abulafia, Jack Holladay, Li Wang and Warren Hill as collaborators in developing the tool and writing the accompanying 2018 JCRS guest editorial. “Double-angle plots are clear and precise for graphic display of astigmatic data. The relationship of data points, the centroids, and the 95% confidence ellipses can only

As Figure 1 from JCRS guest editorial illustrates, all with-the-rule data (WTR) points are displayed on the left of the vertical axis, and against-the-rule (ATR) data are displayed to the right of it.

be accurately displayed on a double-angle plot. This plot is not available in standard software such as EXCEL and can only be found in expensive statistical software such a SPSS, SAS, and XLSTAT costing thousands of dollars. The double-angle plot tool is simple to download and use, and it displays outcomes correctly by simply entering the required data,” he said. As Dr Koch notes, the concept of doubling the angles for astigmatic analysis is not new. “It actually goes back 170 years to Stokes’ original presentation in 1849, so it is fair to say that this is the original way to evaluate astigmatism. It was applied

The relationship of data points, the centroids, and the 95% confidence ellipses can only be accurately displayed on a double-angle plot Douglas Koch MD EUROTIMES | FEBRUARY 2020

by Jaffe and Clayman in their classic 1975 article. However, Jack Holladay deserves credit for introducing it into contemporary astigmatism analysis with his initial article in 1992, which was followed by several additional publications by him and by others applying his methodology. It was even adopted by the Journal of Refractive Surgery in 2006, with Dr Malvina Eydelman as lead author,” he said. As Dr Koch sees it, the tool is extremely versatile in describing astigmatism and astigmatic change in clear and precise graphical form. “I think it is especially useful when comparing prediction errors of astigmatism with formulas and devices where centroids and confidence ellipses are necessary for comparison, just as means and confidence intervals are used for single variables,” he said. The double-angle plots display data more clearly and allow for superior methods of statistical analysis compared to tools that use single-angle plots, said Dr Koch. “Kristian Næser has made a huge contribution here with his elegant method


1 Stokes GG. 19th Meeting of the British Association for the Advancement of Science, 1849. Trans Sect 1850; 10. 2 Jaffe NS, Clayman HM. The pathophysiology of corneal astigmatism after cataract extraction. Trans Am Acad Ophthalmol Otolaryngol 1975; 79:OP615–OP630. 3 Holladay JT, Cravy TV, Koch DD. Calculating the surgically induced refractive change following ocular surgery. J Cataract Refract Surg 1992; 18:429 – 443. 4 Eydelman MB, Drum B, Holladay J, Hilmantel G, Kezirian G, Durrie D, Stulting RD, Sanders D, Wong B. Standardized analyses of correction of astigmatism by laser systems that reshape the cornea. J Refract Surg. 2006;22:81-95.

Examples of two of the three figures (and figure legends to describe them) that are produced using the double-angle tool

A: Cumulative histogram of the magnitude of the preoperative corneal and postoperative refractive astigmatism, vertexed to the corneal plane (n=78). Means and SDs are also shown

Courtesy of Douglas Koch MD

of statistical analysis. The key difference is this – with single-angle plots, against-therule data are split on either side of the graph. With double-angle plots, both with-therule and against-the-rule data are grouped accordingly, allowing easy visualisation of trends, data centroids, confidence intervals and standard deviations,” he said. As Dr Koch sees it, there is nothing inherently difficult in understanding double-angle plots once the basic principle has been grasped. “The only hurdle in understanding is taking the brief amount of time to wrap one’s mind around the concept that in double-angle plots with-the-rule data are displayed on the left and against-the-rule data are displayed on the right. Once you comprehend this, you can see how compelling this type of display is for astigmatism analysis and reporting,” he said. The tool can be downloaded at https://education.escrs.org/rethinkingastigmatism-analysis-for-intraocular-lensbased-surgery-2/


B: Double-angle plots of the preoperative corneal and the postoperative refractive astigmatism (n=78). Centroids and SDs are also shown







Complications with SMILE Most SMILE intraoperative complications related to learning curve. Dermot McGrath reports

2020 Applications are open for the Peter Barry Fellowship 2020. This Fellowship commemorates the immense contribution made by the late Peter Barry to ophthalmology and to the ESCRS. The Fellowship of €60,000 is to allow a trainee to work abroad at a centre of excellence for clinical experience or research in the field of cataract and refractive surgery, anywhere in the world, for 1 year. Applicants must be a European trainee ophthalmologist, 40 years of age or under on the closing date for applications, and have been an ESCRS trainee member for 3 years by the time of starting the Fellowship. The Fellowship will be awarded at the ESCRS Annual Congress in Amsterdam in October 2020, to start in 2021. To apply, please submit the following: l l



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

Closing date for applications is 1 May 2020 Applications and queries should be sent to Danielle Maher at danielle.maher@escrs.org


ost of the intraoperative complications encountered in small incision lenticule extraction (SMILE®) procedures seem to be related to initial surgical inexperience with the technique, according to a study presented at the 37th Congress of the ESCRS in Paris. “We think that the inexperience of the surgeon at the beginning of the learning curve, and in particular the inability to detect the edge of the lenticule with numerous attempts of dissection above or below the lenticule, is the major cause of most intraoperative complications,” said Ahmed El Shahed MD. Dr El Shahed presented the results of a retrospective study by Abdelmonem M Hamed MD of 282 eyes of 141 patients who underwent SMILE surgery for myopia and/or myopic astigmatism at Ebsar Eye Center, Benha, Egypt. Suction loss was found to be the biggest complication, occurring in 18 eyes (6.4%), followed by treatment decentration in six eyes (2.1%), wound bleeding in 21 eyes (7.4%), incomplete bubble separation in three eyes and epithelial defects in 15 eyes (5.3%). To avoid problems of suction loss, Dr El Shahed said it was important to select the appropriate cone size according to corneal diameter and to use a globe fixator if necessary to ensure successful engagement of suction. In cases where suction was lost before the total creation of the lenticule, the procedure could be aborted and rescheduled after the reabsorption of the cavitation bubbles, said Dr El Shahed. If the lost suction occurred after the total creation of the lenticule or during the creation of the cap, the eye could be re-docked and the surgeon could restart the cap, side cut and wound creation and dissect it normally, he said. Decentration can have a significant effect on vision outcomes in SMILE procedures. In the absence of an eye tracker it is important to ensure that the patient is correctly self-fixating on the green microscope light in order to correctly align the treatment on the pupil centre, said Dr El Shahed. Intraoperative wound bleeding is more likely to occur in patients with vascular pannus, noted Dr El Shahed, while the risk of black islands appearing from incomplete bubble separation happens due to meibomian secretions or debris at the interface of the cone and the cornea during docking. “We can overcome this type of issue by washing the eye with BSS before docking and ensure optimal hydration of the cornea before proceeding with the surgery,” he said. Further studies with larger patient numbers were required to evaluate intraoperative complications during SMILE and standardise management strategies, he said. Ahmed El Shahed: dr_aelshahed@live.com


We think that the inexperience of the surgeon at the beginning of the learning curve... is the major cause of most intraoperative complications Ahmed El Shahed MD


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Corneal registry up and running Data on more than 12,000 transplants already submitted to European registry. Priscilla Lynch reports

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


the ECCTR Registry


your Surgical Results

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


he European Cornea and Cell Transplantation Registry (ECCTR) is now up and running successfully, with data on 12,612 transplants from 12 countries already submitted for analysis, according to an update given during the 10th EuCornea Congress in Paris, France. The aim of the ECCTR 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 in ophthalmic surgery. The registry is recording recipient characteristics, donor and eye bank processing data, and transplant procedure information, with a two-year follow-up including survival, outcomes and complications. The project is a three-year programme co-funded by the European Union and the ESCRS; with evaluation and dissemination of the collected data and development of an evidence-based European protocol to follow once recruitment of clinics is complete.

ESTABLISHED CULTURE During his presentation on the ECCTR at the EuCornea Congress, Mor Dickman MD, PhD, University Eye Clinic, Maastricht University Medical Center, revealed that the UK and the Netherlands have been the largest contributors of data to the ECCTR to date. He said that this was because there was already an established culture of recording and reporting corneal transplant data in these countries. Fuchs’ dystrophy is by far the leading indication for transplantation, according to the data submitted to date, he said, followed by graft failure, pseudophakic bullous keratopathy (PBK), keratoconus, infection and trauma. Age wise, most cornea recipients registered with the ECCTR to date are between 70 and 79 years, “the average age being 70”, followed by the 60-to-69 years age bracket, reported Dr Dickman. The most common transplant procedure carried out to date is Descemet’s stripping automated endothelial keratoplasty (DSAEK), followed by penetrating keratoplasty (PK), Descemet's membrane endothelial keratoplasty (DMEK), and deep anterior lamellar keratoplasty (DALK). In many of the countries participating in the ECCTR up to 100% of the cornea donors are local, Dr Dickman said, while others are not self-sufficient, and import tissue from other European countries or the United States. Some countries have a mix of local and foreign donors. Speaking to EuroTimes, EuCornea President Professor Jesper Hjortdal MD, PhD said he was pleased with the uptake of the ECCTR so far, with more European countries now due to join, while others expressed an interest in joining during the Congress. Dr Hjortdal said he hoped to present more comprehensive data findings from the ECCTR during next year’s EuCornea Congress. Jesper Hjortdal: jesper.hjortdal@dadlnet.dk Mor Dickman: mor.dickman@mumc.nl


11th EuCornea Congress

AMSTERDAM 2 – 3 October 2020 RAI Amsterdam, The Netherlands

Abstract Submission Deadline 15 March 2020 www.eucornea.org



DMEK vs DSAEK: what is the latest? Experience of operating surgeon often determines choice of procedure. Priscilla Lynch reports

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escemet stripping automated endothelial keratoplasty (DSAEK) remains the more popular choice in cataract surgery on diseased corneas, but the use of Descemet’s membrane endothelial keratoplasty (DSEK) is increasing and has certain advantages, Frank Larkin MD FRCOphth, UK, told the 37th Congress of the ESCRS in Paris, France. Addressing the joint ESCRS/EuCornea Symposium: ‘Cataract Surgery in Eyes with Diseased Corneas’, Dr Larkin gave a considered overview on when to use DSAEK or DMEK in combination with cataract surgery, with surgeon experience and pre-cut graft availability being key considerations. While discussing meta-analyses and the data reported to date, he said there remains a scarcity of controlled clinical trials and lack of information in particular on longer-term visual outcomes, and complication rates with/without adjustment for surgeon inexperience. Dr Larkin listed the advantages of DSAEK as the donor graft being prepared in advance (faster operating lists and no uncertainty about donor availability), easier graft handling in the anterior chamber, more versatile technique (it can be used in a wider variety of anterior segment disorders and dimensions), and lower complication rates. With regards to DMEK, advantages include faster visual recovery, better visual acuity and quality in the earlier months post-surgery, and a probable lower risk of allograft rejection – “if this is confirmed in prospective studies it may mean needing to use less steroids”. Dr Larkin quoted UK registry data on EK for all indications since 2001 which shows the significant rise in its usage; from just eight procedures in 2001 to over 2,000 procedures in 2018. DSAEK was by far the most popular choice of EK initially, but DMEK has rapidly caught up in the last five years, with 630 DMEK procedures performed in 2018 in the UK. He also highlighted data showing that DSAEK outcomes in Fuchs’ cases are improving over time. However, Dr Larkin also cited results from a 2019 analysis of 88 UK ophthalmic surgeons, which showed that the majority (51) had performed fewer than 20 DMEK procedures, so surgeon experience in the procedure still needs to improve. Summarising the UK registry outcome data to date, he said DSAEK and DMEK outcomes are comparable after accounting for surgeon learning, adjusting for post-DMEK failure and surgeon experience. Concluding, Dr Larkin said DMEK is becoming more established among high-volume surgeons and centres for uncomplicated endothelial replacement with cataract surgery. In the future in such centres DSAEK will remain the preferred procedure in patients with comorbidities, but more detailed studies and longer-term data are needed, he said. Frank Larkin: frank.larkin@moorfields. nhs.uk / f.larkin@ucl.ac.uk


...data showing that DSAEK outcomes in Fuchs’ cases are improving over time Frank Larkin MD FRCOphth


Is now the time to abandon Kmax? Other measures enable earlier detection and treatment. Howard Larkin reports


odern corneal tomography measurements, including anterior and posterior elevation and pachymetric data, can help diagnose and detect progression in keratoconus earlier and more reliably than can changes in maximum anterior sagittal curvature (Kmax), Michael W Belin MD, told the 10th EuCornea Congress in Paris. He outlined several reasons why Kmax is a poor parameter for assessing ectasia severity. Kmax often correlates poorly with clinical measures. For example, a Kmax cone of 55D that overlaps the visual axis may reduce visual acuity much more than an inferior 62D cone that does not, observed Dr Belin, who is professor of ophthalmology and vision science at the University of Arizona, Tucson, USA. “Patients don’t complain of increasing Kmax, they complain of poor vision, glare, night-driving difficulty and distortion.” Nor does Kmax accurately describe morphologic change. In fact, progression from a central nipple cone to a more inferior globular cone is often associated with a decrease in Kmax, Dr Belin noted. Kmax is neither specific nor sensitive enough to reliably diagnose keratoconus. Using 46.1D Kmax as a cut-off would include about 95% of keratoconus patients – but nearly onethird included patients who would not have keratoconus, Dr Belin said. Moving the cut-off to 45.3D would capture 97.5% of keratoconus patients, but more than half the patients identified would not have the condition.

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BETTER MEASURES FOR EARLY TREATMENT Kmax does not identify early disease, Dr Belin said. He showed several cases of extreme posterior ectasia with normal anterior surface curvature. Indeed, by the time ectasia progresses enough to significantly alter Kmax, significant vision loss has occurred in most cases, he noted. “We don’t treat glaucoma only after patients have visual field loss, and we should be doing the same with keratoconus.” So why is Kmax used? It is an artefact of the initial crosslinking study from 2003 in which Kmax was the only parameter statistically associated with a positive effect of cross-linking, Dr Belin explained. It was then adopted by insurers for determining payment for corneal cross-linking and other treatments. Dr Belin and colleagues have developed other measures that can detect ectasia earlier, and are more specific and sensitive in characterising and tracking progress. These include the anterior and posterior radius of curvature taken from a 3.0mm optical zone centered on the thinnest point, minimal corneal thickness and best spectacle-corrected distance visual acuity. These have been combined into an easy-to-interpret Belin ABCD progression display, currently available on the Oculus Pentacam (Oculus GmbH, Wetzlar, Germany). Early detection may allow early treatment, preventing irreversible vision loss, Dr Belin said. Therefore, he advocates abandoning Kmax in favour of more predictive measures. Dr Belin is a consultant to Oculus. He receives no compensation for any of the mentioned products/displays



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Michael Belin: mwbelin@eyes.arizona.edu EUROTIMES | FEBRUARY 2020




Management of DME Tight treatment schedule yields dividends in diabetic macular oedema. Dermot McGrath reports


lthough anti-vascular endothelial growth factor (anti-VEGF) drugs remain the first-line agents of choice in the management of diabetic macular oedema (DME), corticosteroids may still play a role in patients where anti-VEGF is contraindicated, unavailable or unaffordable, according to Sobha Sivaprasad FRCOphth. “We know that the visual outcome will not be as good as anti-VEGF when using steroids when all-comers are considered. As a second-line agent, steroids may potentially be used in combination with an anti-VEGF agent. Although steroid use has been recommended in pseudophakics who are non-responsive to anti-VEGF, the recent evidence from the Protocol U and T studies suggests that switching to combination therapy shows similar visual outcomes to continuing on anti-VEGF in non-responders despite a better macular drying effect with combination,” she told delegates attending the 19th EURETINA Congress in Paris. In terms of reducing risk factors, Prof Sivaprasad said that it was vital for patients first of all to control their blood sugar, blood pressure and cholesterol levels. They should also carefully monitor their haemoglobin A1c levels, as evidence from the Protocol T and VISTA studies both suggest that high HA1c levels equates to poorer visual outcomes. In centre-involving DME cases where there is no visual impairment, the best strategy is observation to start with, said Prof Sivaprasad. She advised that any of the approved anti-VEGF agents should be administered on a tight treatment schedule in cases of DME with mild visual impairment. For patients with visual acuity of 20/50 or worse aflibercept performs better in more severe cases.

We know that the visual outcome will not be as good as anti-VEGF when using steroids when all-comers are considered Sobha Sivaprasad FRCOphth EUROTIMES | FEBRUARY 2020

Sobha Sivaprasad FRCOphth

For non centre-involving DME, the visual acuity in these patients is usually good and observation is normally sufficient, said Dr Sivaprasad. “If the vision is not good in these cases, however, it may be associated with other co-existing pathologies such as macular ischaemia,” she said. She said that based on the ETDRS study of approximately 30 years ago, the recommended approach today in the anti-VEGF era is observation if no clinically significant macular oedema (CSME) was present, with focal or grid laser treatment administered only if circinate CSME was detected. This approach has evolved somewhat on the basis of the findings of the Protocol V study, noted Dr Sivaprasad. She explained that this study tried to ascertain whether eyes with centreinvolving DME and good visual acuity of 20/25 or better should be initiated using anti-VEGF, laser or observation. Patients in the laser and observation arm could be treated with aflibercept if the visual acuity decreased by 10 letters or more in one visit or five-to-nine letters in two consecutive visits. “The results over two years showed that the proportion of patients with five letters’ loss or more after two years were very similar for all groups, and that observation did just as well as laser and aflibercept as the initiating option. When it comes to patients with moderate visual impairment due to DME, we know from

Protocol T that with any anti VEGF agent we will gain on average about eight letters by the end of two years. “If the visual acuity impairment is more significant, all three anti-VEGF agents work well, but aflibercept performed best, with a 15-letter gain at the end of one year,” she said. A very tight treatment schedule needs to be followed for good visual acuity outcomes in DME cases, said Dr Sivaprasad. “We need to follow the Protocol T treatment schedule, where we repeatedly inject the patients every four weeks until stabilisation is reached, and once stable we resume injections if the visual acuity or OCT worsens. We can apply focal or grid laser after 24 weeks only if persistent DME is not improving after at least two injections,” she said. For proliferative diabetic retinopathy (PDR), panretinal photocoagulation remains the standard of care in 2019 despite some promising outcomes in the Protocol S and CLARITY studies with anti-VEGF agents, said Dr Sivaprasad. “Anti-VEGF treatments may offer significant advantages in proliferative diabetic retinopathy but we need a good surveillance programme to be able to provide urgent therapy if there is recurrence or reactivation of new vessels. If we don’t treat this condition promptly, the consequences are disastrous,” she concluded.

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OCT-A RELIABLE AND REPRODUCIBLE Optical coherence tomography angiography (OCT-A) measurements of the retinal Macular Microvasculature with Spectralis II OCT are reliable and repeatable according to new study. In the prospective trial, 23 eyes of 23 persons underwent en face OCT-A imaging in combination with a newly made software, the Erlangen-Angio-Tool (EA-Tool). Bland-Altman plots showed a good reliability of two consecutive scans of each sector and testing of reproducibility showed no statistically significantly different sectorial coefficients of variation. S Hosari et al, “OCT Angiography: Measurement of Retinal Macular Microvasculature with Spectralis II OCT Angiography – Reliability and Reproducibility”, Ophthalmologica 2020, volume 243, issue 1.


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A review of studies of anti-Vascular Endothelial Growth Factor (Anti-VEGF) agents in neovascular AMD patients and their extension studies published from January 1, 2013, to June 30, 2018, shows that clinical trials demonstrated that initial visual acuity (VA) gains maintained for up to seven years. However, in real-world practice studies, patients are usually undertreated, with a corresponding decline in VA over time. A primary reason is the general mindset in the ophthalmological community that sustained benefits with treatment are not possible, the authors maintain. J Mones et al, “Undertreatment of Neovascular Age-Related Macular Degeneration after 10 Years of Anti-Vascular Endothelial Growth Factor Therapy in the Real World: The Need for A Change of Mindset”, Ophthalmologica 2020, volume 243, issue 1.




Fluorescein angiography and OCT-A have their individual strengths and are best used in combination in patients with diabetic retinopathy, a new study suggests. In 42 diabetic retinopathy patients who underwent fluorescein angiography (FA) and en face OCT-A, the mean size of the foveal avascular zone (FAZ) was 0.39 mm2 when measured with FA and 0.42 mm2 when measured by OCTA and the mean microaneurysm count was 14 when measured by FA and 13 when measured by OCT-A. The assessability was favourable to OCT-A in 38-41/53 eyes regarding the FAZ and favourable to FA in 45-49/53 eyes regarding MAs. C Enders, et al, “Comparison between Findings in Optical Coherence Tomography Angiography and in Fluorescein Angiography in Patients with Diabetic Retinopathy”, Ophthalmologica 2020, volume 243, issue 1.



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Old Diseases now Increase in tuberculosis and syphilis in UK presents new challenges for ophthalmic diagnosticians. Roibeard Ó hÉineacháin reports


iseases long thought to have been largely vanquished by modern medicine and improved living standards have been making a return in recent years. Among these are tuberculosis (TB) and syphilis, both of which have ocular manifestations that ophthalmologists must learn to recognise if patients are to receive appropriate treatment, said Professor Nicholas Jones FRCP, Clinical Director of Uveitis Service, Manchester Royal Eye Hospital. Prof Jones noted that the incidence of TB in the UK decreased steadily from the early 20th Century, largely due to socioeconomic improvements. Mortality from the disease fell very steeply following the introduction of streptomycin in 1943. However, in the late 20th Century the incidence of the disease began to rise again, due primarily to immigration from countries where TB is endemic. The incidence of TB in the UK is highest in London and Manchester where the incidence per 100,000 population is 26.2 and 25.8, respectively, compared to a 9.2 per 100,000 population in the UK overall. The incidence of TB-induced uveitis was likewise higher in these regions, Dr Jones said. “Tuberculosis has not gone away and in our clinic it is a regular provider of patients to our uveitis service. It is a disease which must be treated differently from most cases of uveitis and therefore it needs to be spotted,” he stressed. Prof Jones noted that TB-associated uveitis comprises a spectrum of inflammation that ranges from direct infection to TB-induced autoimmune infection, which does not necessarily require the presence of any mycobacteria in the eye.

STEROID THERAPY “If I see an eye with uveitis and am confident that we are dealing with tuberculosis then I try and observe it first on anti-tuberculosis antibiotics alone for a couple of weeks to see whether the lesions will go away without steroid therapy, and that can be the final proof of our disease’s diagnosis,” he explained. Prof Jones presented his experience at the Manchester Uveitis Clinic (MUC) where 182 TBU cases have been treated. All had ocular signs of TB and evidence of previous exposure.


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However, only half had a history of TB exposure or risk, only 20% had radiological evidence of previous TB such as Ghon focus lesions and mediastinal lymphadenopathy, and only 10% had evidence of concurrent active pulmonary or extrapulmonary TB. As in most uveitis centres in the UK, the MUC uses the standard six-month regimen of treatment for TB-associated uveitis, starting with four antibiotics for two months, followed by two antibiotics for four months, with oral steroid as required. Six months after completing the antibiotic regimen, 80% of their patients are inflammation-free but of those, 40% are still receiving a topical and/or oral steroid. “So we’re not talking complete success at all and there are many possible reasons for this including misdiagnosis. The second is the argument that that six-month treatment may not be adequate,” he said.

SYPHILITIC UVEITIS Syphilis is another disease that has been making a comeback in recent years, Prof Jones said. After a sharp decline following the introduction of antibiotics in the 1940s the incidence began to rise again in the 1960s, most likely as a result of the sexual liberation of those times, but then the incidence decreased again due the AIDS crisis. Now with the introduction of AIDS medication that is much less toxic than the earlier antiviral agents and the added availability of HIV prophylaxis medication, together also with the wide use of social media for arranging casual liaisons, the incidence of syphilis is again on the rise, Dr Jones noted. “Almost all patients with secondary syphilis which includes ocular involvement, present first to an ophthalmologist. Vigilance is therefore necessary to distinguish the condition from other forms of uveitis early in the course of the disease and provide effective treatment. “The neurosyphilis antibiotic regime is curative, but prolonged oral steroid alone, or intraocular steroid, is blinding,” Dr Jones added. Nicholas Jones: Nicholas.jones@mft.nhs.uk




Winter Meeting

Vilnius 20–21 March Radisson Blu Hotel Lietuva, Lithuania

Registration & Hotel Bookings available at www.euretina.org




Euretina Congress Amsterdam

1–4 October 2020

RAI Amsterdam, The Netherlands Free Paper, Poster & Video Abstract Submission Deadline: 22 March 2020


Posterior capsule rupture and IVIs Recent intravitreal anti-VEGF injection portends increased PCR risk. Cheryl Guttman Krader reports


atients undergoing cataract surgery are at increased risk of intraoperative posterior capsule rupture if they received an intravitreal antiVEGF injection within the previous 12 months, according to a retrospective study presented at the 2019 meeting of the Association for Research in Vision and Ophthalmology (ARVO) in Vancouver, Canada. The researchers from the University of Colorado School of Medicine, Denver, US, undertook a medical record review to identify patients who had cataract surgery at their institution between January 1, 2014, and December 31, 2016. After excluding eyes of patients aged less than 18 years, those with traumatic cataracts, those that had anti-VEGF injections at a different clinic, or surgery combined with pars plana vitrectomy, their sample included 5,529 eyes, of which 139 had received an anti-VEGF injection within the year before cataract surgery. Posterior capsule rupture occurred during surgery in three (2.2%) eyes that received anti-VEGF injections and in 19 (0.4%) control eyes without that history. Analysis for predictors of posterior capsule rupture using univariate logistic regression with general estimating equations found that that the odds of posterior capsule rupture were 6.2fold higher among eyes in the anti-VEGF injection group compared to controls (p=.004). “Our findings are consistent with those of previous studies that reported the risk of posterior capsule rupture was increased in eyes with a history of intravitreal injections. In contrast to other studies, we chose to specifically focus on an association between posterior capsule rupture and intravitreal injections within the previous year,” D. Claire Miller BS, lead author of the study and research assistant, Department of Ophthalmology University of Colorado School of Medicine, told EuroTimes. “We were hoping that we might also determine if other variables related to the injections, including the number received, the interval between the most recent injection and cataract surgery, or indication for the anti-VEGF treatment, had an effect on posterior capsule rupture risk. Identifying such associations might provide insights on cause. We are collecting more data to look at those issues in the future because our initial sample size was too small.” Karen L. Christopher MD, Assistant Professor of Ophthalmology, University of Colorado School of Medicine, noted that a strength of the study is its data collection method. “The data were harvested by manual extraction from the medical record, which avoids errors that can occur using insurance claims databases in which surgical complications or injection data may be coded incorrectly,” she explained. Dr Christopher continued, “The primary message of our study is that cataract surgeons should specifically ask patients if they have received anti-VEGF injections, and for those who have, discuss the increased risk of intraoperative complications and take extra care intraoperatively to avoid manoeuvres that may increase susceptibility to posterior capsule rupture.” D. Claire Miller: claire.c.miller@ucdenver.edu Karen L Christopher: karen.christopher@ucdenver.edu



DIABETIC retinopathy today Paradigm shift in understanding and treatment of DR. Dermot McGrath reports


ecent decades have seen a profound transformation in the understanding of the complex pathophysiology of diabetic retinopathy (DR), with the evolution of new treatment strategies that move beyond purely metabolic control to try to mitigate the sight-threatening ocular complications of the disease, according to Professor Francesco Bandello MD, FEBO. “We have witnessed a paradigm shift in the interpretation of diabetic retinopathy in the last 50 years from a disease of pure microangiopathy to one of neurovascular coupling dysfunction in which all the microvascular districts such as the iris, optic nerve, and macula are involved,” said Prof Bandello, in his EURETINA Medal Lecture at the 19th EURETINA Congress in Paris. In a broad overview of the evolution of knowledge pertaining to DR, Prof Bandello said its development reminded him of the way historians divide the study of their discipline into two broad categories: prehistory, before the introduction of written records, and history. “This is pretty much the same with DR. The prehistory period was when the ophthalmoscope was not available, and theories were proposed on the basis of intuition but without the opportunity to witness directly what they were talking about. This changed after the introduction of ophthalmoscopy in the mid-19th Century,” said Prof Bandello, Full Professor and Chairman at the Department of Ophthalmology, University

I like the concept of subdividing DME into different subgroups because only then will be able to select the best treatment for each individual Francesco Bandello MD, FEBO

Vita-Salute, Scientific Institute San Raffaele, in Milan, Italy. The very early history of DR research was hampered to a significant degree by the celebrated ophthalmologist Albrecht von Graefe’s claim in 1856 that there was no proof of a causal relationship between diabetes and retinal complications, noted Prof Bandello. “Although von Graefe got it wrong, there was another giant of ophthalmology at the time, Eduard Jaeger, who said the opposite and was able to recognise lesions that were due to diabetes,” he said.

BREAKTHROUGHS The introduction of fluorescein angiography (FA) and laser photocoagulation proved to be a game-changer in the modern era of DR diagnosis and treatment, said Prof Bandello. “The combination of these two events, one for diagnosis and one for therapy, made a huge difference in understanding the pathogenesis of retinal lesions in diabetes and to begin to treat them with laser,” he said. In the 1960s, key fluorescein studies of the retina in diabetics were carried out by Scott and Dollery, along with the pioneering work of John Gass, who first described retinal ischaemia and the appearance of new vessels with hyperfluorescent aspects using FA. Prof Bandello also cited the work of Koichi Shimizu in describing mid-peripheral fundus involvement in DR and also the relationship between ischaemia and new vessels. Another important milestone came with the publication of the results of two key studies: the Diabetic Retinopathy Study, which showed that laser photocoagulation reduced the two-year incidence of severe visual loss by more than half in eyes with proliferative diabetic retinopathy, and the Early Treatment Diabetic Retinopathy Study (ETDRS), which demonstrated that focal macular laser reduced the risk of moderate vision loss by up to 50% in eyes with clinically significant macular oedema. Other major advances came with the introduction of optical coherence tomography (OCT) into clinical practice followed closely by intravitreal steroids and anti-VEGF therapies.

“I think we would all agree that both of these developments completely transformed the way we diagnose, treat and follow-up our patients,” said Prof Bandello. Prof Bandello cited the work of his own research team over the years in elucidating the complex pathophysiology of DR. “We were among the first to underline the importance of FA to understand the pathogenetic mechanism between the bloodretinal-barrier (BRB) breakdown and the appearance of macular oedema. We have also worked hard to promote the concept of lighter-intensity laser modalities for optimal therapeutic effect in patients with clinically significant macular oedema,” he said.

NEW CLASSIFICATION SYSTEM With so many treatment options currently available, Prof Bandello said that a new classification system of DME into distinct categories will help orient treatment choice. “I like the concept of subdividing DME into different sub-groups because only then will be able to select the best treatment for each individual patient. We cannot proceed as before using only one therapeutic option, which was laser. We have developed an algorithm to help guide the treatment once the subtype has been identified,” he said. Prof Bandello added that the integration of standard investigations with new diagnostic techniques will allow prompt recognition and personalised treatment of both retinopathy and maculopathy in the near future. The need for such an evolution is all the more evident given the impending global epidemic of diabetes and its impact on health systems everywhere, warned Prof Bandello. “This is important because we know diabetes is exploding worldwide and as ophthalmologists we must do what we can to prepare for the consequences of that for our patients’ vision. We need to be able to work with our public health administrators and politicians in order to apply the best of what we have today for the diagnosis and treatment of DR,” he concluded. Francesco Bandello: bandello.francesco@hsr.it EUROTIMES | FEBRUARY 2020




The case for trabeculectomy Trabeculectomy outcomes are improving, but more progress is needed. Howard Larkin reports


hile comparing data over time is problematic, recent studies suggest that trabeculectomy has become safer with improved intraocular pressure (IOP) control over the last 20 years, James Kirwan MA, MBBS, FRCOphth, told the Glaucoma Day at the 37th ESCRS Congress in Paris. Better trabeculectomy outcomes are important because patients are living longer, leaving much more time for patients with advanced or progressive disease to lose vision, he added. “Trabeculectomy is still, in my view and I think in most people’s view, the most efficacious surgical procedure for glaucoma, particularly when we are looking at long-term data. It’s the only option that I am aware of that has any evidence to show it actually deals with progression of the disease,” said Mr Kirwan, who is a Consultant ophthalmologist at the Portsmouth Hospitals NHS Trust, UK.

EARLY DEVELOPMENT The origins of trabeculectomy date to the mid-19th Century, Dr Kirwan said. Mackenzie described paracentesis in 1854, though the procedure was ineffective. A few years later De Wecker developed anterior sclerotomy. In the 1960s, H Saul Sugar MD coined the term “trabeculectomy” for a procedure removing a portion of the trabecular meshwork and scleral spur, leading to temporary IOP reduction. In 1967, JE Cairns described trabeculectomy as a ‘guarded fistula’ that enabled controlled aqueous drainage, reducing pressure without complications in some cases. The procedure was refined throughout the 1970s to the 1990s, and became reasonably effective, particularly in populations that had not had extensive treatment with topical drop therapy, Mr Kirwan said. Multiple studies showed 60-to-90% of trabeculectomy patients achieving less than 21mmHg IOP for EUROTIMES | FEBRUARY 2020

periods of five-to-15 years, though complications were common. By the 1990s, use of antimetabolites was also changing the paradigm.

21ST-CENTURY EXPERIENCE Early in this century, the significant increase in the uptake of anti-metabolites such as mitomycin-C and 5-fluorouracil improved success rates in most cases, but also increased complications, including hypotony maculopathy and bleb infection risk. An early review suggested that trabeculectomy infection rates could be as high as 2.8% per year with other studies suggesting a 1% per year risk. More recent studies make clear that this is a marked overestimate. Infection rates ranging from 0.1-to-0.2% per year have been reported in recent series. “So, there is progress, here,” he said. How much progress is difficult to quantify for several reasons, particularly when evaluating efficacy, Mr Kirwan said. Lack of a common definition of procedure success is a major problem – one review of 100 studies found 92 different definitions with rates varying from 36-to-98% for the same studies. The WGA guidelines have been written to help address the challenges in fairly describing outcomes. Success rates also tend to reflect the type of study and author intentions, Dr Kirwan added. They generally are higher in case series, where the surgeon is presumably happy with the results (often, now with long follow-up); than in randomised clinical trials, where trabeculectomy is used as a comparator to a commercially supported new innovation and the investigators are presumably looking for a better alternative than their own trabeculectomy outcomes. Most studies are also too short-term to assess results he added. Other factors complicating efficacy comparisons over time include the greater use of more effective IOP-lowering drugs today, the downward migration of the level of IOP deemed successful, changing indications for surgery and increased combined surgery. Differing anti-

Trabeculectomy is still, in my view and I think in most people’s view, the most efficacious surgical procedure for glaucoma, particularly when we are looking at longterm data James Kirwan MA, MBBS, FRCOphth metabolite regimens and changes in nonpenetrating therapy further complicate historical efficacy comparisons, Dr Kirwan noted. Evidence for improved safety is stronger. A 2002 audit in the UK found hyphema, shallow anterior chamber and hypotony in about one-quarter of patients each, with visual acuity loss of more than one line, cataract or wound leak each occurring at about one-in-five. The 2013 ‘Trabeculectomy in the 21st Century’ report published in Ophthalmology found complications greatly reduced, with hyphema and hypotony in single digits, shallow AC under 1% and visual loss at 13%. Hypotony maculopathy fell to less than 1%. Only cataracts were more common, at 29%, though this may be due to changes in treatment thresholds over time, Dr Kirwan said. For the future, Dr Kirwan looks to better control of wound healing, possibly with anti-VEGF agents, and better training to improve outcomes. He called for more research to generate better evidence to support better care. James Kirwan jfkirwin@mac.com


Lessons from India Cost and social pressure spark innovations in access, efficiency – and research. Howard Larkin reports


eveloped nations have much to learn about eye care from the developing world, particularly in reducing costs, improving the environment, increasing efficiency and patient access – and leveraging huge patient data sets to improve outcomes, Alan L Robin MD told Glaucoma Subspecialty Day at the 2019 ASCRS ASOA Annual Meeting in San Diego, USA. Pressure to treat millions of patients with little or no income, and a lack of regulation, have promoted rapid innovation in India, said Dr Robin, who is the Executive Vice President of the American Glaucoma Society, Professor of Ophthalmology and international health at Johns Hopkins University in Baltimore and Professor of Opthalmology at the University of Michigan, Ann Arbor. By focusing on low-cost systems and products to meet broad population needs, organisations including the Aravind Eye Care System have developed networks that dramatically increase access to eye care with predictable quality. Aravind’s networks include local eye care outposts run by female technicians it recruits and trains that offer routine eye exams and screening for the equivalent of approximately €0.45. By manufacturing its own intraocular lenses and other surgical supplies, and highly systematising its hospitals, Aravind has reduced its cataract surgery costs to as little as €40 per case with a standard lens, noted Dr Robin, who is on the board of the Aravind Eye Foundation and has conducted multiple research projects with the organisation. This enables Aravind to more than cover the cost of free and reduced fee care to low income patients through charges to patients who can pay. In 2017 and 2018 the organisation conducted 4.1 million outpatient examinations, nearly halfa-million surgical, laser and intravitreal injection procedures, and prescribed and dispensed 630,000 prescription spectacles. Aravind’s comprehensive electronic record system enables benchmarking individual surgeon performance, and comprehensive outcomes and quality improvement studies, Dr Robin added. Among recent findings: cataract surgeons who do 350 or more cases per year have much lower complication rates than surgeons who operate less; sharp-edged PMMA lenses resist PCO much longer than acrylic lenses; there is no difference in outcomes between single- and three-piece IOLs in patients with pseudoexfoliation at five years; and intracameral moxifloxacin reduces the risk of endophthalmitis 11-fold for phaco surgery, based on more than 600,000 cases. “Where else are you going to find 600,000 cases at the same institution? I don’t know of anywhere else.” This huge data resource helps put Aravind on the cutting edge of artificial intelligence as well. For example, an algorithm derived by Google from millions of patient retinal images may predict five-year risk for myocardial infarction and stroke. Further innovations are coming that will improve health care around the world, Dr Robin believes. “It’s amazing. Let’s see what happens when glaucoma becomes part of the artificial intelligence algorithm.” Studies are already under way at two Aravind centres, with more to begin soon.

Keep learning. Stay relevant.

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

∙ Refractive Surgery ∙ Visual Optics

Trainers: use the task list to assign courses for trainees and monitor their progress.

Learn more at http://elearning.escrs.org

Alan L Robin: arobin@glaucomaexpert.com EUROTIMES | FEBRUARY 2020




Measles on the rise Outbreaks pose dangers to patients around the world, as vaccination rates drop. Sean Henahan reports


urging rates of measles across the globe pose a significant threat to vision, particularly in the paediatric population, where it remains a leading cause of blindness. The numbers are astonishing. Outbreaks have been reported everywhere in 2019 – from Madagascar, with more than 33,000 confirmed cases, and Democratic Republic of Congo, with 87,000, where more people have died of measles than from the Ebola virus, according to research by Médecins Sans Frontières (MSF). In the first decade and a half of this century most outbreaks were being reported in developing nations with poor access to vaccination services. However, this changed dramatically after 2015. Outbreaks have been confirmed by the World Health Organization (WHO) in 42 European countries this year, with deaths reported in three countries: Albania, Romania and Ukraine. The number of cases reported across Europe has more than tripled since 2017, and is 10 times higher than the numbers reported in 2016, according to the WHO. Measles cases in Europe primarily occur in unvaccinated or undervaccinated populations in both adults and children, according to the European Centre for Disease Prevention and Control. Large outbreaks with fatalities are ongoing in countries that had previously eliminated or interrupted endemic transmission. Factors driving this trend include exposure to unvaccinated travellers, inadequate public health measures and anti-vaccine propaganda. In many European countries vaccine coverage is below the 95% level considered necessary for herd immunity. Outbreaks of measles have occurred in almost every country in Europe. Countries reporting more than annual 2,000 cases include Serbia, France, Italy, Russia, Georgia, and Greece. The situation in Ukraine is particularly dire. That war-torn country has had more than 25,000 measles cases in the first two months of 2019 alone, more than anywhere else in the European area. That dubious distinction has been attributed by pubic health observers to corruption, changing political tides, war with Russia, vaccine shortages and anti-vaccine phobia. At the turn of the century the US Centers for Disease Control (CDC) announced that measles was on the brink of elimination in

America. Yet in recent years the numbers have increased steadily. The CDC reported 1,250 cases of measles through October 2019, a significant increase from the 372 cases seen in the preceding year. In the US, measles outbreaks have been traced to exposure to visitors from endemic areas such as Israel and Ukraine.

VAX AND ANTI-VAX Widespread use of the vaccine made from live, attenuated measles virus brought the disease to the brink of elimination in the developed world. Recent measles outbreaks have followed the spread to virulent anti-vaccine propaganda and misinformation on social media, fed by fear and ignorance. The United Nations children’s fund (UNICEF) launched a campaign this year, #VaccinesWork, to counter the backlash against vaccination. The American Academy of Ophthalmology also launched an outreach programme targeting both physicians and the public. Health authorities in the US responded to the relatively modest increase in measles cases by tightening vaccination requirements. Vaccination was already mandatory, but with allowances for religious and personal beliefs. More recent legislation has attempted to eliminate those loopholes, allowing exemptions only where medically indicated, such as in cases of immune compromise. Measles vaccination is not mandatory in all European countries, even as vaccine hesitancy continues to increase. France, which has some of the highest rates of measles in Western Europe also has the highest rates of vaccine hesitancy, according to a WHO study. “We are backsliding, we are on the wrong track. We have a worrying trend that all regions are experiencing an increase in measles except for the region of the Americas, which has seen a small decline,” warned Dr Kate O’Brien, director of WHO’s department of immunisation, vaccines and biologicals, at a news briefing earlier this year. Médecins Sans Frontières (MSF): www.msf.org/measles European Centre for Disease Prevention and Control: https://www.ecdc.europa.eu/en/measles WHO: https://www.who.int/immunization/diseases/measles/en/ US CDC: www.cdc.gov/measles

Measles FAQ Measles is caused by exposure to the Rubeola virus, which belongs to the Paramyxovirus family. The highly contagious disease is spread by contact with airborne droplets spread through coughing and sneezing. The virus can remain airborne for hours. The incubation period is 21 days. In the developed world measles results in death in 1/1000 cases. In the developed world this increases to one in every hundred cases. Most cases in the developed world are limited to the three Cs – cough, coryza, conjunctivitis. Conjunctivitis seen in the early stages can progress to more serious problems including keratitis and corneal ulcers, which can lead to significant vision loss. Less common complications such as retinitis and optic neuritis can result in blindness.


Ocular complications are more common in the developing world. This has been associated not only with the measles infection directly but also with secondary herpes or bacterial infection, or a chemical conjunctivitis resulting from incorrect and inappropriate topical therapy or vitamin A deficiency. There is no anti-viral treatment for measles once it occurs, hence the importance of vaccination. Patients are treated with supportive measures to relieve fever, coughing and dehydration. Vitamin A therapy has been shown to reduce the rate and severity of complications, particularly croup, pneumonia and diarrhoea, and to reduce the duration of hospital stays in more serious cases.

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


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

Saturday 3 October 2020 Burton Kushner


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

Sunday 4 October 2020 Marie-José Tassignon


Kanski Medal Lecture A Thing of Beauty is a Joy Forever

Registration & Abstract Submission Open

Key Dates FRIDAY 28 FEBRUARY 2020 Abstract Submission closes for Free Papers, Posters & Video Competition

FRIDAY 2 – SUNDAY 4 OCTOBER 2020 WCPOS V (5th World Congress of Paediatric Ophthalmology and Strabismus)


REGISTRATION NOW OPEN! annualmeeting.ascrs.org

GUCOMA DAY 2020 Sponsored by the ASCRS Glaucoma Clinical Commiee

Coinciding with

May 14-15

Boston Convention and Exhibition Center | 415 Summer Street | Boston | MA







Gaining insight on how to make a specific diagnosis

Inherited retinal diseases (IRDs) are not a simple group to learn. It’s not that the pathology is inherently more difficult than any other. Instead, making a specific diagnosis can take so long that, as residents, by the time the diagnosis has been made for that one interesting case during your residency’s retina rotation, most residents have already moved on to a new rotation. This, along with the phenotypic heterogeneity make mastering this subfield of retinal disease especially challenging. The “Atlas of Inherited Retinal Diseases” (Springer), edited by Stephen H. Tsang and Tarun Sharma might deliver some insight. It “provides a thorough overview of various inherited retinal dystrophies with emphasis on phenotype characteristics and how they relate to the most frequently encountered genes”. This 260-page book is a true atlas and, as with other retina atlases, images are the primary focus. Particularly striking are the fundus autofluorescence images, which are crucial to diagnosis and follow-up. The clear depictions and analysis of the OCT images are also crucial, as this is the most commonly used retinal imaging modality and the most likely way that these retinal abnormalities will first be detected. Comprised of eight sections, it opens with an overview of basic principles of the imaging modalities used to manage patients with IRDs. Sections 2, 3 and 4 categorises the diseases based on their inheritance pattern (X-linked, autosomal dominant and autosomal recessive, respectively), while section 5 is dedicated to those IRDs associated with systemic manifestations. Section 6 illustrates the genetic phakomatoses and section 7 describes IRDs with no known underlying genetic mutations. Section 8 offers a practical approach to IRDs for the clinician, the genetic testing and its interpretation. This atlas is intended for ambitious residents, retina fellows and retina specialists who are tasked with managing patients with IRDs. PhD students and researchers will also benefit from this text, as they might otherwise rarely encounter the phenotypes of the genes they work on. With its highly organised structure and clear overview of rarer retinal disease, it can also help the ready study for large examinations.

NOTES ON THE DRUG DEVELOPMENT PROCESS “Standards for Ocular Toxicology and Inflammation” (Springer), edited by Drs Gilger, Cook & Brown is “an international effort to standardize the language, terms and methods used in ocular pharmacology and toxicology”. This refers to the efforts to help improve the drug development process, both during early testing on laboratory animals and later, in the context of ocular findings during the development programmes of new drugs and devices. PUBLICATION The book includes many photographs that highlight STANDARDS FOR OCULAR how potential toxicological findings can appear, as well as TOXICOLOGY AND pointers on how to best describe them for others. INFLAMMATION The book is intended for the medical industry, EDITORS pharmaceutical companies and employees of governmental BRIAN C. GILGER, CYNTHIA EUROTIMES | MONTHwho YEARall work together to help develop new agencies COOK AND MICHAEL BROWN therapeutics for ophthalmology. PUBLISHED BY SPRINGER

Ocular trauma can dramatically change the patient’s life in an instant, and the ophthalmologist’s role is to limit the ocular, aesthetic and psychological damage as much as possible. In contrast to other pathologies, time is nearly always of the essence, and one must always be prepared ahead of time to make rapid decisions when the time comes. The “Atlas of Ocular Trauma” (Springer), edited by Hua Yan, aims to prepare the surgeon for exactly this. Starting with an introduction to trauma, it is further organised by the injured structure, from conjunctiva and cornea all the way through to a ruptured globe. This 190-page atlas is full of good clinical photographs and is a useful addition for anyone asked to manage ocular trauma.


ALL COMPLICATIONS GREAT AND SMALL Despite vast improvements in both surgical skills and surgical equipment, cataract surgery doesn’t always go as planned. However, there’s usually a way to fix whatever went wrong. But how? “Optimizing Suboptimal Results Following Cataract Surgery: Refractive and NonRefractive Management” (Thieme), edited by Priya Narang and William B. Trattler, aims to answer this question. It focuses not only on the dramatic problems like toxic anterior segment syndrome, endophthalmitis and bullous keratopathy, but also on how to approach tear film disorders, residual refractive error and everything in between. This includes refractive enhancement procedures of every stripe. This concise book is intended for anyone who operates cataracts, as well as those of us to whom complications are sent.

If you have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland




Beyond base camp


In the first piece in a new series, Sorcha Ní Dhubhghaill MD reports on how the learning curve never really ends

At the start of our tear the capsule when gliding the climb towards chopper to the periphery of the becoming a great lens and i felt stressed enough surgeon, we face learning how to place an entirely a simple choice: different type of lens. Now that I Learn to do this, or give up on have mastered the lens, I decided being a surgeon altogether, let to combine it with chopping. alone a great one. So we all did it. We read the STEP ONE: GETTING books, we watched the videos, THE THEORY DOWN and did whatever it took to I’ve been reading the books and convince ourselves that we could watching videos online. YouTube do this. Obviously, we couldn’t can be useful in a pinch but do it. We were still learning EyeTube is where some of the to. And each time we made a best surgical videos can be found. mistake, or a complication David Chang (changcataract. would arise, our supervisor com) provides lecture and would bail us out. That’s why we resources on line and I absorbed learn under their watchful eye. as much as I could from them. They are our safety net. Ready to step in when things go south. STEP TWO: PRACTICE Fast-forward a decade or two, I have followed some wetlabs, but and now you’re mid-career. An most wetlabs use pig eyes and independent surgeon, working these can be difficult to simulate away, doing your thing. So the chop manoeuvre. Unless they how do you go about learning are pre-treated, most porcine something new at this stage? lenses are very soft and not the Because this time the question ideal practice material. Artificial is not as straightforward. You models with a more wax-based can learn to do this new thing, lens (simulatedocularsurgery. or you could not. You could just com) can be more useful and keep on doing what you know, You can learn to do this new thing, since it’s not biological, you can and know to work. or you could not. You could just keep bring them to the operating room It’s a question that has been to practice, unlike the pig eye. on my mind a lot lately as I on doing what you know, was thinking about how to best and know to work handle specific cataract cases. STEP THREE: IMPLEMENT My preferred approach to I am currently working with the cataract surgery is the divide DORC EVA phaco so I called and conquer technique. It’s reliable, and it’s what most of my the representatives to overhaul my settings. They added a surgical trainers used. In general, it leads to good results, and phaco chop dual linear control step. Once everything was set happy patients. up, I reviewed my patient list to find the best candidates. Like But it’s no silver bullet. For hard, brunescent lenses, a chop a beginner surgeon, I looked for cataracts that were not too technique has its benefits. It reduces both the zonular stress from soft, too hard or had any zonular compromise. Once I had the rotation, and the amount of phacoemulsification energy required. theory, the practice, the settings and the patients it was time to This reduced energy has piqued my interest recently as my clinics get started – and that was the hardest part. But I took it slow, have been filling with endothelial dystrophies. very slow, and things have been going very well. So I have decided that I want to start chopping again. But Practice makes perfect. Going through another learning it is very difficult to look at a cataract and try something new, curve as a senior surgeon can be a real hit to the ego and selfknowing full well that the patient before you would be perfectly confidence but it can also be a powerful lesson in staying humble fine with normal technique. It’s hard to step out of our comfort and open for new techniques. Cataract surgery is constantly zone but it’s a choice we all have to make. At every point, changing and improving. We have to be able to change with surgeons had to deal with the same dilemma; Treat the patient it, or risk not being able to give our patients the best options in the old reliable way or take a risk and try something that available. So that learning curve – your climb to the top of your might be better. I wanted to try something better so I decided craft – never really ends. to chop again. I learned a horizontal chop approach many years ago but when Sorcha Ní Dhubhghaill MB PhD MRCSI(Ophth) FEBO is an I converted to using the “Bag-in-the-lens” as my primary lens Anterior Segment Ophthalmic Surgeon at the Netherlands I started to make 5mm anterior and posterior capsulorhexis. I Institute for Innovative Ocular Surgery (NIIOS) and Antwerp was worried that the smaller size would make me more likely to University Hospital Illustration by Eoin Coveney






Clinical Director

Heidelberg Engineering has appointed Christopher Mody as its Clinical Director. In this new role, Dr Mody, an ophthalmic scientist with 30 years’ clinical ophthalmology experience in the public sector and seven years at Heidelberg Engineering UK, will be facilitating the exchange of scientific information between the global ophthalmic community and the company. “Chris Mody is ideally suited to support our translational science program designed to deliver comprehensive, clinically relevant solutions to our customers. His knowledge will continue to strengthen our research alliances, while his passion for education will enhance the company’s role in advancing patient care.”, said Ali Tafreshi, Head of Product Management and Clinical Affairs at Heidelberg Engineering. www.heidelbergengineering.com/int/company

MARKETING AUTHORISATION APPLICATION Aerie Pharmaceuticals has submitted the marketing authorisation application (MAA) for Roclanda® (netarsudil and latanoprost ophthalmic solution) 0.02%/0.005% with the European Medicines Agency (EMA). Roclanda® is currently marketed in the US as Rocklatan®. ”As EMA review of the Roclanda® MAA begins, we will be completing and analysing our Mercury 3 study, which compares Roclanda®to the leading fixed-dose combination product in the EU,” said Vicente Anido, Jr., Ph.D., Chairman and Chief Executive Officer at Aerie. www.aeriepharma.com.

REIMBURSEMENT RECOMMENDATION Santen Canada Inc., a subsidiary of Santen Pharmaceutical Co., Ltd. has announced that the Canadian Agency for Drugs and Technologies in Health Canadian Drug Expert Committee released a reimbursement recommendation for Verkazia TM (cyclosporine 0.1%) eyedrops. “This recommendation marks an important step towards providing patients access to this new formulation of cyclosporine eye drops in Canada. Provincial jurisdictions are the final decision makers on public reimbursement,” said a Santen spokeswoman. www.santen.com



PRIZE 2020

Young ophthalmologists are invited to write an 800-word essay on “Will Clinicians Be Replaced By A Robot To Perform Cataract Surgery?” The prize is a travel bursary worth €1,000 to attend the 38th Congress of the ESCRS in Amsterdam,The Netherlands

CLOSING DATE FRIDAY 29 MAY 2020 Entries to be sent to:


For further information visit: www.escrs.org.




Illustration by Claire Prouvost


Fine-tuned vision Maryalicia Post reflects on the lasting impact of a hoof to the head


omeone asked me the other day if I have 20/20 vision. And actually, I don’t know. What I can say is that I can see quite well as soon as I get my eyes ‘tuned’. That requires me to tilt my head slightly to the left and down, which – I like to think – gives me the appealing look of an alert robin while at the same time bringing the two eyes into agreement as to where things are. I must say I don’t much notice this procedure. I’ve been ‘tuning’ them for decades – ever since I had the misfortune to fall under a galloping horse and get hit in the head by a hoof. The little crescent on my velvet riding cap marked the point of contact. The broken stirrup strap explained the fall. When I woke up in hospital about six hours later my right eye was stuck up in the corner of my eye socket and remained there for six months. I wore an eye patch during that half a year. As I was still smoking small cigars then I made a lasting impression on those who met me for the first time. Another thing that has been remembered – by those for whom I poured a cup of tea or EUROTIMES | FEBRUARY 2020

coffee in those days – was how they had to position their cup under the spout of the pot so that what I poured landed in the cup some of the time. During those six months, I met a lot of friendly fellas at the eye hospital In Dublin; mostly hurlers who had been clobbered with a hurley stick. Not many years afterwards, the first steps were taken to reduce the number of eye injuries hurlers used to accept as par for the course (http://bit.ly/ET-hurling). We enjoyed our sessions in front of a device trying to bring two sets of drawings into one, exchanging comradely high fives when we came close. Times move on but ocular damage due to sport continues. Paintballing is among the newer hazards (http://bit.ly/ ET-paintballing). And so are the bullets and darts from the popular children’s toy, the Nerf gun (http://bit.ly/ET-nerf). As for me, I’ve given up horses (and cigars). I’m planning to channel my inner robin and focus, on the garden (http://bit.ly/ ET-bees). It’s a jungle out there. I’ll keep my eyes tuned.




Enter the ESCRS Innovation Award Entries are now open for the ESCRS Practice Management and Development Innovation Award 2020


A library of symposia, interviews, video discussions, supplements, articles and presentations Spotlight on: l

Toric IOLs and Presbyopia




Ocular Surface Disease


Corneal Therapeutics

Visit forum.escrs.org for details


his award will focus on innovations from ophthalmologists and their practice staff that enhance patient services. The competition enables ophthalmologists to demonstrate what they have achieved with their entrepreneurial skills and show colleagues what they may be able to do in their own businesses. Entries should be based on a recent innovation introduced into a practice, clinic or hospital by an ophthalmologist. The innovation may be business- and/or customer- and/or societyfocused, and its impact should be proven and measurable in qualitative and quantitative terms. There is no fee to enter and the competition is open to all ophthalmologists. Entrants are invited to submit a 200-word summary of their project along with a Powerpoint presentation with 10 slides, including the title and concluding slides. Entries should be sent to innovation@escrs.org. The closing date for entries is Friday July 24, 2020. A shortlist of entries will be selected by of the Practice Management and Development Committee with the shortlisted entrants invited to give a presentation on their projects at the 38th Congress of the ESCRS in Amsterdam, the Netherlands, during the Practice Management and Development Programme. The winner will be announced after the presentation of the shortlisted entries. The winning entrant will receive a €1,500 bursary to attend the 39th Congress of the ESCRS in Barcelona, Spain, in September 2021. The inaugural Innovation Award was presented to Julien Buratto, Operation Manager at the Neovision Cliniche Oculistiche, Milan, Italy at the 37th Congress of the ESCRS in Paris, France. The Neovision team developed a packet that included a card with vision and cataract information as well as a phone number to make a consultation – since those of the baby boomer generation are more likely to want to speak to a real person, rather than going online to make appointments. They then sold this online at amazon.it. Citing pioneering research scientist Everett Rogers and his diffusion of innovations theory – which broke people down into the categories of innovators, early adopters, early majority, late majority, and laggards – Buratto noted that the Neovision clinic was the first to provide a medical service on Amazon. Buratto was keen to stress that the packet, which includes the price of a consultation, is not discounted. It’s not their goal to drive down prices, but rather to encourage people to care for their loved ones. “Medicine is not something that is frozen and cold, it must be sensitive to people’s emotions,” he said.

The Neovision team developed a packet that included a card with vision and cataract information as well as a phone number to make a consultation




All India Ophthalmology Conference 2020 13–16 February Gurugram, India https://aios.org/aioc2020.php

14–15 February Bangkok, Thailand http://cophyaa.comtecmed.com/

24th ESCRS Winter Meeting 21–23 February Marrakech, Morocco www.escrs.org

MARCH Frankfurt Retina Meeting 2020 14–15 March Mainz, Germany www.eckardt-frankfurt.de

6th Annual Congress on Controversies in Ophthalmology Asia-Australia (COPHy AA)

The 10th EURETINA Winter Meeting will take place in Vilnius, Lithuania

34th International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery 19–22 March Athens, Greece https://www.hsioirs.org/en/ 34th-international-congress-ofhsioirs-19-22-march-2020/

10th EURETINA Winter Meeting 20–21 March Vilnius, Lithuania www.euretina.org

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

APRIL 18th Congress of the Black Sea Ophthalmological Society 24 –26 April Tbilisi, Georgia www.bsos-tbilisi2020.org


3–7 May Baltimore, USA www.arvo.org/annual-meeting/

SFO 2020 Congress

9–12 May Paris, France https://www.sfo.asso.fr/

World Cornea Congress VIII

13–15 May Boston, USA www.corneasociety.org

The 6th Annual Congress on Controversies in Ophthalmology Asia-Australia (COPHy AA) takes place in Bangkok, Thailand





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

EyeAdvance 2020

29–31 May Mumbai, India https://www.eyeadvance.org/

14th EGS Congress

May 30–June 2 Brussels, Belgium https://www.eugs.org/eng/default.asp

JUNE 20th EVRS Meeting 2020 June 11–14, Stockholm, Sweden http://www.evrs.eu

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

The 20th EVRS Meeting 2020 will take place in Stockholm, Sweden




XXI International Congress of the Brazilian Society of Ophthalmology

20th Euretina Congress

AAO Annual Meeting 2020

2–4 July Rio de Janeiro, Brazil https://sistemacenacon.com.br/site/ sbo2020/mensagem

ASRS 2020

23–28 July Seattle, USA www.asrs.org

SEPTEMBER 5th International Glaucoma Symposium

4–5 September Mainz, Germany https://glaucoma-mainz.de/

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

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

WCPOS V 5th World Congress of Paediatric Ophthalmology and Strabismus

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

100th SOI National Congress

25–28 November Rome, Italy https://www.congressisoi.com

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

38th Congress of the ESCRS 3–7 October Amsterdam, The Netherlands www.escrs.org


Web-Based Registry

Cataract, Refractive and Patient Reported Outcomes in One Platform


the EUREQUO Platform




your Surgical Results

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

EUREQUO is free of charge for all ESCRS members


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2020 3-7 October RAI Amsterdam

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